Science & Sensibility

[Editor's Note: This marks the beginning of our coverage of the 5th International Normal Labour & Birth Research Conference, taking place July 20-23 in Vancouver. Sharon Dalrymple, staff development nurse, prenatal educator, doula, and Lamaze's first Canadian president, will present a session she developed with maternity care quality expert and Lamaze's president-elect, Debra Bingham. They were both part of a research team that investigated how women perceive terms like "normal birth" and "natural birth" and what that means for helping them understand evidence-based information to make health and healthcare choices. There are many reasons that women's perceptions and priorities matter in birth. One is that meaningful improvements in maternity care quality and safety are impossible without a strong consumer movement. Dalrymple's and Bingham's findings have major significance for "normal birth," however we each define it.

Remember, there's an Open Thread for conference attendees and enthusiasts to post messages. You can follow all of the updates from the conference on Twitter by following the #birthconf hashtag and find more analysis here on the blog - AMR]

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For the past 50 years Lamaze International has been promoting normal birth practices in North America and more recently worldwide. Despite these educational efforts women are being over-treated more now than they have been in over 30 years. For example, 31% of women in the United States give birth by cesarean surgery. The overuse of interventions with harmful side effects when there is little or no expected benefit for mother or baby has led to worsening maternity care outcomes in the United States and many other countries. In addition, women do not get adequate information so they are aware of the excess, unnecessary risks they and their infants are being exposed to.

One of the reasons these educational efforts may not have been as effective as desired is that our conversations may not be persuasive enough or clear enough. For example, it is not universally understood or agreed upon how to define a normal birth, the differences between normal and natural birth, and which behaviors constitute a normal birth. Conversations and language affect how persuaded others are to make changes. In fact, 50 years of diffusion of innovation research tell us that for women to demand safe, high quality maternity care, we must engage in clear conversations that outline specific desirable behavior changes and show that women and babies can expect better health outcomes if these changes are made.

Lamaze International hired a public relations market research firm to conduct research and identify which messages are the most effective for persuading women to adopt normal birth practices. Online surveys were conducted among 811 women aged 16-44  and 408 Lamaze Certified Childbirth Educators.

Indeed, the research showed that the meaning of the words “normal” and “natural” was not interpreted by the women and educators the same way. For example, 36% of women felt that ALL vaginal births are “normal birth”, while 63% of Lamaze Certified Childbirth Educators defined “normal birth” to be a birth without medical intervention. Women and Lamaze childbirth educators are likewise divided when deciding if the terms “natural birth” and “normal birth” are generally similar or generally different in meaning.

Lamaze International found that the words safe and healthy are the most effective words for communicating and promoting the birth practices Lamaze has endorsed for years. Everyone wants a safe and healthy birth. Mothers are particularly motivated to keep their baby and themselves safe and healthy. Most importantly, the practices are safe and healthy.

As a result of these and other findings, Lamaze International updated our six evidence-based key practice papers in Fall 2009 to ensure women realize that these practices simplify the birth process with a natural approach that helps alleviate fears and manage pain, with the ultimate goal of keeping labor and birth as safe and healthy as possible for each individual woman. Every woman needs clinicians who promote, support, and protect these six practices:

1. Let labor begin on its own

2. Walk, move around and change positions throughout labor

3. Bring a loved one, friend or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on your back and follow your body’s urges to push

6. Keep mother and baby together – It’s best for mother, baby and breastfeeding

Conflict of Interest Disclosure: The research was funded by Lamaze International.

Sharon Dalrymple Uncategorized childbirth education, lamaze, Normal Labour & Birth Conference

OK, I’m not making a claim that nursing in public protects against infant mortality (but hey, it’s certainly plausible, on the public health level at least.) No, I’m writing about these two topics today because I’m hoping you’ll go read my two guest posts, hosted on two of my favorite blogs.

Over on Giving Birth With Confidence, I wrote a post called, From the Bedroom to the Board Room: How I learned to nurse in public. It’s about the fact that early in my mothering, I actually breastfed at the board room table while presenting a report to Lamaze’s Board of Directors. And it totally shaped my perception on breastfeeding, my body, and family-friendly policies:

I look back on this time now and I realize how fortunate I was. My earliest experiences of opening my baby’s and my universe to others reinforced that nursing is normal, joyful, and important. In a way, it was totally unremarkable to nurse my baby while addressing my supervisor and her Board of Directors. But at the same time, it was something to be celebrated. The people at the table weren’t weirded out that I was breastfeeding. They loved it – reveled in it. We even talked about how it is important to have babies at our conferences. Our work affects them!

That post is part of the Nursing in Public Blog Carnival. The carnival coordinators got so many great posts, they started a new (amazing!) web site, Nursing Freedom. Go spread the word!

I also have a new post up at RH Reality Check about disparities in infant mortality. I challenge birth advocates to get behind prenatal care models that are effective and proven to reduce preterm birth and close the gap between blacks and whites. I discuss my own experiences with incredible prenatal care from my home birth midwives, and come to the chilling conclusion:

THIS is how prenatal care should be. Right? Well, not necessarily. Unless and until there is a major upheaval in healthcare financing and staffing patterns, having this kind of prenatal care is a privilege. And I don’t mean privilege like “I’m so lucky.” I mean privilege in the sense that I can’t have that kind of care unless others are deprived of it.

If everyone woke up tomorrow and realized that they deserved to have every question answered, every fear and concern explored, every test/procedure/diagnosis explained, we would quickly run out of midwives to provide that care. That is, if our solution was to provide one-to-one care on the traditional prenatal schedule. In short, that kind of prenatal care, however great it is, is not scalable to levels that could benefit all women and babies.

I also discuss CenteringPregnancy, an evidence-based, relationship-centered model of group prenatal care that has shown to reduce preterm birth rates, especially among African American mothers.

I wrote that post as part of Courtroom Mama’s blog carnival at The Unnecesarean. Check out the link to read through the other important posts.

And for those of you who are interested in learning more about infant mortality and disparities in perinatal care, here are a couple of great resources.

This widget from Kids Count, a project of the Annie E. Casey Foundation, let’s you see data for any U.S. state or territory on different indicators including the infant mortality rate, child poverty rate, and teen pregnancy rate.

And here’s a fantastic recent documentary on disparities in infant mortality in Tennessee, one of the states with the highest infant mortality rates, and where funding to address the problem was recently on the chopping block. (Mercifully, the programs seem to have been spared in budget cuts.)

Amy Romano Uncategorized blog carnival, breastfeeding, infant mortality, lamaze

Earlier this month, we announced that Lamaze had released the latest revision of our Health Birth Practice Papers. These are evidence-based statements about the care practices that ease and facilitate labor, prevent complications, and protect breastfeeding and early mother-infant attachment. The response from the blogging community has been wonderful – many bloggers have already begun sharing their thoughts about and personal experiences with these practices.

We decided it’s time to bring those great blog posts together in one place, and motivate other bloggers to share their perspectives as well. Over the next couple of months, Science & Sensibility will host a series of Blog Carnivals – one for each of the Six Healthy Birth Practices. We’ll start with the first, of course: Let labor begin on its own. We’re looking for posts from a broad range of bloggers on any aspect of labor onset. Your contribution can be a personal story, an analysis of a research or media item, exploration of a common myth, advice for pregnant women, you name it. I will compile a list of contributions here at Science & Sensibility, with links to the blogs where each is posted.

Participation is easy:

1. If you are a blogger, write a blog post on the Carnival theme (Let labor begin on its own). Post it on your blog by Sunday, October 4. Make sure the post links back to this blog post, to the Healthy Birth Practice Paper, or to the Mother’s Advocate video, Healthy Birth Your Way: Let Labor Begin on its Own. You may also submit a previously written post, as long as the information is still current.
2. Send an email with a link to your post to amyromano [at] lamaze dot org.
3. If you do not have a blog but would like to participate, you may submit a guest post by emailing it to me.
4. I will compile and post the Blog Carnival here at Science & Sensibility the week of October 5.

Amy Romano Lamaze news blog carnival, induction, lamaze

As most readers of this blog are probably already aware, The Today Show ran an inflammatory piece about home birth this morning that parroted ACOG’s long-standing scare tactics and anti-midwife rhetoric.

Since I just wrote a post on the safety of home birth, I thought that rather than repeating the same old story that home birth is safe for healthy women with qualified attendants and access to referral, I would share with readers some other thoughts, culled from this blog, the rest of Lamaze.org, and other trustworthy resources.

One of the first posts I wrote for Science & Sensibility (actually written as a guest post at the Giving Birth with Confidence Blog while this site was getting up and running) was titled, “Why the Largest Study of Planned Home Births Won’t Sway ACOG.” ACOG prefers to hold home birth to a standard of evidence to which hospital birth was never held.  Even while actively compiling the lowest form of evidence on the supposed “perils” of home birth in a membership survey, ACOG repeatedly calls for a randomized controlled trial comparing perinatal death rates in the two settings, fully aware that such a trial is literally guaranteed never to happen. I discuss some of the reasons why in my post, concluding that we face much more urgent research priorities for the study of planned home birth than a full-scale clinical trial.

We need more and better research on home birth. We can use data from the Netherlands to determine the safety of home birth in systems that support and integrate home birth midwifery. After all, it is the only place left with a maternity care system that lends itself to home birth safety research, and national registers to conduct that research soundly. In the U.S., we must study how we can reform our maternity care system to provide access to midwife-led care in all settings, and best practices for caring for the women who rightly and inevitably will continue to desire birth at home.

Why exactly do women desire to birth at home? It’s is not because they are hedonistic or selfish, as ACOG likes to suggest. Judith Lothian, PhD, RN, LCCE, wrote recently about the qualitative research she will present at next month’s Lamaze Conference. (Rixa Freeze, PhD, Lamaze International’s 2009 Media Award recipient, has conducted similar research.) Judith asked women themselves why they planned to give birth at home, and then observed them doing so. Their responses describe motivations far from reckless desire and hedonism. She writes:

I was surprised that all of the women described themselves as “mainstream”. They all wanted a natural birth. All the women came to believe that “intervention intensive” maternity care increased risk for them and their babies. They valued the personal relationship with their midwife and believed that this relationship increased safety. They believed they could manage the work of labor more easily and more safely in their own homes. They all expressed confidence that a hospital and skilled physician care were available if needed. ‘Being Safe’ emerged as the theme that captured the essence of women’s decision to plan a home birth. In stark contrast to the current thinking, that birth is safer in hospitals under the care of an obstetrician, these women believe that giving birth at home is safer for them and their babies.

It seems likely that women believe that home birth is safer than hospital birth because word is getting out that hospitals routinely deprive women of the style of care that is proven to produce the safest, healthiest outcomes. Just last week, Lamaze released the third revision of the Healthy Birth Practice Papers, a collection of evidence-based articles about the care practices that ease and facilitate labor, prevent complications, and protect breastfeeding and early mother-infant attachment:

1. Let labor begin on its own

2. Walk, move around, and change positions throughout labor

3. Bring a loved one, friend, or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on the back and follow the body’s urges to push

6. Keep mother and baby together – it’s best for mother, baby, and breastfeeding

The 2006 U.S. Listening to Mothers II Survey revealed what anyone who advocates for home birth could tell you even without the data: almost no one who births in a hospital actually experiences these care practices. The survey found that fewer than 2% of women had all 5 of the care practices that the survey measured. (The practice they were unable to measure was “no routine interventions”. Since interventions are routine and rampant in hospitals, this likely means that the proportion of hospital birthing women who experienced all six care practices was effectively zero.)  Instead, the authors of the survey tell us what is happening in current, hospital-based maternity care:

The data show many mothers and babies experienced inappropriate care that does not reflect the best evidence, as well as other undesirable circumstances and adverse outcomes. This sounds alarm bells…Few healthy, low-risk mothers require technology-intensive care when given good support for physiologic labor. Yet, the survey shows that the typical childbirth experience has been transformed into a morass of wires, tubes, machines and medications that leave healthy women immobilized, vulnerable to high levels of surgery and burdened with physical and emotional health concerns while caring for their newborns.
- Maureen Corry, Executive Director of Childbirth Connection.

In fact, ACOG themselves acknowledged in a press release today that the current style of obstetric practice (high-tech defensive medicine) “ultimately hurts patients“.

I continue to believe that if hospitals provided the Six Healthy Birth Practices as the standard of care and offered evidence-based treatments for women and babies experiencing complications, hospital birth would be safer and so would home birth. That’s because midwives would initiate transfers with more confidence that it would improve the outcome, women would transfer more willingly, and care at the receiving facility would be safe and effective. What’s not to like about that plan, ACOG? Now, let’s make it happen!

Amy Romano research for advocacy ACOG, breastfeeding, freedom of movement, home birth, hospitals, interventions, lamaze, Lamaze 2009 Annual Conference, maternity care systems, midwives, newborns, no separation, safety, second stage

Launched in 2004 to summarize the evidence for a healthy, safe, and natural approach to labor and birth care, Lamaze’s Care Practice Papers, have just undergone their second update. Now referred to as  The Six Lamaze Healthy Birth Practices, the latest update incorporates current evidence as well as more clear language that we know will resonate with women more effectively. These papers supplement the video series and handouts launched earlier this summer in partnership with InJoy Birth & Parenting Videos, and are trustworthy resources for women as well as childbirth educators and other birth professionals.

Each of the Healthy Birth Practices is supported by decades of high quality research. I like to think of the practices as “the basic needs of childbearing women.” Some women will need high tech monitoring and intervention to birth safely, but the standard should be care that supports and facilitates the normal physiologic processes, intervening with the safest, most effective, and least disruptive approach only when a medical need arises and with fully informed consent.

Routinely depriving women of The Healthy Birth Practices makes birth unnecesarily difficult, and complications more likely.  Got it? Good.

So here they are! Drumroll, please…

1. Let labor begin on its own - lead author Debby Amis, RN, BSN, CD(DONA), LCCE, FACCE

2. Walk, move around, and change positions throughout labor - lead author Teri Shilling, MS, CD(DONA), IBCLC, LCCE, FACCE

3. Bring a loved one, friend, or doula for continuous support - lead authors Jeanne Green, MT, CD(DONA), LCCE, FACCE, and Barbara A. Hotelling, MSN, CD(DONA), LCCE, FACCE

4. Avoid interventions that are not medically necessary - lead author Judith A. Lothian, RN, PhD, LCCE, FACCE

5. Avoid giving birth on the back and follow the body’s urges to push - lead author Joyce DiFranco, RN, BSN, LCCE, FACCE

6. Keep mother and baby together – it’s best for mother, baby, and breastfeeding – lead author Jeannette Crenshaw, MSN, RN, NEA-BC, IBCLC, LCCE, FACCE

Amy Romano Uncategorized announcements, childbirth education, continuous support, freedom of movement, Healthy Birth Practices, induction, interventions, lamaze, no separation, safety, second stage