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Series: Welcoming All Families – Supporting the Orthodox Jewish Family

July 28th, 2015 by avatar

Today on Science & Sensibility, we continue with our occasional series: Welcoming All Families by examining how an educator might make their class inviting for the Orthodox Jewish family who attends. There are rich traditions and customs that are unique to observant Jewish families and a knowledgeable educator can help families to prepare for birth and navigate the protocols of  the birth location feeling ready and confident that their practices will be respected and accommodated. Check out the entire series and learn how your childbirth class can be a place where all kinds of families feel respected, accepted and comfortable. – Sharon Muza, Science & Sensibility Community Manager.

By Jodilyn Owen, CPM, LM

By Adam Jones [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

By Adam Jones [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

As educators, our first jobs are to meet families where they are at and work with them in that place. As educators who have the responsibility to prepare families to navigate a complex healthcare system, we have a mighty task. The layers of birth preparation are unique for each family we will encounter. Establishing a baseline of knowledge about cultural and religious or spiritual backgrounds and practices will allow us to educate in a much more complete way.

The term “Orthodox Jewish” encompasses a great variety of practices and beliefs, so the most important take-away message here is that like all things related to the intersection of culture, religion, and birth, we must remain open to learning as we go, from the family, what their unique practices are. The basic premise that Orthodox Jewish families live by is that G-d exists, that the Torah (also known as the “Old Testament”) is true, and that G-d gave it as His instructions for living and navigating life. The families you work with accept these ideas and therefore live lives that are, for them, enriched by fulfilling what they see as G-d’s will by keeping the laws of the Torah and the Rabbis who mold and shape those laws in every generation and community around the world.

There has been a lot of buzz lately about hospitals that serve large populations of Orthodox families having extraordinarily low cesarean rates. This is being attributed to the tendency for large families in this community and the sense of importance around avoiding operative deliveries for the safety and health of future deliveries. Cesarean birth typically requires longer recuperation times which is very hard on a family with several children. Discussion in class around laboring at home until mom is in established active labor becomes critical to the process she will experience. This is in line with the efforts to reduce primary cesarean rates and an important part of the new ACOG guidelines .

While the theme of this article definitely revolves around variation in religious practices amongst Orthodox families, there are some commonalities you may encounter that are worth exploring. Perhaps the greatest gift as an educator you can give to your students is to illuminate the way that their behavior may be perceived so they do not have unnecessarily difficult interactions with the staff. These families have been navigating the world until this point and they likely have the tools they need to be who they are in new settings. Even so, you may help them clarify ways to mitigate the common pitfalls in the system so that they can proactively and effectively engage providers.

Let’s explore some key areas of interest. A bit of a disclaimer: As a licensed midwife practicing out of hospital, I have a lot of time to get to know my clients, their religious and cultural preferences and needs, and how I can best support them. I hope most out of hospital practices are similar. Therefore I refer here consistently to challenges that come up in the hospital. Jewish women have a long and beautiful history of being tended to by midwives, but in today’s society, most will seek care from an OB and choose to birth in a hospital.

Jewish Law

Many families observe a variety of Jewish laws that affect how they behave during the labor, birth, and postpartum times. This includes things such as saying blessings over the food and liquid that they drink, praying at prescribed times during the day, and even saying a brief prayer after using the bathroom to thank G-d for their body working the way it was designed to work.

  • In the hospital

If a person is praying they will not interrupt their prayers to answer questions or engage in any discussion. You can remind families that letting their nurse know that they are going to be unavailable for a short time will help avoid the nurse assuming that they are difficult to communicate with. They will need access to Kosher food—most families will bring their own if the hospital or birth center does not have any. Call around to find out which hospitals offer Kosher menus so that you can inform families during your class.

Consulting with the Rabbi

While there are dozens of laws that govern everyday life for Jewish families, they will all turn to their Rabbi for help with making decisions when it is unclear to them either how to apply the laws to their current situation or for guidance as they navigate life’s greater challenges. Mothers may want to talk with their Rabbi about the Jewish laws related to childbirth or decision points that come up during the pregnancy, birth, or postpartum time. This is not a sign of weakness or submission—it is a source of strength and guidance and a deeply valued relationship within the family and community structure. Most often the Rabbi will help a family work out ways to approach and solve problems, helping to build life skills within the context of Jewish law and philosophy. There is a lot of sensitivity to a family’s capacity at any given time, and their Rabbi may offer advice that varies from family to family. Thusly you may hear of a custom or law being observed in a several different ways—this is normal within the Jewish community.

  • In the Hospital

A woman may defer decision making until she and her husband evaluate which path to take in order to best meet the structure of Jewish law. This is not an act of defiance against authorities but can be taken that way. Teach skills that build capacity for creating space to talk over options alone.

The Yearly Calendar

Jewish families live very rich community and family lives that occur in conjunction with the Sabbath (often referred to as Shabbat or Shabbos), holidays and fast days. There are a total of 25 holidays and fast days, each with their own purpose and rituals that families will observe even during labor and birth. Fasting can be a health issue during early and mid-pregnancy. Women should be advised to talk with their doctor and their Rabbi before fasting. A retrospective study of 725 births found that fasting for 25 hours is an independent risk factor for preterm birth.

The Sabbath is well known as a day of rest. In Orthodox families it is a time to gather with family and friends and enjoy community. Many families avoid the use of electronics including phones, cars, and elevator buttons. This is something to keep in mind when scheduling your classes—Orthodox families will be preparing for Shabbat on Friday and observing it from sunset on Friday through sundown on Saturday night. Sunday and weekday schedules will accommodate this population well.

  • In the Hospital

This is a great time to talk about the role of a doula. It helps to have an advocate who can bridge the gap between the family and the hospital technology and normal protocols. Women will not sign papers, adjust the bed, or use the call button on Shabbat. Holiday laws are similar to Shabbat laws and families will need help facilitating their entry and stay in the hospital. Most hospitals in locations where there are large Jewish populations are prepared to work with observant families.

Modesty

Women will observe the laws of modesty in varying degrees depending on community customs and personal choice. Most women will wear clothing that covers their arms down to their elbows and skirts that are just below the knee or longer. Because it is normal for them to wear clothing that covers their body, hospital gowns that are short sleeved or short in length can leave a woman feeling vulnerable. Offer education for families on talking with the hospital staff about wearing their own clothing. Advise families that it is normal for Jewish women to wear a skirt of their choosing and to simply lift it up at the time of birth. Many women throw away the skirt after the birth but a half bottle of hydrogen peroxide with their normal laundry soap will remove any staining.

Many Jewish women cover their hair. You may see a hat, a handkerchief or scarf, or a wig used. Some women cover their hair throughout the birth process. Birth is unpredictable and for many women regardless of religion or culture, having clothing touch their bodies during the heat of labor becomes unbearable. Having attended dozens of births with Orthodox women, I can confidently say that it is normal for many women to forego their usual levels of modesty during transition and birth, while others maintain their norm. They can ask their doula or hospital staff for help covering up again when they are ready. They should also be made aware that they can always ask for a bed sheet if they want something light to wrap up in.

  • In the Hospital

Many women prefer to wear their own clothes during labor and birth. If the hospital insists on a gown, let women know that they can wear one gown with the opening in the back and another with the opening in the front over it. Women can wear their head covering if they wish to during the entire labor and birth. They need to tell their provider to let the father know when an exam will be done that exposes the mother’s body in case she prefers him to leave the room. Some fathers leave the room for the actual birth and come back in after the mom is sutured and in bed. Others sit on a chair or stand by their wife’s side at the head of the bed and they can be reminded that encouraging and loving words are always welcome during this time!

Touching and Passing

There are Jewish laws that govern physical separation between man and wife, and revolve around the woman’s cycle or evidence of uterine bleeding, including childbirth. Again, every family has unique customs they have built up that work for them. This may involve the couple not touching at all. Many couples report a high level of marital satisfaction having this separation each month, they come back to each other with renewed energy for connection and have space to develop their relationship outside the realm of physical intimacy. This is one of the most misunderstood set of laws in Jewish life—many looking from the outside project ideas of shaming or submission, inferiority or inequality in the relationship onto what they see. In fact Jewish women hold, by contract, much of the power of the relationship. A Jewish marriage contract is a standardized document that charges the wife with control of the home, purchases, and mandates the husband provide her sexual satisfaction, fidelity, support for the household expenses and any children, gifts on holidays, the highest standard of living he can supply, and alimony. This is a living functional legal document that is signed by witnesses at the time of marriage and given to the bride at the wedding for her safekeeping. Women are held in high regard in the majority of Orthodox communities and this carries into the privacy of their home. The time of physical separation may include the direct passing of items to each other. If one is passing the salt, they will set it down on the table before the other picks it up. If they are keeping these laws during labor, birth, and the postpartum time there are a number of areas this would affect.

  • In the Hospital

This is another great point to recommend a doula! The father may be emotionally and verbally supportive during the birth or they may have decided together that they prefer he read prayers. He may want to leave the room or go to a corner where he will not see the actual birth of his baby in an effort to keep the laws in accordance with his tradition. There is a huge variety in the ways that couples observe the laws relating to touch during labor, birth, and the immediate postpartum time. It can affect everything from passing the mom a cup of juice or a snack, providing physical support such as holding her head or hand while pushing, and even passing the newborn baby to be held by the other parent. Educate families on how normal it is for a nurse to ask a partner to pass something to the mom or to support her leg or neck during pushing. Nursing staff may see the father’s lack of touch as unsupportive and even neglectful if they do not understand what they are seeing. They may send a report to the hospital social worker asking for an evaluation that is inappropriate and unnecessary. Preparing families to talk openly with their nurse about their religious practices is of prime importance in the education of Orthodox families.

In the Community

Birth is a celebrated, treasured, and well supported community event. The family will very likely receive dinner every day for 2-4 weeks postpartum from community members and help with managing and care of older children and the home. There are many traditions involved in the welcoming of a baby over the first month of life. These may include a postpartum baby shower, because many Jewish families do not believe in purchasing items for the baby until after the baby has arrived. This tradition is rooted for some in a kind of superstition that arose in Eastern Europe and for others it is a matter of family tradition though they don’t necessarily share the feelings of superstition. Most families will circumcise their baby boy on the 8th day of life. This is a custom that celebrates the unique and individual relationship the boy has with G-d. Orthodox Jewish families will not need resources from you regarding where or how to contact professionals for newborn rituals, they will get that information from their synagogue.

  • In Class

Community standards and norms can be covered in class by contextualizing information based on the ideas that families will have strong customs and an interest in learning, gathering information, and talking things over with their trusted Rabbi. Education for families can point towards the need to balance community events with rest and healing and it might be a nice addition to class to get into the physical and emotional needs of the postpartum mother in some details. They are coming from a community where mothering is a valued and well promoted event in a woman’s life. For women who don’t feel happy or struggle with depression or anxiety, it can be very isolating. Be sure to share resources for mental health and hormonal support. Acupuncture is excellent for balancing hormones and a qualified practitioner can provide significant relief within 2-4 visits.   Pharmacological treatment provides help for those who prefer that route or don’t find relief from acupuncture. It is important to stress the normalcy of these mood disorders and the causes behind them.

For mothers with several small children, pelvic health must be discussed. One can look to the practices of other cultures for supporting the body as it transitions back into a non-pregnant state.

It is important to tell families that they need to either have a car seat with them when they go to the hospital or have a friend or family member go get one after the birth so that they can bring baby home if they are having a hospital birth. You might consider making a short list of items needed for a layette and encourage them to have those items picked up for them as well. If you are presenting current research on the effects of circumcision, do so without bias or judgment. Present the evidence and offer opportunities for questions just as you would for any other topic. These families will make their decision on their own and you have the opportunity to help them make that from an informed place—not a place of fear.

Conclusion

In conclusion, serving Orthodox families is about awareness for a culture that wraps its life around the yearly cycle of communal gathering and creates space to connect in time-honored ways within the family. While there is no one prescription for teaching childbirth classes to an Orthodox Jewish family, the approach of open-mindedness, cultural awareness and sensitivity, and leaving room for class participants to ask questions and share their ideas, ideals, and fears will always be just right.

Have you had Orthodox Jewish families in your childbirth classes?  What have you done to make them feel welcome.  Do you have any tips to share with other educators?  Let us know in the comments section below. – SM

About Jodilyn Owen

owen head shotJodilyn Owen, LM, CPM is co-author of The Essential Homebirth Guidea guide for families planning or considering a homebirth.  She is a practicing midwife at Essential Birth & Family Center in Seattle, WA and is a wife and mother.  Jodilyn is passionate about bringing babies into the arms of healthy mothers. Jodilyn’s newest venture is the Rainer Valley Community Clinic – a midwifery-led clinic in South Seattle, WA. The clinic serves an area that is a Federally Designated Medically Underserved Community. Rainier Valley Community Clinic is sponsored by the South Seattle Women’s Health Foundation, which is dedicated to creating spaces for high quality, individualized perinatal care and increasing capacity within the community for jobs in the healthcare industry for local women, especially those of color and immigrant women.  She enjoys hiking, camping, boxing, and watching her kids on the basketball court.  Jodilyn welcomes your comments and questions and can be reached through her website

Childbirth Education, Guest Posts, Maternity Care, Series: Welcoming All Families , , , ,

Introducing the Lamaze International LCCE Educator Social Media Guide

July 23rd, 2015 by avatar

LI_0350215_LCCE-SocialMediaGuide-FINALThis past Tuesday, I collected and shared a multitude of Lamaze International resources that are available on a variety of social media platforms that many of you might already be familiar with – Pinterest, YouTube, Facebook and many more.  The vast majority of these resources are available to any birth professional or consumer, and a scarce few are limited to Lamaze International members.  There is one more resource for Lamaze International members that I would like to make you aware of – the just released LCCE Educator Social Media Guide.  The Social Media Guide satisfies one of the Lamaze International Strategic Framework Goals for 2014-2017: Continue to build-out social media presence and engagement, and build educator skill and engagement in social media outreach.

Lamaze International has long provided a LCCE Educator Marketing Toolkit to help educators market their Lamaze classes to their community.  The Social Media Guide augments that Toolkit and is a comprehensive document that explains the different social media platforms so that you can select the one(s) that best meet your needs and serve your purpose.  We then help you get started, if you are new to the selected platform. There is also additional information if you are already a user and want to take your professional social media usage to the next level.

The Social Media Guide shares how it might benefit you and your business to engage with potential clients and students on social media, and what impact it might have on your business.  And as everyone knows, using social media can sometimes feel like falling into a big, black hole.  The Social Media Guide helps you to understand the importance of a) setting limits and b) using your limited time wisely.

Have you wondered if you should have a personal AND professional social media account or use the same account for both purposes?  We can help you decide, as the guide discusses the pros and cons of both.  We also provide various social media graphics that you can incorporate into your profiles, helping you to create a brand identity as a premier childbirth educator.

Each platform section is full of “Pro Tips,” useful suggestions and examples that can help you to use the platform effectively, efficiently and wisely.  There is information for all skill levels from beginner to current user.

There is even a comprehensive glossary so that you can make sure to understand all the abbreviations, acronyms, and keywords that are associated with each platform.

Being active and engaged on social media positions you as an expert in your field and can really help consumers to see both the benefits and value in utilizing your services. It also helps share evidence based information that can help guide families to safer and healthier births.  With a smart and effective social media strategy, you will be able to see the return on your time and energy investments with increasingly full classes and further recognition as an expert in serving families during the childbearing year.

If you are a current Lamaze member, head right over, log in and check out and download your copy of this comprehensive guide. If you are not currently a Lamaze International member, this guide along with all the other benefits offered to members is a real value for the price of a membership.

I also want to share that my colleague Jeanette McCulloch and I are teaching an interactive and jam-packed preconference workshop- “Social Media Smarts: Strategic Online Marketing for the Busy Childbirth Professional” on Thursday afternoon, right before the Lamaze International/ICEA 2015 conference starts, on September 17th, in Las Vegas, NV.

Social media marketing may be free, but your time isn’t. With Facebook views on the decline and increasing competition for your audience’s attention, how can you reach new families and fill your childbirth classes or client calendar without spending your day online? Join us for the workshop and advance your skills!  More info on the conference website.  Early bird registration for the conference and this workshop is available through August 1st.  Register now.

Have you had an opportunity to get a peek at the Lamaze International LCCE Educator Social Media Guide.  Share your experiences putting some of the information to work for you in our comments section.

 

 

Childbirth Education, Conference Schedule, Continuing Education, Lamaze International, Lamaze News , , , ,

Lamaze International Has The Up-to-Date Resources You Need! Are You Connected?

July 21st, 2015 by avatar

lamaze connectedLamaze International offers a large variety of useful material for Lamaze Certified Childbirth Educators and others to use to increase professional knowledge and help you when working with and sharing information with expectant and new families.  There are YouTube videos, infographics, a smartphone app, professional and consumer blogs, a Pinterest account, weekly newsletters for families, bi-weekly newsletters for Lamaze members, Facebook pages, a Twitter account, Instagram photos, live and recorded webinars and more all available to help you better serve the families that you work with. No matter what type of resource material you choose to access, you can be sure that it is evidence based, current and presented in a professional manner.  Here is a summary of many of these resources in one place so that you can use this post as a reference for easy access to useful information whenever you want.

Blogs

Science & Sensibility blog for birth professionals – if you are reading this,  of course you have already found this blog.  Published twice a week, you can get all the news, analyses of recently published studies, teaching ideas and more.  You can subscribe to this blog to be sure never to miss a post.

Giving Birth with Confidence – Lamaze International’s consumer blog written by Cara Terreri, CD(DONA), LCCE.  Follow along with families as they move through their pregnancies, get up to date information on pregnancy, birth and postpartum information – all delivered in a consumer friendly, easy to read format.

Videos

Lamaze International YouTube channel – a variety of videos, including “From the President’s Desk,” where Lamaze President, Dr. Robin Elise Weiss shares information on a variety of current issues, short and informative videos on many of our infographics, Six Healthy Birth Practices, and many more professional and consumer friendly videos that promotes safe and healthy births.  You can subscribe to this YouTube channel to receive updates when new videos are added.

Facebook

Pinterest

Twitter

  • @LamazeOnline – educators and parents can follow along on lots of updates and a great interactive monthly Twitter chat.
  • @LamazeAdvocates – connects birth pros with peers, professional development & resources to support expectant parents on their journey to a natural, safe & healthy birth, as well as participate in a monthly Twitter chat on a variety of topics.

Pregnancy & Parenting Smartphone App

A great tool for families to use through pregnancy, labor/birth and parenting.  Comprehensive, full of great evidence based information and simply very useful.  Check out the Pregnancy & Parenting app page on the Lamaze International website to see all the useful features, and find resources to help you introduce the app to the families you work with.

Infographics

Evidenced based information in an easy to read (and easy to share), visually appealing infographic format.  Topics include:

  • VBACs (new!)
  • Cesareans
  • Labor Support
  • Healthy Birth Practices
  • Electronic Fetal Monitoring
  • Epidurals
  • Separating Mom and Baby
  • Restricted Food & Drink
  • Restricted Movement
  • Avoiding the First Cesarean
  • Inductions

Find them all here, in both web-based and jpeg formats suitable for printing at your convenience. Don’t forget about the accompanying videos that are based on the infographics.

Email Newsletters

Your Pregnancy Week By Week – a weekly evidence based newsletter designed for parents that provides them with helpful information, tips and resources, delivered right to their inboxes weekly, based on their due date.

Inside Lamaze – a vital resource for continuing education available to Lamaze Members. The latest news, research, and information on upcoming events right in your inbox two times a month. Join Lamaze now to receive this valuable bi-weekly newsletter.

Webinars

Professional webinars for birth professionals with contact hours that are accepted by many maternal and infant health organizations, including nursing associations. Many of the webinars are free and only incur a small cost for contact hours.

Instagram – a place to find all the Lamaze pregnancy, birth and postpartum news that is fit for a picture!

Lamaze has you covered with great resources that keep you informed, up-to-date and connected on a variety of platforms and in diverse formats.  Stay connected with Lamaze International and have a plethora of useful information always at your fingertips and ready to share with expectant families.  How do you stay connected with Lamaze?  What’s your favorite Lamaze resource? Let us know in the comments section below.

Childbirth Education, Evidence Based Medicine, Lamaze International, Lamaze News, New Research, Research, Webinars , , , , , ,

New Report Provides Information on America’s Children, Including Key Birth Indicators

July 16th, 2015 by avatar

flickr photo by [derekmswanson] http://flickr.com/photos/derekmswanson/4875902007 shared under a Creative Commons (BY) license

flickr photo by [derekmswanson] http://flickr.com/photos/derekmswanson/4875902007 shared under a Creative Commons (BY) license

The just released report – America’s Children: Key National Indicators of Well-Being, 2015 is a collaboration between 23 different Federal agencies, all participating in the Federal Interagency Forum on Child and Family Statistics, which was chartered in 1997 with a mission to collect and document enhanced data on children and youth in the United States, improve the publication and dissemination of information to interested community members along with the general public and capture more accurate and extensive data on children at the Federal, state and local levels.

This extensive report is prepared from the most reliable Federal statistics and research and represents large segments of the population, examining 41 key indicators that represent important aspects of the lives of children. It is designed to be easily understood by the general public.  This is the 17th report in the series.  The key indicators found in the report can be divided into seven domains: family and social environment, economic circumstances, health care, physical environment and safety, behavior, education, and health.  America’s Children: Key National Indicators of Well-Being, 2015 is an exhaustive but fascinating report that makes for interesting reading.

I have pulled out some of the updated statistics and interesting facts as it relates to pregnancy, birth and newborns.

  • The United States had 73.6 million children in 2014 and this number is expected to increase to 76.3 million in 2030. While the number of children living in the United States has grown, the ratio of children to adults has decreased.
  • The continued growth of racial and ethnic diversity will be more an more apparent in the population of children in the USA. In 2020, less than half of all children are projected to be White, non-Hispanic and by 2050, 39 percent are projected to be White, Non-Hispanic and 32 percent of the children will be Hispanic.
  • In 2013, there were 44 births for every 1,000 unmarried women ages 15–44, down from 45 per 1,000 in 2012. The birth rate in 2013 was highest for women in the 25-29 age group (67 per 1,000), followed by the rate for women ages 20–24 (63 per 1,000). The percentage of births to unmarried women among all births decreased from 41.0 percent in 2009 to 40.6 percent in 2013.
  • The adolescent birth rate was 12 per 1,000 adolescents ages 15–17 in 2013, which was a record low for the country.
  • The percentage of infants born preterm declined to 11.4 percent in 2013; it was the seventh straight year the percentage declined.  In 2013, as in earlier years, Black, non-Hispanic women were more likely to have a preterm birth (16.3 percent) than were White, non-Hispanic (10.2 percent) and Hispanic (11.3 percent) women.
  • The percentage of infants born with low birthweight was 8.0 in 2013.  Low birth weight is defined as less than 2,500 grams, or 5 lbs. 8 oz. Black, non-Hispanic women were the most likely to have a low birthweight infant in 2013 (13.1 percent, compared with 7.0 percent for White, non-Hispanic, 7.5 percent for American Indian or Alaska Native, 8.3 percent for Asian or Pacific Islander, and 7.1 percent for Hispanic mothers).
  • The infant mortality rate of 6 deaths per 1,000 live births in 2012 was unchanged from 2011. The mortality rates of Black, non-Hispanic and American Indian or Alaska Native infants have been consistently higher than the rates of other racial and ethnic groups. The Black, non-Hispanic infant mortality rate in 2012 was 11.2 infant deaths per 1,000 live births and the American Indian or Alaska Native rate was 8.4 per 1,000 live births; both rates were higher than the rates among White, non-Hispanic (5.0 per 1,000 live births), Hispanic (5.1 per 1,000 live births), and Asian or Pacific Islander (4.1 per 1,000 live births) infants.

When you read these facts and look at the other fascinating information included in the report – what comes to mind for you?  Do you see opportunities for providing services beyond what you already provide?  Might there be a need for education, information and resources designed to serve another demographic than the current populations you serve?  Could you help improve outcomes (prematurity, low birth weight, teen pregnancy) by adding classes, providing additional information or making your current classes accessible to a more diverse population?  Let us know in the comments section after you have a chance to poke around the information available in the recently released report –  America’s Children: Key National Indicators of Well-Being, 2015.  For more general information, including supplemental reports and an overall summary, check out the ChildStats.gov website.

Babies, Childbirth Education, Newborns, Research , , ,

Elective Induction at 40 Weeks? “Decision-Based Evidence Making” Strikes Again

July 14th, 2015 by avatar

Today on Science & Sensibility, contributor Henci Goer takes a look at a systematic review released in spring that examined the impact of elective inductions on the cesarean rate.  Sound analysis or a house of cards?  Looking closer at the studies reviewed provides insight into how the conclusions reached by the investigators might need to be examined more closely.  Henci does that in this review.  Have you read this new systematic review?  Did you come to the same conclusions?  I invite you to share your thoughts in our comments section below. – Sharon Muza, Community Manager, Science & Sensibility.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340  CC licensed.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340 CC licensed.

Yet another systematic review has surfaced “Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials”  in which reviewers claim that electively inducing healthy women, this time at 40, not 41 weeks, offers benefits and doesn’t increase the cesarean surgery rate (Saccone 2015).

Let’s take a closer look.

Reviewers included five trials: three of them conducted in the 1970s (Cole 1975; Martin 1978; Tylleskar 1979), the fourth published in 2005 (Nielsen 2005), and the fifth in 2014 (Miller 2014). Already we have a problem. Induction management in the 1970s is sufficiently different from management today that results are unlikely to apply to contemporary care, but let’s get down to specifics. Two of the 1970s trials were deemed inadequate for inclusion in the Cochrane review of elective induction (Gulmezoglu 2012), and Miller 2014 is published only as an abstract. Quality systematic reviews exclude abstracts because they don’t provide enough information to evaluate the study. For these reasons, these three trials should be taken off the table..

That leaves us with the other two. Nielsen 2005 states in the title “Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial” that it is confined to women with favorable Bishop scores. Anyone familiar with elective induction research should know that inducing when the cervix is ready to go won’t increase the cesarean rate compared with spontaneous onset, but inducing with an unripe cervix is a different story even when using cervical ripening agents (Dunne 2009; Jonsson 2013; Le Ray 2007; Macer 1992; Prysak 1998; Thorsell 2011; Vahratian 2005). As you move the induction date earlier and earlier, more and more women will have an unfavorable cervix, so including a trial limited to women with a ripe one will tilt the playing field in favor of induction. Furthermore, half the participants were multiparous women (113/226). Women with prior vaginal births will go on having vaginal births pretty much no matter what you do to them, which raises another point: inducing earlier means a higher percentage of the inductees will be first-time mothers because first time mothers tend to run longer pregnancies (Mittendorf 1990). Nulliparous women are much more vulnerable to anything that pushes them in the direction of a cesarean. That’s not all: The authors tell us that their hospital has a 7% cesarean rate for dystocia in women at term. If a hospital has a cesarean rate much higher than that—and many do—then results can’t be generalized to it, although, frankly, if the doctors are performing cesareans left and right, induction or spontaneous onset may not make much difference. In short, Nielsen (2005) doesn’t make a compelling argument for 40-week elective induction.

flickr photo by Selbe <3 http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

flickr photo by Selbe < http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

This brings us to the last trial, Cole (1975). Investigators allocated healthy women either to induction at 40 weeks (111 women) or 41 weeks (117 women). As with Nielsen, half the women had prior vaginal births. Despite being healthy, 22 women were induced for “obstetric complications” (undefined) in the 41-week induction group before reaching 41 weeks. If their doctors induced labor because they had concerns, then this would likely put the women at heightened risk for cesarean. Another 32 women were induced for exceeding 41 weeks. This means that overall, nearly half (46%) of the comparison group didn’t begin labor spontaneously, which would mask any association between induction and cesarean. Leaving the induction vs. spontaneous onset issue aside, the U.S. cesarean rate in the early 1970s was around 5%, which means it was a rare woman who would have one regardless of circumstances. Again, not exactly a strong case for inducing at 40 weeks.

What about the benefits? The best reviewers can come up with are a clinically meaningless reduction in mean blood loss (-58 ml); a lower rate of meconium-stained amniotic fluid (4% vs. 14%), not, mind you, a reduction in meconium aspiration, and therefore clinically meaningless as well; and an equally meaningless reduction in mean birth weight of -136 g (5 oz). If they had found something more impressive, surely they would have reported it.

Really? This merited a pre-publication media blast? Because it amounts to a textbook example of “garbage in, garbage out.” I can see only three possibilities to explain it: either 1) the authors and peer reviewers at the American Journal of Obstetrics and Gynecology (AJOG) don’t know as much as they should about what constitutes a quality systematic review, 2) they are so steeped in medical model thinking—“How early can we get the baby out of that treacherous maternal environment?”—that their judgment is compromised, or 3) we have a “pay no attention to what’s behind the curtain” effort to promote elective induction. I don’t know which is the more troubling, but if it’s the last one, the sad thing is that because it’s got the magic words “systematic review,” “meta-analysis,” and “randomized controlled trials” in the title, it’s likely to succeed.

References

Cole, R. A., Howie, P. W., & Macnaughton, M. C. (1975). Elective induction of labour. A randomised prospective trial. Lancet, 1(7910), 767-770.

Dunne, C., Da Silva, O., Schmidt, G., & Natale, R. (2009). Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can, 31(12), 1124-1130.

Gulmezoglu, A. M., Crowther, C. A., Middleton, P., & Heatley, E. (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev, 6, CD004945.

Jonsson, M., Cnattingius, S., & Wikstrom, A. K. (2013). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Martin, D. H., Thompson, W., Pinkerton, J. H., & Watson, J. D. (1978). A randomized controlled trial of selective planned delivery. Br J Obstet Gynaecol, 85(2), 109-113.

Miller, N., Cypher, R., Pates, J., & Nielsen, P. E. (2014). Elective induction of nulliparous labor at 39 weeks of gestation: a randomized clinical trial. Obstet Gynecol,132(Suppl 1):72S.

Mittendorf, R., Williams, M. A., Berkey, C. S., & Cotter, P. F. (1990). The length of uncomplicated human gestation. Obstet Gynecol, 75(6), 929-932.

Nielsen, P. E., Howard, B. C., Hill, C. C., Larson, P. L., Holland, R. H., & Smith, P. N. (2005). Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial. J Matern Fetal Neontal Med, 18:59-64.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: a case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Saccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. American journal of obstetrics and gynecology.

Thorsell, M., Lyrenas, S., Andolf, E., & Kaijser, M. (2011). Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Acta Obstet Gynecol Scand, 90(10), 1094-1099. doi: 10.1111/j.1600-0412.2011.01213.x

Tylleskar, J., Finnstrom, O., Leijon, I, et al. (1979). Spontaneous labor and elective induction – a prospective randomized study. Effects on mother and fetus. Acta Obstet Gynaecol Scand, 58:513-518.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.out

About Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.

 

ACOG, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , , ,

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