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Working to Improve Perinatal Depression Rates – An Interview with Researcher Nancy Byatt, DO

September 1st, 2015 by avatar

By Walker Karraa, PhD.

sad mother and baby dropboxPerinatal and/or postpartum depression affects more than 15% off all women during pregnancy or after birth.  Many women are not diagnosed and therefore are not referred on to specialists who can help them with appropriate treatment. Last month, the Centers for Disease Control (CDC) announced an inaugural grant of 2.5 million dollars to University of Massachusetts Medical School researchers for the purpose of exploring the feasibility and effectiveness of obstetricians diagnosing and treating women suffering from perinatal or postpartum depression within their current obstetrical practice.  The ability of obstetricians to identify and treat affected women may help to close the gap that exists in women receiving treatment, and ensure adequate care is available and provide the ability to monitor how the women respond to treatment.  Creating a network of resources and providing OB access to psychiatric specialists for consultations can result in more women receiving more effective treatment faster from the provider they are already seeing.  Dr. Walker Karraa, perinatal mental health expert interviewed on of the co-investigators, Dr. Nancy Byatt about this research grant and what it might mean for women suffering from perinatal depression. – Sharon Muza, Community Manager, Science & Sensibility.

Walker Karraa, PhD: How is this grant first of its kind?

Nancy Byatt, DO: This is the first time the Centers for Disease Control put forth a request for applications for the Evaluation of a Stepped Care Approach for Perinatal Depression Treatment in Obstetrics and Gynecology Clinics.

WK: How long have you and your colleagues been working on this grant?

NB: Our team began working on understanding how depression could be addressed in obstetric settings in 2010. Driven by our commitment to helping women get treatment by leveraging the obstetrical care setting, we were awarded two institutionally funded grants to conduct three formative research studies with obstetric providers and staff, postpartum patients and pregnant women.

Jeroan Allison, MD, Nancy Byatt, DO, and Tiffany Moore Simas, MD.

Investigators Jeroan Allison, MD, Nancy Byatt, DO, and Tiffany Moore Simas, MD.

Our preliminary studies evaluated the perspectives of obstetric providers and postpartum women, about ways to improve depression treatment in the obstetric setting. We found that barriers occurring at the patient, provider, and systems-level prevent perinatal women and obstetric providers from addressing depression. Our preliminary data led us to hypothesize that transforming obstetrical practice to include depression treatment would enhance women’s access to and engagement in treatment and thereby improve depression outcomes.

WK: Tell us about the pilot study and how it revealed the gaps in treatment. What are the gaps identified? Why do you feel these gaps exist?

In our formative studies, and literature reviews, we identified a number of patient, provider, and systems-level barriers and facilitators to the treatment of perinatal depression and reviewed clinical, programmatic, and systems-level interventions. Provider and systems-level barriers include: (1) lack of obstetric provider training in technical aspects of depression care and communication skills; (2) absence of standardized processes and procedures for stepped depression care; (3) lack of mental health providers willing to treat pregnant women; (4) lack of referral networks; and, (5) inadequate capacity for follow-up and care coordination. These are exacerbated by patient-level barriers. Perinatal women report they fear stigma, losing parental rights, and being judged as an unfit mother. Many women perceive obstetric providers and staff as unsupportive, unavailable, and inadequately trained in depression.  We have built the RAPPID program to address these critical barriers at the provider, patient, and system level.

WK: If readers wanted to learn more about your work and/or the gaps in treatment, what literature would you recommend?

NB: We have several peer-reviewed articles that summarize our work. (see the reference section below.)

WK: What was your original vision for MCPAP?

NB: We aimed to translate the successful Massachusetts Child Psychiatry Access Project (MCPAP) to address perinatal depression. MCPAP has transformed the delivery of child mental health services in Massachusetts by making immediate psychiatric consultation available to pediatricians, to address depression in obstetric settings.   Our vision was that expanding MCPAP to create MCPAP for Moms, a new program that could provide obstetric, psychiatric, primary care and pediatric providers with access to care coordination and psychiatric telephone consultation to help them address perinatal depression. We aimed to create a population-based program that would help the entire state of Massachusetts address depression by building capacity of the frontline providers who are serving pregnant and postpartum women in their medical setting.

WK: Can you explain how the RAPPID program will be compared to the MCPAP program?

NB: To build on and address the limitations of MCPAP for Moms, we developed and pilot tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program to create a more comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to the immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers via MCPAP for Moms; (2) clinic-specific implementation of stepped care, including training support and toolkits; and, (3) proactive treatment engagement, patient monitoring, and stepped treatment response to depression screening/assessment. RAPPID was developed using formative data and feedback from key stakeholders.

We will compare two active interventions, enhanced usual care (access to MCPAP for Moms) vs. RAPPID in a cluster randomized controlled trial (RCT) in which we will randomize 12 Ob/Gyn clinics with diverse patient populations to either RAPPID or enhanced usual care.

WK: How is stepped care different than collaborative care?

NB: Stepped care models involve initial determination of treatment based on illness severity and intensification of care (such as stepwise increases in dose of antidepressant medication) for those with persistent illness.

WK: What has inspired your work in this field?

NB: I have been moved by women’s stories and how hard it was for them to access the care that they needed and deserved. In the beginning of my career I was seeing this time and time again.

I am inspired by the women I serve. I have worked with countless pregnant and postpartum women. Perinatal women initially or in a prior pregnancy were not able to access the care they needed and deserved. This led me to want to make an impact beyond patient care and I envisioned a program would help pregnant and postpartum women access treatment for their depression.

WK: What are the most critical issues in perinatal mental health today?

NB: Despite having evidence based treatments available, depression is not detected among many pregnant and postpartum women and even if it is detected, many women will not be able to access treatment. Depression during pregnancy is twice as common as diabetes and it needs to be a routine part of obstetric care just as diabetes is a routine part of obstetric care.

References

  1. Byatt N, Levin L, Ziedonis D, Moore Simas T, Allison J. To What Extent Does Screening and Referral Improve Depression Outcomes and Mental Health Care Utilization Among Perinatal Women? Obstetrics and Gynecology. In Press.
  1. Byatt N, Rui X, Dinh K, Waring EM. Trends in Mental Health Care Use in Relation to Depressive Symptoms Among Pregnant Women. Archives of Women’s Mental Health. 2015 Apr 7. Epub ahead of print.
  1. Weinreb L, Byatt N, Moore Simas TA, Tenner K and Savageau JA. What happens to mental health treatment during pregnancy? Women’s experience with prescribing providers. Psychiatr Q. 2014;85:349-355.
  1. Byatt N, Biebel K, Friedman L, Debordes-Jackson G, Pbert L, Ziedonis D. Patient’s Views on Depression Care in Obstetric Settings: How Do They Compare to the Views of Perinatal Health Care Professionals? General Hospital Psychiatry. 2013;35(6):598.
  1. Byatt N, Biebel K, Debordes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D. Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly. 2013;84(2):169-174.
  1. Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):143-61.
  2. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debordes-Jackson G, Ziedonis D. Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression. Journal of Reproductive and Infant Psychology. 2012;30(5):436-439.
  3. Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):143-61.

About Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M.

© Nancy Byatt

© Nancy Byatt

Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M is a psychiatrist focused on improving health care systems to promote maternal mental health. Dr. Byatt is an Assistant Professor at UMass Medical School in the Departments of Psychiatry and Obstetrics and Gynecology. Byatt is a psychosomatic medicine psychiatrist with subspecialty expertise in perinatal mental health. She provides expert psychiatric consultation to obstetric, psychiatric, primary care and pediatric providers serving pregnant and postpartum women. She is the Founding and Statewide Medical Director of the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms). MCPAP for Moms addresses perinatal depression across Massachusetts by providing mental health consultation and care coordination for medical providers serving pregnant and postpartum women.

Byatt’s research focuses on developing innovative ways to improve the implementation and adoption of evidence-based depression treatment for pregnant and postpartum women. She has a Career Development Award that funds her research to help women access and engage in perinatal depression treatment in obstetric settings. She has also received federal funding from the Center for Disease Control to test an intensive, low-cost program that aims to ensure that pregnant and postpartum women with depression receive optimal treatment. Her academic achievements have led to numerous peer-reviewed publications and national awards.

 

Babies, Depression, Guest Posts, Infant Attachment, Maternity Care, New Research, Newborns, Perinatal Mood Disorders, Postpartum Depression, Research , , , , , , ,

The PregSense Monitor: A useful new tool or fear-based marketing

August 18th, 2015 by avatar

By Deena Blumenfeld, ERYT, RPYT, LCCE 

pregsensePart of a parent’s job description is to worry about their children. In doing so, parents can help the child maintain their physical health and their emotional wellbeing. However, when the line is crossed into fear based parenting; they may become overprotective to the point of stifling a child’s natural curiosity and the need to learn by making mistakes. They are then at risk of becoming “helicopter parents”.

This is an issue of control. When parents take full control, of their child’s overall well being, they feel that they are protecting them from all the negative aspects of the world. This is a fallacy.

Advertisers and marketers play into this fear and the need for control, that feeds into the parents’ feelings of limited or lack of control. Companies create and market products that provide the impression of safety and security. These products provide a false sense of control for parents, which furthers the illusion that they are doing something “good” or “right” as they “protect” their baby.

Making the rounds of Facebook, and other social media feeds, was this nifty little video about an at-home, wearable baby monitor. It’s called the PregSense Monitor by Nuvo Group. The general consensus from the online community, both mothers and professionals alike, was “Wow! This is amazing! We’ll save so many babies this way!”

My own reaction was a bit different. I’m a skeptic at heart and like all Lamaze educators; I’m a big fan of evidence based products, treatments, procedures and medications. So, I knew I needed to learn more about the PregSense monitor. What’s the evidence behind it? Would it really meet expectations, and save babies and reduce moms’ anxiety?

I attempted to contact Nuvo Group for an interview, but I have not received a response from them at the time of this writing.

Nuvo Group claims

The Israeli tech firm hopes the device will reassure anxious mothers like Michal, in week 32 of her pregnancy, who require monitoring without having to see her doctor.

Claim:  “(The monitor will) allay mothers’ fears by transmitting data about the health of the mother and fetus.”

  • It appears to monitor all of the mother’s vital signs, not unlike a Fitbit or other activity tracker. But how does having the knowledge about your own vital signs and getting additional information about baby’s activities reduce fear?
  • What if the monitor malfunctions? What does that do to a mother’s level of fear?
    • Can one make the assumption that if the monitor isn’t picking up the baby, the mother will become more worried, rather than less. This might lead to increased health care provider visits and further unnecessary medical testing.
  • Could wearing this monitor increase anxiety and potentially cause mothers to be so focused on the monitor it becomes a bit of an obsession?
    • Mothers may become hypervigilant and reliant on the constant stream of “data” available to be reviewed.
  • How would a mother feel if she was unable to wear the monitor one day? Would that increase her fears, even if those fears were unfounded?
    • Removing access, even for a short time could increase worry and interefere with a mother’s ability to continue her daily activities.
  • When there is a constant stream of data it becomes easy to tune out the information. Wouldn’t that defeat the purpose of this device?
    • The information may become white noise and fade into the background, because it’s a nonstop stream.

Claim: Mothers can connect, see and hear the fetus whenever they want, without needing to consult a doctor.

  • Do mothers need a device to help them connect with their babies?
    • This product is trying to create a consumer need that does not exist.
    • Mothers connect with their babies all the time by feeling their movements; talking to them; touching their growing bellies, etc. Would the device reduce this natural mother/fetus interaction? Would a mother be more likely to turn to her smartphone for results from the monitor instead of paying attention to what her baby is actually doing throughout the rhythm of the day.?
  • Using this device would require a health care provider to be monitoring all of these women, all the time. This doesn’t take into account staffing levels or time to complete the task. 24/7 monitoring would be a massive time commitment and responsibility.
  • What about additional liability for the health care provider for not monitoring a woman properly or correctly identifying a problem?
    • We live in a very litigious society. A care provider might be facing a lawsuit if the data from the monitor is not evaluated regularly and an anomaly was missed.
  • Since there are two monitor types – the clinical monitor and the consumer monitor, this raises additional questions. What if the mother is low-risk and healthy, but chooses to wear the consumer model, without a prescription to “reassure” herself that all is well?
    • Would the physician then be required to monitor this mother, if there is no medical need and was not advised by the physician?
    • What is the physician’s liability in this case?

Claim: “We will be able to analyze this data to predict about events of pregnancy, like preterm labor, like preeclampsia and more and we will be able to intervene in the right time…”

  • Preterm labor may be able to be detected with continuous monitoring. However, the monitor is only identifying contractions. It’s not looking at vaginal discharge, cervical change, flu-like symptoms or downward pressure from the baby.
  • Would the monitor be able to tell the difference between Braxton-Hicks contractions and early labor?
    • The limited information on Nuvo Group’s website and in their press release does not provide enough information to say for sure.
  • What about those women who experience Braxton-Hicks regularly throughout pregnancy but are not in labor? Would the monitor be helpful or harmful for them in identifying mothers in preterm labor? Would they be in and out of their care provider’s offices more frequently, causing disruption to their daily lives?
  • Preeclampsia cannot be prevented at this time. So, at best, the monitor would let the mother and her care provider know that her blood pressure is high. It would not test for protein in her urine, swelling in her face, headaches, vision changes or any of the other symptoms of preeclampsia, so it’s an incomplete test. Would preeclampsia be missed because mother’s blood pressure is borderline and no other tests were administered.

Claim: Regarding monitoring high risk mothers with continuous monitoring in hospital; the monitor will benefit the health care provider by replacing a bulky machine with one that is lightweight and not connected to the wall.

  • We already have telemetry units for Electronic Fetal Monitoring (EFM), in many hospitals. This device is now redundant and may not integrate with the current software used to monitor the EFM units.
  • How much will this cost a hospital to replace all of their current EFM units by purchasing these PregSense clinical monitors? Is the financial outlay for a new convenience worth the expense?
  • Does the new monitor increase safety for mother and baby in comparison to traditional EFM. Is this alternative truly better for mothers and for doctors in an in-patient setting? Where are the studies that compare the two options? Is the data we get any better? Or are we still subject to human interpretation of the data in identifying the appropriate course of action?

Claim: The PregSense monitor is safer than ultrasounds that can cause tissue damage

nuvo-ritmo-beats-pregsenseAt this point in time there is no evidence and no research, to support monitoring mothers at home during pregnancy. All of the literature refers to full time electronic fetal monitoring (EFM) during labor. Therefore my assumptions are based off of that literature.

Consensus among professional and governmental groups is that, based on the evidence, intermittent auscultation is safer to use in healthy women with uncomplicated pregnancies than electronic fetal monitoring (EFM).  (Heelan 2013) These professional groups include ACOG and AWHONN.

The issue with the beneficial claims made by Nuvo Group is they are in opposition to what the research finds for routine continuous EFM. Continuous EFM in low risk mothers provides no benefit for babies and increases the risk of cesarean for mothers. Therefore the whole concept of the PregSense Monitor is based on an erroneous assumption. It is not possible to prevent a problem by monitoring the baby. A problem can only be detected as it is occurring. So, even if a problem is observed while doing at home monitoring, by the time the mother makes it to the hospital it is may be too late to intervene effectively.

There is also the risk of false positive results. The monitor may detect an anomaly that then increases the mother’s fear about her baby’s well being only to be examined to find out that her baby is doing just fine, causing undue stress and panic.

The claims of the manufacturer of this product don’t hold up under current EFM guidelines and are not FDA approved.

Simplifying fetal monitoring for the care provider may not actually be the case when we look at 24/7 monitoring which still needs to be interpreted by a human being and a potentially large financial investment for a hospital that already has an EFM system that is adequate.

The claim that this product is safer than what currently exists with today’s EFM technology and ultrasonography is unsubstantiated. Without proper research, we do not know if it is safer, more harmful or neutral in relation to EFM and ultrasound as they are done today.

Resolving mother’s fears and helping her connect with the baby are at best an assumption regarding the “softer side” of the product’s results. It may be that some women do have greater piece of mind and feel a greater connection with their baby when using the device. Selling a feeling does not provide medical benefit to mother or baby. It is, however, good marketing.

The takeaway for your students is to have them look at all products with a discerning eye. Fear based marketing is insidious and plays to their emotions. They need to be making informed decisions based on accurate and evidence based information, rather than an emotional response to something that hits them in the heart.

References:

 Nuvo Group’s website

Reuters, “Wearable device provides continuous fetal monitoring”

Dekker, Rebecca, Evidence Based Fetal Monitoring, 2012

Dekker, Rebecca, What is the Evidence for Fetal Monitoring on Admission, 2012

FDA, Avoid Fetal “Keepsake” Images, Heartbeat Monitors, 2014

FDA, Ultrasound Imaging

ACOG Practice Bulletin #106, “Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles,”, July 2009

ACOG press release, ACOG Refines Fetal Heart Rate Monitoring Guidelines, 2009

Lisa Heelan, MSN, FNP-BC, Fetal Monitoring: Creating a Culture of Safety With Informed Choice, J Perinat Educ. 2013 Summer; 22(3): 156–165.

 

 

 

ACOG, Babies, Fetal Monitoring, Guest Posts, Medical Interventions, News about Pregnancy , , , ,

Series: Building Your Birth Business – Using Facebook Ads to Advertise Your Birth Business

August 11th, 2015 by avatar

By Janelle Durham, MSW, LCCE

Building Your Birth Business- Using FacebookToday we have another post in the Building Your Birth Business series.  You may be interested in growing your own independent childbirth education or birth related business.  Maybe you already have such a business already established but are looking to take it to the next level. Even if you work for a hospital or organization, this information is useful as well, if they are looking to expand their reach.  Today’s post by author and educator Janelle Durham, MSW, LCCE, helps you to understand Facebook Ads and how to customize them.  Targeted to your specific audience, Facebook Ads can increase traffic to your website or Facebook page where families can learn more about your services. You can find all the posts in this series here– Sharon Muza,  Science & Sensibility Community Manager

Facebook ads let you write an ad that appears on someone’s Facebook feed. So, as they’re scrolling through for news of their friend’s adventures, they see your ad. This is a good way to raise awareness of your services. For $10, you can put your ad in front of about 800 people, and about 15 of them will click through to learn more. But, the best part is that you can target these ads to very specific demographics, like expectant parents who live in Monroe, Washington. You don’t waste money showing it to anyone who doesn’t fit that description. (Unlike that newspaper ad, which is mostly read by retirees.)

Note, this type of ad raises awareness of your business. I can’t guarantee it will get you clients and students! When someone was reading Facebook, they weren’t necessarily looking for a doula or a childbirth class, so they may not immediately click through and call you up. But, you have increased the chance they’ll do that in the future. It’s worth $10.

Here’s How to Create a Facebook Ad

First, if you don’t already have a Facebook page, create one here. (Here are some tips on pages for businesses.)

Then, log on to your page

Click on Create ad (it probably displays on your left sidebar under the heading “pages” or it might appear on the top right corner of your page)

It will ask you what kinds of results you want to get: choose ‘clicks to website’. Paste in the website address. (Make sure you choose the specific page you’ll want them to land on on YOUR website.)

Defining Your Audience

durham fb audience-definition

There’s lots of variables you can adjust here. Each changes the potential total audience for the ad – the total number of Facebook users who fit the description you’ve chosen.

Keep an eye on the little “audience definition” meter on the right hand side, and also, at the bottom of that column, it will tell you “potential reach” of your ad. Make choices, and see what gets you to the number you want… it usually takes a little experimentation to get it just right. I have found that if I spend $10 on an ad, it’s typically going to be displayed to about 800 – 1200 people, so I’m looking to narrow my demographics down to a total potential audience in the range of 2000 – 4000 people who are the closest possible match I can get to who I’m looking for. I won’t reach them all, but I’ll reach a good percentage of them. This gives me the best bang for my buck. If you had a bigger budget, you would want higher numbers for potential audience.

  • Location. Where it says “Include”, type your city in. It will then offer to do a radius around that city (you’ll see that it says “Carnation+25 miles”). You can adjust that. Next to “+25 miles”, there’s an arrow for a drop-down menu. You can adjust the radius there. You can also exclude things. Like for Carnation, I want everyone in the Snoqualmie Valley to see it (the rural areas north, east, and south of Carnation). But, I know no one from Seattle, Bellevue, Kirkland or Redmond (urban areas) is going to drive to Carnation for a class! Note, when excluding cities, choose “no radius”.

durham fb location

  • Age. You can limit by age group. I’m trying to reach expectant parents, and parents of very young children. While we welcome teen and young adult parents, we have found they don’t usually sign up, so, since my advertising dollar is limited, I target to age 24 and up. On the older side, I set it at 46 or so. (There is an irony in this, since I’m a 48 year old mom of a preschooler…) Note: Ad targeting is NOT about who is welcome or not welcome in our classes!! It’s about focusing our ads on the type of people most likely to be looking for a program like ours.
  • Gender: It’s a stereotype, but likely true, that moms make more decisions about classes than dads do. I do both genders if that gets my audience to the right size, but if I really want to target my ads for best value, I limit to women.
  • Language: I generally leave blank. It will go to anyone in my area, no matter their primary language.
  • More demographics: there’s a LOT of choices here. Some examples: Home >> Household Composition >> Children in Home or Parents >> All Parents >> (0 – 12 months): New Parents or Parents >> Moms >> Stay-at-home moms
    • Note: when you write your ad, think about who you’re going to target. For example, if you’re targeting to “stay at home moms” vs. “parents 0 – 3 years” your ad might be written differently. SAHM might not click on an ad for a preschool if they think of preschools as a 5 day a week thing… so your ad might say something about it being ‘2 mornings a week – great opportunity for a little social interaction for you and your child’.
    • For childbirth classes, I might choose married or partnered. Again, I’m not trying to be biased here… single parents are VERY welcome in the classes, but again, if I have limited ad dollars, I know that partnered moms are more likely to choose to enroll in a class…
  • Interests: You could choose people who are interested in Family and Relationships, and that gets you people who have “liked” pages about Family and Relationships
  • Behaviors. Again, there are lots of things to choose from here. I have tried targeting a preschool ad to Purchase Types >> Baby products and had similar results (click-through rates) to when I targeted at parents of kids 0 – 12 months. Note: use EITHER the “more demographics” section OR “Interests and Behaviors.” If you use both, the ad will only go to people who fit all the descriptions in both sections, and that usually limits your audience too much.

How Much Do You Want to Spend

Now you need to choose your budget. I do the lifetime budget. That refers to the lifetime/lifespan of the ad. I’ve been generally running $10-20 lifetime budget. Then set your start and end dates. I run ads for about 5 days.

durham fb ad budget

Bidding and Pricing

I “optimize for clicks to website” and “get the most website clicks at the best price” and “run ads all the time” and delivery type standard.

Create Your Ad

It asks “How do you want your ad to look.” Although the “multiple images in one ad” is interesting, let’s make it simple now, and choose “a single image”

Then it asks “What creative would you like to use”. Choose “select images”. It will automatically upload some pictures from your website, but if those aren’t the ones you want to use, you can delete them, and upload anything you want. You can choose multiple pictures, and it will randomly choose one whenever it runs an ad, so if you don’t have a single favorite picture, that’s a fine option. You can “crop” the images to make sure they’re displaying the part of the photo you want to display.

durham fb ad ad-design

In the Text and Links section:

  • On Connect Facebook page, make sure it lists the correct page
  • On headline and text, it may have auto-filled the title and description from your webpage. You’ll almost always want to change this for an ad to make them as appealing as possible.
  • Headline: usually this would be the name of your program (25 characters or less)
  • Text: Wants to be a clear, engaging overview of your program, with perhaps an invitation (join us, check us out, be a part, etc.). You’ve only got 90 characters, so make them count.
  • Note: On the mobile ads, all that appears is: name of your Facebook page / text / headline / web address. So, make sure that the text works well in this context as well as on desktop news feed. (Many more people will see your mobile ad than your desktop ad!! 48% of Facebook users access it ONLY on mobile devices; many more use a mixture of mobile and desktop) So, I make sure it includes location, age group – those sorts of key information that tell viewers whether the ad applies to them.
  • Call to Action: Choose one. I like “learn more” or “sign up”
  • Click “show advanced options”, and it will give you a box for news feed link description. You definitely want to use this, as it gives you an opportunity to provide lots more info for those viewing it on a desktop. It’s 200 characters. I use it for a longer summary of the program.
  • Once you’ve done this, make sure you look at the previews for desktop feed, mobile devices, right column display and mobile apps to make sure you’re happy with all versions of the ad.
  • Then place order.

What results will you get?

It’s really hard for me to predict that. It depends on what market you’re trying to reach, what your product is and so on. I also think that what results I’m getting in August of 2015 may be different in August 2016. I just don’t know how yet. Facebook ads are somewhat new, they’re REALLY easy, really cheap, and get good results. So, a lot of people are using them right now. If that use increases so much that Facebook users get sick of ads, we might see a backlash, and worse results, or Facebook may continue to evolve tools that get even better results. All I can tell you is what I’ve seen with my market, my product, in summer 2014 and 2015.

I’ve been running ads for our program: classes for parents and babies, parents and toddlers, and cooperative preschools. For each audience, I’ve targeted as described in the directions above, with some minor adjustments. For each type of class I spent $10, and had a potential audience from about 2000 – 7000 people. For each of the ads, they’ve been displayed to approximately 800 – 1100 people. The clicks to the website ranged from 8 – 35 per program. Click through rates ranged from 1%. Cost per click ranged from 27 cents to $1.25. So, as an approximation, I figure can get about 15 clicks for $10.

I advertised my blog, More Good Days to a national audience. Married women, age 24 – 44, parents of kids 0 – 3 years old. That’s a potential audience of over a million. I knew I was only going to reach a very small fraction of those. But that was OK… I wanted to reach people all over, under the hope that maybe if someone in Minnesota liked it, she’d tell her friends, and so would someone in New Mexico and so on. I spent $30. Ad displayed to 5200, 79 clicked through. That’s a click-through rate of 1.5%, at a cost-per-click of 38 cents.

I did an ad for our program where instead of setting the goal of what kind of results I wanted to “clicks to website” I chose “Promote your page.” (For some programs, this is a better option than clicks… a click just gets them to look at your website once and take action or not on that day. But if they like your Facebook page, then every time you post something, it appears on their Facebook feed, so you get repeated exposures.) I targeted that ad to expectant parents and parents of kids 0 – 3 in 4 nearby cities. Potential audience of 17,600. I spent $14. Ad displayed to 2443 people (14% of audience). 11 liked the page (my goal), 2 liked the post. That’s a click-through rate of 0.7% and a cost-per-like of $1.20.

I primarily choose ads that are optimized for clicks to website. I find that some of the people who see that ad choose to go to our Facebook page to check us out, and some choose to like the page based on that. In one week of running ads, where our ads were displayed to 11,000 people, we gained 22 likes on our Facebook page as a side effect of those ads.

Setting up your first ad will take you 30 – 45 minutes. It gets faster after that! I can do one in 5 – 10. Try experimenting with one today!

To learn more about online advertising, check out my website at www.janelledurham.com.

Have you had previous experience using Facebook Ads and would like to add some additional information?  Do you think you will give these simple and affordable ad options a try?  Share your experience now or after your first round of ads and let us know how it goes in the comments section below. – SM

About Janelle Durham

Janelle headshotJanelle Durham, MSW, LCCE, has taught childbirth preparation, breastfeeding, and newborn care for 16 years. She trains childbirth educators for the Great Starts program at Parent Trust for Washington Children, and teaches young families through Bellevue College’s Parent Education program. She is a co-author of Pregnancy, Childbirth, and the Newborn and writes blogs/websites on: pregnancy & birth; breastfeeding and newborn care; and parenting toddlers & preschoolers. Contact Janelle at jdurham@parenttrust.org.

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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

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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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