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Celebrate International Day of the Midwife! ACOG Calls for Universal ICM Standards

May 5th, 2015 by avatar

Lamaze and Midwives IDM 2015Lamaze International and Science & Sensibility join with other partners around the world to celebrate International Day of the Midwife.  This global celebration is observed every year on May 5th and was officially recognized by the International Confederation of Midwives in 1992. (Read Judith Lothian’s report from the 2014 ICM Congress here.) This year’s theme is “The World Needs Midwives Today More Than Ever.”

Key midwifery concepts and model of care

Key midwifery concepts as defined by the International Confederation of Midwives describe the unique role that midwives have in providing care to women and families:

  • partnership with women to promote self-care and the health of mothers, infants, and families;
  • respect for human dignity and for women as persons with full human rights;
  • advocacy for women so that their voices are heard and their health care choices are respected;
  • cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
  • a focus on health promotion and disease prevention that views pregnancy as a normal life event;
  • advocacy for normal physiologic labour and birth to enhance best outcomes for mothers and infants.  (Fullerton, Thompson & Severino, 2011).

ACOG advocates universal standards

http://www.flickr.com/photos/eyeliam/

http://www.flickr.com/photos/eyeliam/

On April 20, 2015, the American College of Obstetricians and Gynecologists (ACOG) endorsed the International Confederation of Midwives education and training standards and suggested that this criteria be adopted as the minimum requirements for midwifery licensure in the United States.  ACOG “advocates for implementation of the ICM standards in every state to assure all women access to safe, qualified, highly skilled providers.” In the same document, ACOG calls for a single midwife credential.  Currently, in the USA there are certified nurse midwives (CNM), Certified Midwives (CM) and Certified Professional Midwives (CPM) and they all have different core competencies and educational requirements.  You can read the entire ACOG statement here.  This document is meant to accompany their Levels of Maternal Care statement that I wrote about in a previous blog post.  Both of these recent statements signify a recognition that families have choices about the type of health care provider they receive their maternity care from and that more and more families every year are choosing midwifery.

Five interesting facts about midwifery

  1. There are approximately 26,000 midwives in the USA.  This number includes Certified Nurse Midwives, Certified Midwives and Certified Professional Midwives.
  2. Midwives practice and catch babies in hospitals, birth centers and in families’ homes.
  3. Midwives who are educated and regulated to international standards can provide 87% of the essential care needed for women and newborns. (UNFPA, 2014)
  4. 11.3% of all babies born in the USA in 2013 were caught by midwives (Martin, Hamilton, Osterman, et al. 2015)
  5. Approximately 0.6% of all midwives in the USA are male. (Pinkerton, Schorn, 2008)

Summary

How are you celebrating International Day of the Midwife in your community and in your classes?  Have you reached out to the midwives in your community and let them know that they are appreciated?  Take a moment to do so and join Lamaze International in thanking midwives for helping families have safe and healthy  births.

References

Fullerton, J. T., Thompson, J. B., & Severino, R. (2011). The International Confederation of Midwives essential competencies for basic midwifery practice. An update study: 2009–2010. Midwifery, 27(4), 399-408.

Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2013. National vital statistics reports; vol 64 no 1. Hyattsville, MD: National Center for Health Statistics. 2015.

Pilkenton, D., & Schorn, M. N. (2008). Midwifery: a career for men in nursing.Men in Nursing Journal, 3(1), 32.

UNFPA. The State of the World’s Midwifery 2014. A Universal Pathway. A Woman’s Right to Health. United Nations Population Fund, New York; 2014

Breastfeeding, Home Birth, Midwifery, Uncategorized , , , , , , , , ,

ACOG & SMFM Standardize Levels of Maternal Care to Improve Maternal Morbidity & Mortality

February 5th, 2015 by avatar

obThe American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine released their second joint consensus statement on January 22nd, 2015. This consensus statement, Levels of Maternal Care is published in the February 2015 issue of Obstetrics and Gynecology (Green Journal).

What are the objectives of this statement?

The objectives of the statement, Levels of Maternal Care, is fourfold:

  1. To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States
  2. To develop standardized definitions and nomenclature for facilities that provide each level of maternal care
  3. To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion
  4. To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services

With a system in place that defines the levels of care, it will be clear when a transfer of care is deemed necessary to a facility that is better able to provide risk appropriate care to those women who need a higher level of maternity care.  This will improve maternal outcomes and reduce maternal morbidity and mortality.

Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country. – Sarah J. Kilpatrick, MD/PhD, Lead Author

The USA ranks 60th in maternal mortality worldwide (Kassebaum NJ, 2014) and while some states  have established programs for a striated system of maternity care separate from the needs of the newborn, designations of what level of maternal care center will best serve the mother is not consistent and and creates confusion with a lack of uniform terms and definitions. Data supports better outcomes for mothers when certain maternal complications are handled in a facility deemed most appropriate for that condition.

Many years ago, thanks to the efforts of the March of Dimes, a similar system of levels of neonatal care was designated for the newborn, with each level having clear definitions of the type of services they were best able to provide, how they should be staffed and when a baby was to be transferred to a higher level facility based on newborn health conditions.  This newborn level of care system improved outcomes for babies in the USA, as they were assigned to a location that could best meet their medical needs. The levels of maternal care compliment the levels of care for the neonate, but should be viewed independently from the neonatal designations.

What are the levels of maternal care?

The statement defines five levels of care – Birth Center, Level I (Basic Care), Level II (Specialty Care), Level III (Subspecialty Care) and Level IV (Regional Perinatal Health Care Centers).

For each level, there is a definition, a list of capabilities that each facility should have, the types of health care providers that are assumed to be competent to work there and examples of appropriate patients.

Each level requires meeting the capabilities of the previous level(s) plus the ability to serve even more complicated situations until you reach Level IV, suitable for the most complicated, high populations.

The risk appropriate patient deemed suitable for each level takes into account the skills and training of the midwives or doctors who staff that facility and the ability of those individuals to initiate appropriate emergency skills and response times for the patient.  As a woman becomes less and less “low risk”, she will need to have her care transferred to the appropriate level.  This transfer may occur prenatally, intrapartum or during the postpartum period.

Recognition of the out of hospital midwife and the birth center

The consensus statement recognizes the credentials of the Certified Midwife (CM), the Certified Professional Midwife (CPM) and the Licensed Midwife (LM) as appropriate health care providers, along with Certified Nurse Midwives, OBs and Family Practice doctors, for low risk women in out of hospital facilities where those individuals are legally recognized as able to practice.  The low risk woman is defined as low-risk women one with an uncomplicated singleton term pregnancy with a vertex presentation who is expected to have an uncomplicated birth.

The statement also officially recognizes the freestanding birth center as an appropriate place to give birth for low risk women, along with supporting the collaboration of birth center midwives with the health care providers at higher level maternal care facilities.

Clear capabilities and requirements

The statement also outlines the type of staffing requirements to be available for services, consultation, or emergency procedures at each type of facility.

The consensus statement acknowledges that the appropriate level of  care for the baby may not align with the appropriate level of care for the mother.  Care guidelines that have been long established and well determined for the newborn should also be followed.

Consensus statement receives strong support

The consensus statement has been reviewed and endorsed by:

American Association of Birth Centers

American College of Nurse-Midwives

Association of Women’s Health, Obstetric and Neonatal Nurses

Commission for the Accreditation of Birth Centers

The American Academy of Pediatrics leadership, the American Society of Anesthesiologists leadership, and the Society for Obstetric Anesthesia and Perinatology leadership have reviewed the opinion and have given their support as well.

Additionally, the Midwives Alliance of North America was pleased to see this consensus statement and read how the role of out of hospital midwives was addressed.

MANA applauds ACOG’s identification of the need for birthing women to have a wide range of birthing options, from out of hospital settings for low-risk women to regional perinatal centers for families experiencing the most complicated pregnancies. As ACOG states, a wide variety of providers can meet the needs of low-risk women, including Certified Professional Midwives, Certified Nurse Midwives, Certified Midwives, and Licensed Midwives. We strongly concur with the need for collaborative relationships between midwives and obstetricians. Treesa McLean, LM, CPM, MANA Director of Public Affairs

What does this mean for the childbirth educator?

I encourage all birth professionals to read the consensus statement (it is easy to read) to understand the specifics of each level of maternal care.  As we teach classes, we can discuss with our families that there may be circumstances during their pregnancy or labor that require their care to be changed or transferred to a facility that offers the level of maternal care appropriate for their condition. Some of us already work in hospitals that are Level IV while others of us might teach elsewhere. We can help families to understand why a transfer might be necessary, and how to ask for and receive the information they need to fully understand the reason for a transfer of care and what all their options might be.  Families that are prepared, even for the events that they hoped to avoid, can feel better about how their labor and birth unfold.

Thank you ACOG and SMFM for working hard to clarify and bring about uniform standards that can be applied across the country that will improve the outcomes for mothers giving birth in the USA.

Photo source: creative commons licensed (BY-NC-SA) flickr photo by Paul Gillin

References

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004. [PubMed]

Levels of maternal care. Obstetric Care Consensus No. 2. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15.

American Academy of Pediatrics, Childbirth Education, Evidence Based Medicine, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Practice Guidelines, Pregnancy Complications , , , , ,

Thank You Midwives! join Lamaze in Celebrating National Midwifery Week!

October 7th, 2014 by avatar

midwifery week poster 2014Please join Lamaze International and Science & Sensibility as we celebrate National Midwifery Week.  Midwives can and should play an integral part of healthy and safe birth practices here in the United States and around the world. Maternal infant health organizations and consumers alike are now aware that we have reached a tipping point.  Our cesarean rate is too high, the availability of VBAC supportive providers is dismal, the rate of inductions, particularly before 39 weeks is cause for concern, labor augmentations are commonplace and infant mortality – particularly amongst babies of color, in our country puts the United States ranking at an embarrassing 56 amongst all the other countries.

The midwifery model of care offers women and babies care by qualified, skilled health care providers who are experts at normal physiologic birth and meeting the needs of healthy, low risk, pregnant women.  The midwifery model of care respects the shared decision making process between the mother and her health care provider, the importance of the mother’s emotional health as well as her physical health and recognizes pregnancy and birth as part of a woman’s normal lifecycle, rather than an illness or pathological condition.  There is respect for the normal physiological process of birth, and the recognition that when things deviate from normal, collaboration and referral to obstetricians and other specialists is appropriate.  When midwives have the opportunity to care for more healthy low risk women, the United States might start to see some of the dismal statistics reverse, and women and babies will benefit from the new trend.

The American College of Nurse Midwives has created a consumer website, Our Moment of Truth, where women can learn more about midwifery, increase awareness and understanding of the different care options available, make informed choices about the type of care they would like to receive and even find a midwife in their area.  There is also a brochure available – “Normal Healthy Childbirth for Women and Families: What You Need to Know” to download in English and Spanish and share with your students and clients. This document and the ACNM program “Our Moment of Truth” was supported and endorsed by Lamaze International along with many other maternal infant health organizations.

The ACNM has a very nice “Essential Facts about Midwives” info sheet that contains some great statistics and information about Certified Nurse Midwives and Certified Midwives.  Midwives can catch babies in hospitals, birth centers and at home and Medicaid reimbursement is mandated for CNMS/CMs in all 50 states.  In 2012, CNMs/CMs attended over 300,000 births in the U.S.  When you add in Certified Professional Midwives/Licensed Midwives who also attend births at birth centers and homes, the number of midwife attended births goes up even further.

ACNM has created a fun video highlighting midwives and the care they provide.  I have also collected of a few of my favorite videos about midwives that you might enjoy viewing and sharing.

Mother of Many from emma lazenby on Vimeo.

What are you doing to celebrate and honor midwives this week?  Do you talk about the midwifery model of care in your childbirth classes and with your doula clients?  What resources do you like using to help your students understand the scope of practice and benefits of working with midwives?  Share with others in our comments below.

Babies, Childbirth Education, Healthy Birth Practices, Home Birth, Midwifery, Newborns , , , , , , ,

Thank You Midwives! Celebrate International Day of the Midwife Today!

May 5th, 2014 by avatar

2014 day of midwife_600pxMay 5th has been recognized as the International Day of the Midwife since 1992. The International Confederation of Midwives (ICM) supports, represents and works to strengthen professional associations of midwives throughout the world.  The purpose of this day is to “celebrate midwifery and to bring awareness of the importance of midwives’ work to as many people as possible.” There are currently 108 Midwives Associations, representing 95 countries across every continent. ICM is organized into four regions: Africa, the Americas, Asia Pacific and Europe. Together these associations represent more than 300,000 midwives globally.

Midwives play a crucial role in maternal and infant health.  This year’s theme is “Midwives: changing the world one family at a time.” There are many key messages that highlight how midwives around the world are helping mothers, babies, families and communities.  Some of these global messages, backed up by research and investigation include:

  • In midwife-led care, women experience less preterm births, less assisted deliveries and greater satisfaction with care.
  • Midwives change the world by caring for mothers and babies. By caring for them, midwives help ensure that women are healthy, thus contributing to a strong community and economy. When babies survive, they start growing into healthy children and adults.
  • If every childbearing woman received care with a well- educated, adequately resourced midwife, most of maternal and newborn deaths could be prevented.
  •  Investments in midwifery education as well as regulation, provision of infrastructure and information will improve access to midwifery care
  •  Midwifery services are economic and cost effective.
  •  Investment in midwives means commitment to a healthy and wealthy nation.

In many countries around the world, access to maternity care is limited by economics, social status, distance and many other factors.  Trained and qualified midwives can have a significant impact on mortality rates for mothers and babies worldwide.  For healthy, low risk women in developed countries, midwifery care is appropriate, cost effective and provides excellent outcomes for mothers and babies.

Are you or your community doing anything special to honor the midwives who work in your area?  Let us know some of the events planned.

Please join  Lamaze International, Science & Sensibility and myself in celebrating the women and men (yes, men are midwives too!) who serve as midwives to our partners, our wives, our sisters, our friends, our daughters and granddaughters all around the world.  Take a moment to thank them for their hard work and the gentle care they provide to birthing women and families.  You may want to send a customized “International Day of the Midwife” ecard to your favorite midwife, and  thank them for their contribution to healthy mothers and babies.  I am going to take a few minutes today to thank the midwives in my community for taking good care of families in my area.

Additionally, as an avid reader of books, I thought in honor of the International Day of the Midwife that I would share some of my favorite books that I have read about midwives.  I would love to hear your suggestions for future reading on this topic, as I enjoy the genre and would welcome your reading suggestions in our comments section.

Baby Catcher: Chronicles of a Modern Midwife by Peggy Vincent

Lady’s Hands, Lion’s Heart: A Midwife’s Saga – by Carol Leonard

The Birth House - by Ami McKay

The Midwife of Hope River – Patricia Harman

The Blue Cotton Gown: A Midwife’s Memoir – Patricia Harman

Arms Wide Open: A Midwife’s Journey – Patricia Harman

A Midwife’s Story  – Penny Armstrong and Sheryl Feldman

Orlean Puckett: Life of a Mountain Midwife - Karen Cecil Smith

Monique and the Mango Rains: Two Years with a Midwife in Mali - Kris Holloway

The  Midwife: A Memoir of Birth, Joy and Hard Times – Jennifer Worth

Call the Midwife: Shadows of the Workhouse – Jennifer Worth

Call the Midwife: Farewell to the East End – Jennifer Worth

A Midwife’s Tale: The Life of Martha Ballard, Based on her Diary, 1785-1812 – by Laura Thatcher Ulrich

Laboring: Stories of a New York City Hospital Midwife  by Ellen Cohen

The Midwife’s Apprentice – by Karen Cushman

Listen to Me Good: The Story of an Alabama Midwife – by Margaret Charles Smith

Babies, Home Birth, Maternal Mortality, Maternal Mortality Rate, Midwifery , , , ,

The Best Practice Guidelines: Transfer from Home Birth to Hospital – Collaboration Can Improve Outcomes

April 17th, 2014 by avatar

 By Lawrence Leeman, MD, MPH and Diane Holzer, LM, CPM, PA-C

© http://www.mybirth.com.au/

© http://www.mybirth.com.au/

On Tuesday, readers learned about the history and objectives of the Home Birth Consensus Summit, a collective of stakeholders, whose goal is to improve maternal infant health outcomes and increase collaboration between all those involved in serving women who are planning home births.  The interdisciplinary collaboration that occurs during the Summits brings representatives from many different perspectives to the table in order to improve the birth process for women and babies. You may want to start with the post “Finding Common Ground: The Home Birth Consensus Summit” and then enjoy today’s post on the Home Birth Consensus Summit’s just released “The Best Practice Guidelines: Transfer from Home Birth to Hospital.”  Today’s post was written by Dr. Lawrence Leeman and Midwife Diane Holzer, two of the members on the HBCS Collaboration Task Force, a subgroup tasked with developing these transfer guidelines.  Share your thoughts on these new guidelines and your opinion on if you feel that they will improve safety and outcomes for mothers and babies. – Sharon Muza, Community Manager, Science & Sensibility

Leea Brady was a second-time mother whose first baby was born at home. One day past her due date, an ultrasound revealed high levels of amniotic fluid, which can pose a risk during delivery. Although she planned to have her baby at home, on the advice of her midwife, Leea transferred to her local hospital.

“I knew that we needed to be in the hospital in case anything went wrong,” said Brady. “I was really surprised when I arrived and the hospital staff told me they had read my birth plan, and they would do everything they could to honor our intentions for the birth. My midwife was able to stay throughout the birth, which meant a lot, because I had a trusting relationship with her. She clearly had good relationships with the hospital staff, and they worked together as a team.”

A recent descriptive study (Cheyney, 2014) reports that about ten percent of women who plan home births transfer to the hospital after the onset of labor. The reason for the overwhelming majority of transfers are the need for labor augmentation and other non-emergent issues. Brady’s transfer from a planned home birth to the hospital represents the ideal: good communication and coordination between providers in different settings, minimizing the potential for negative outcomes.

However, in some communities, lack of trust and poor communication between clinicians during the transfer have jeopardized the physical and emotional well being of the family, and been frustrating for both transferring and receiving providers. Lack of role clarity and poor communication across disciplines have been linked to preventable adverse neonatal and maternal outcomes, including death.(Guise, 2013,Cornthwaite, 2008) With optimal communication and cooperation among health care providers, though, families often report high satisfaction, despite not being in the location of their choice.

Recent national initiatives have been directed at improving interprofessional collaboration in maternity care.(Vedam, 2014) This is why a multi-disciplinary working group of leaders from obstetrics, family medicine, pediatrics, midwifery, and consumer groups came together to form a set of guidelines for transfer from home to hospital. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital are being officially launched today by the Home Birth Consensus Summit and will be highlighted at a series of upcoming presentations at conferences and health care facilities.

The authors of the guidelines, known as the Home Birth Summit Collaboration Task Force, formed as a result of their work together at the Home Birth Summits.

© http://flic.kr/p/3mcESR

© http://flic.kr/p/3mcESR

“Some hospital based providers are fearful of liability concerns, or they are unfamiliar with the credentials and the training of home birth providers,” said Dr. Timothy Fisher, MD, MS, at the Hubbard Center for Women’s Health in Keene, NH and an Adjunct Assistant Professor of Obstetrics and Gynecology, Dartmouth Medical School. “But families are going to choose home birth, for a variety of cultural and personal beliefs. These guidelines are the first of their kind to provide a template for hospitals and home birth providers to come together with clearly defined expectations.”

The guidelines provide a roadmap for maternity care organizations developing policies around the transfer from home to hospital. They are also appropriate for transfer from a free-standing birth center to hospital.

The guidelines include model practices for the midwife and the hospital staff. Some guidelines include the efficient transfer of records and information, a shared-decision making process among hospital staff and the transferring family, and ongoing involvement of the transferring midwife as appropriate.

“When the family sees that their midwife trusts and respects the doctor receiving care, that trust is transferred to the new provider,” said Dr. Ali Lewis, a member of the HBCS Collaboration Task Force. She became involved with the work of the committee in part because of her experiences with a transfer that was not handled optimally. “It is rare that transfers come in as true emergency. But when they do, if the midwife can tell the family she trusts my decisions, then I can get consent much more quickly, which results in better care and higher patient satisfaction.”

The guidelines also encourage hospital providers and staff to be sensitive to the psychosocial needs of the woman that result from the change of birth setting.

“When families enter into the hospital and feel as if things are being done to them as opposed to with them, they feel like a victim in the process,” said Diane Holzer, LM, CPM, PA-C, and the chair of the HBCS Collaboration Task Force. “When families are incorporated in the decision-making process, and feel as if their baby and their body is being respected, they leave the hospital describing a positive experience, even though it wasn’t what they had planned.”

The guidelines are open source, meaning that hospitals and practices can use or adapt any part of the guidelines. The Home Birth Summit delegates welcome endorsements of the guidelines from organizations, institutions, health care providers, and other stakeholders.

References

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(4), 571-581.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health.

Guise, J. M., & Segel, S. (2008). Teamwork in obstetric critical care. Best Practice & Research Clinical Obstetrics & Gynaecology, 22(5), 937-951.

Vedam S, Leeman L, Cheyney M, Fisher T, Myers S, Low L, Ruhl C. Transfer from planned home birth to hospital: inter-professional collaboration leads to quality improvement . Journal of Midwifery and Women’s Health, November 2014, In Press.

About the Authors:

leeman larry headshotDr. Lawrence Leeman, MD, MPH/Medical Director, Maternal Child Health, received his degree from University of California, San Francisco in 1988 and completed residency training in Family Medicine at UNM. He practiced rural Family Medicine at the Zuni/Ramah Indian Health Service Hospital for six years. He subsequently earned a fellowship in Obstetrics. He is board certified in Family Medicine. He directs the Family Medicine Maternal and Child Health service and fellowship and co-medical director of the UNM Hospital Mother-Baby Unit. Dr. Leeman practices the family medicine with a special interest in the care of pregnant women and newborns. He is Medical Director of the Milagro Program that provides prenatal care and maternity care services to women with substance abuse problems. Dr. Leeman is a Professor in the Departments of Family & Community Medicine, and Obstetrics and Gynecology. He is currently the Managing Editor for the nationwide Advanced Life Support in Obstetrics (ALSO) program. Areas of research include rural maternity care, pelvic floor outcomes after childbirth, family planning, and vaginal birth after cesarean (VBAC). Clinic: Family Medicine Center

Diane Holzer head shotDiane Holzer, LM, CPM, PA-C, has been a practicing midwife for over 30 years with experience in both home and birth center. She was one of the founding women who passionately created an infrastructure for the integration of home birth midwifery into the system. She sat on the Certification Task Force which led to the CPM credential and also was a board member of the Midwifery Education and Accreditation council for 13 years. She served the Midwives Alliance of North America on the board for 20 years and is the chair of the International Section being the liaison to the International Confederation of Midwives. Diane is the Chair of the Collaboration Task Force of the Home Birth Summit and currently has a home birth practice and works as a Physician Assistant doing primary health care in a rural Family Practice clinic.

Babies, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Practice Guidelines, Transforming Maternity Care , , , , , , , ,

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