Midwives Don’t Deliver? What's the Catch?

by Melissa Garvey, ACNM Writer and Editor

In preparation to launch the A.C.N.M. Foundation’s online quiz at www.DeliverMyBaby.org, one of the biggest hurdles was choosing a name. Our review panel consisted of midwives around the country of varying ages and practice settings, A.C.N.M. Foundation Board members, and the ACNM communications team. DeliverMyBaby had that snappy ring we were looking for, but there was that word…“deliver.”

Our review team members had opinions both for and against “deliver.” Most midwives prefer saying “I will attend a woman’s birth” or “I will be there to catch a woman’s baby”—not deliver a woman’s baby. It’s a noteworthy distinction, which acknowledges that the woman does the work of birthing the baby.

Midwives have a distinct style of care, and it shows up even in their word choices. Many midwives say they have clients—not patients. Some clients end up needing a cesarean birth—not a cesarean section.

But, of course, there is a flip side when it comes to naming an online quiz. The quiz was made for expectant parents who may have never considered using a midwife as their care provider. What are they most likely to click on: attend, catch, or deliver my baby?

This reasoning is causing some traditional midwifery word preferences, such as "client" and "catch," to take a back seat to more mainstream, commonplace terms of today’s health care scene. As an ACNM communications team member, I prefer the traditional, unique words used by midwives whenever possible and appropriate. I do, however, think there is a time and a place for both “deliver” and “catch.”

What do you prefer? And what do you think about the evolution of how midwives are using these words?

Can We Reduce Premature Birth with Better Communication?

by Eileen Ehudin Beard, CNM, FNP, ACNM Senior Practice Advisor

We are so time conscious in our society. Life in the fast lane frequently requires scheduling out major events. Childbirth is one of the important life events that cannot and should not be scheduled. I wonder if midwives and other health care providers are taking the time to explain why. More specifically, how many women understand how the estimated due date (EDD) is calculated and what constitutes a full-term pregnancy?

Last month, we looked at a study in Obstetrics and Gynecology that analyzed women’s perceptions of full-term birth. And in December, we made note of the rising incidence of premature birth in the United States. I’d like to expand on one aspect of the study authors’ conclusion:

“…with the trend of an increased patient role in medical decision-making, ensuring that women understand the implications of the timing of delivery may be an important component of interventions to reduce the number of elective or semi-elective late preterm and early term deliveries.”

Do women and their families really understand the possible consequences of a preterm delivery? Perhaps we need to spend more time explaining how the EDD is calculated and why it is important to avoid delivery before 39 weeks.

Midwives need to take time to explain that the 40 weeks used to calculate EDD is 9 months because there are 4½ weeks in most months. We need to explain that for the EDD to be most accurate, a woman must be certain of her last normal menstrual period and have a regular 28-day cycle. Even then, EDD is an estimate. Women are not machines and don’t always have the same cycle. The EDD can often be unreliable, which may unwittingly lead to early induction of what looks like a full-term pregnancy on paper—more reason to avoid unnecessary induction.

Since many women and obstetricians are “scheduling delivery’” before 40 weeks, the picture can get pretty fuzzy for women. Early delivery may appear safe since it happens so often. There are many important issues to discuss on the initial prenatal visit, but I wonder if we breeze over the issue of what constitutes preterm delivery and how the EDD is calculated. We need to give this topic the careful explanation that it deserves. It could turn out to be a key intervention that helps decrease the incidence of late preterm and early term delivery.

Quality of US Maternity Care on Track to Improve With or Without Legislation

by Melissa Garvey, ACNM Writer and Editor

As you may have already heard from ACNM Federal Lobbyist Patrick Cooney, health reform legislation has reached a startling, disappointing halt. We are not sure what this means for the numerous provisions that would increase access to midwifery and birth centers.

In the face of this development, I’d like to take time out to raise everyone’s spirits and highlight a few exciting initiatives that are moving full steam ahead, whether or not health reform legislation passes soon. Each initiative has the same mission as many of the Senate’s proposed health reform provisions: to improve the quality of maternity care for US women.

1. The March of Dimes released a webcast edition of its Symposium on Quality Improvement to Prevent Prematurity, which ACNM cosponsored last October. Registration is free and gives you access to information from expert speakers, including ACNM President Melissa Avery and A.C.N.M. Foundation Secretary Nancy Jo Reedy.
   
   
2. This week, the Joint Commission issued an alert on preventing maternal deaths during and after pregnancy. The alert points out that maternal mortality rates in the United States are not declining, and may be on the rise. Even more disturbing is that for every mother who dies from pregnancy-related causes, 50 more mothers will become very ill due to significant problems during pregnancy, labor, and delivery. This isn’t good news, but it does promote awareness and proposes steps toward improvement. Lamaze International has taken this opportunity to issue its own set of recommendations for preventing maternal deaths.
   
   
3. Childbirth Connection has released findings from its 2009 Transforming Maternity Care Symposium. This was a major effort by numerous stakeholders in US maternity care, including ACNM, the American College of Obstetricians and Gynecologists (ACOG), and the Midwives Alliance of North America (MANA), with the purpose of transforming US maternity care into a wellness, woman-centered model. Their vision document, blueprint for action, and more are now available. I suspect midwife Amy Romano, CNM, will weigh in with more commentary at Science and Sensibility soon.
   

These are just three initiatives among many in progress toward improving the quality of US maternity care. What other initiatives and projects are you keeping an eye on or participating in?

How to Help Women and Children in Haiti

by Eileen Ehudin Beard, CNM, FNP
ACNM Senior Practice Advisor

The tragic situation in Haiti continues to send shock waves around the world. When you look at a picture of a young mother holding her newborn in the midst of chaos, you can’t be depressed about the economy or your 401K anymore. Those things don’t matter.

The knee-jerk reaction is to drop everything and hop a plane to Haiti, but, as we’ve all heard, that’s not the right thing to do in a disaster situation. Unless you prepare yourself mentally and physically you’ll be in a similar situation to the people you’re trying to help.

Many organizations are taking immediate action to help and are preparing to send teams of volunteers to Haiti when the time is right. Last week I participated in a conference call with representatives from ACNM, the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). We agreed on the need for a particular focus on ensuring that women, infants, and children have access to the services that they need in camps and tent cities, and that they are protected from violence and sexual assault. The Cochrane Collaboration has published Evidence Aid, a Web site of up-to-date, relevant evidence to help people trying to cope with the aftermath of the disaster. Midwives for Haiti is organizing volunteer teams of health professionals to go to Haiti over the coming weeks and years that this country will need help.

If you are not trained to be a responder in a disaster, you can still help Haiti by donating money to a trusted organization. The Better Business Bureau has several resources and tips for choosing a legitimate charity. You can also view ratings of various organizations through Charity Navigator at www.charitynavigator.org. Please stay tuned to the Global Health Council for continuing updates on the situation in Haiti and a list of organizations that need your financial support.

Restricting food and drink in labor is not justified

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

Listen to this great podcast about the new Cochrane review showing that the policy of restricting food and drink in labor is not justified. It’s a nice summary of how and why the research was conducted. In addition, I particularly liked these tidbits:

1. Rather than asking “is eating and drinking in labor safe?” the reviewers turned the question around to ask “is there any justification for restricting food and drink in labor?” This is not just a nuance. How a researcher asks a question can influence both the findings and the conclusions, as I have discussed previously.

2. Since they identified no benefits (nor harms) of restricting oral intake, the reviewers concluded that women should be able to eat and drink according to their preference.

3. It was her experience teaching antenatal classes that led one of the reviewers to study food and drink in labor. Listening to women’s concerns and anxieties made her question the justification for restricting women’s autonomy in labor.

In perusing the web to try to find an image for this post, I came across this heartbreaking picture of a woman begging for a drink in labor and being told no. (I’d post it here but it is copyrighted.) When the researchers said they found “no harms” of restricting food and drink in labor, they pointed out that no one had actually studied women’s preferences or experiences. I’m heartened to know that some of those who tout evidence based care are beginning to recognize that emotional distress is itself a harm. If there is no counterbalancing benefit, the conclusion is clear.

Attention, ACNM Members! Who Will You Choose to Lead Your Profession?

We interrupt our regularly scheduled posts to remind ACNM members that the 2010 election forum is live now through February 5. This is your chance to choose who will lead the profession of midwifery into the future. Now is the time to pose questions to the candidates. You can even read their responses to other members’ questions.

Up for election are:

• Region II representative
• Region III representative
• Treasurer
• Two members for the Nominating Committee
  

Show that midwifery matters to you by reading each candidate’s bio, and then swing by the forum to find out more. Voting begins February 10. Will you be ready to cast an informed vote for the future of midwifery?

Are consumers at the bottom of the evidence pyramid?

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

I have argued (here, here, and here) that strategies that involve increased participation by women and families in maternity care hold major potential for improving our rather dismal maternal and infant health outcomes.

A study reported in the current issue of The International Journal of Gynecology & Obstetrics highlights a major obstacle to implementing consumer-led health strategies: lack of comparative effectiveness research supporting their use.

The researchers analyzed all Cochrane Systematic Reviews addressing pregnancy, childbirth, newborns, or children up to age five. They categorized each systematic review by the level of consumer involvement versus health care system involvement the intervention required. They found that 62% of Pregnancy and Childbirth reviews, 94% of Neonatal reviews, and 71% of Children’s Health reviews addressed interventions that involved no consumer participation, such as cesarean surgical techniques, or intensive care treatments. Interventions that could be implemented within the community (such as nutritional programs) or that involved woman- or family-centered health care (e.g., labor support techniques, family-centered pediatric approaches) were far less likely to be studied. The researchers concluded:

The vast majority of research is performed on interventions that are solely in the realm of the providers. Maternal and child health research needs to be directed toward innovative interventions involving consumer participation, particularly those that can be implemented in middle- and low-income countries where the accessibility and quality of the health systems are poor.

This study highlights one of the major systemic biases we see in research. When so much of our research comes from academic medical institutions, what happens outside of those institutions – even if it has a far greater potential impact on the health and wellbeing of the institution’s beneficiaries – doesn’t get studied much. Nor do interventions that can happen within institutions (e.g. doula support in labor) but challenge the institutional hierarchy, which too often puts patients and families at the bottom.

One area in which we need far more research is perinatal education. Few studies evaluate strategies to educate, engage, and inform women. In addition, according to a review in the current issue of The Journal of Perinatal Education, even when researchers do evaluate perinatal information giving and education, they tend to evaluate approaches that accommodate medical concepts of efficiency (e.g. leaflets or DVDs) rather than meet women’s own stated needs and preferences (e.g. opportunities to discuss options in depth with their care providers or in small peer groups facilitated by knowledgeable professionals).

Pregnant women and new mothers are avid seekers of health information – online, in childbirth education classes, from health care providers, and in their communities. This natural impulse to take responsibility for their health, connect with other women, and engage in their care is currently being overwhelmed by the application of one-size-fits-all maternity care policies, including mandated cesarean surgery for women with risk factors or more subtle threats to autonomy like restricting mobility, denying access to food and drink, and excluding family members and other support people from care settings.

Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming these barriers to safe, effective care. In fact, it sometimes seems to be the only force driving meaningful change. Fifty years ago, the American Society for Psychoprophylaxis in Obstetrics (now Lamaze International) helped lead a charge to let fathers into the delivery room and challenged the harmful, demeaning childbirth routines that prevailed as standard practice. Just last month, CNN reported the happy outcome for a woman who avoided cesarean surgery she did not need or want. In advocating for her own care, she has inspired a generation of other women facing vaginal birth bans in their own communities.

Consumers are the least powerful contingent in the health care system, even though our knowledge, attitudes and actions could be the most important influence on our own health and safety. It’s time for major paradigm shifts in research, policy, and practice.

References:

Belizán, J. M., Belizán, M., Mazzoni, A., Cafferata, M. L., Wale, J., Jeffrey, C., et al. (2010). Maternal and child health research focusing on interventions that involve consumer participation. International Journal of Gynecology & Obstetrics, 108(2), 154-155.

Nolan, M. L. (2009). Education and information giving in pregnancy: A review of qualitative research, The Journal of Perinatal Education, 18(4), 21-30.