Tuesday, July 28, 2009

ACOG Revises Labor Induction Guidelines

Midwives are applauding the American College of Obstetricians and Gynecologists (ACOG) latest revision to their labor induction guidelines. The new ACOG practice bulletin recommends avoiding labor induction before week 39 of pregnancy—an improvement over the previous 37-week recommendation.

This comes on the heels of more good news: a recent study at Brigham and Women’s Hospital in Boston found that 10-year episiotomy rates have steeply declined, thanks to peer pressure to stop performing the procedure as well as significant research on the topic. A Medscape article also says that researchers acknowledge "several other contributing factors, including long-standing CNM service in hospital-based practice, and the addition of CNMs to Harvard Vanguard Medical Associates in 1990."

Midwives may be blue in the face from their decades of trumpeting the need for judicious use of interventions, but it looks like their music has not fallen on deaf ears.

Thursday, July 23, 2009

Denis Walsh, mommy wars, and coming together On Common Ground

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

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate. I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.

Introducing Science and Sensibility

Blogger Amy Romano, CNM, and Lamaze International have graciously agreed to share their posts from Science and Sensibility with Midwife Connection readers. Check back for periodic Science and Sensibility posts that are of interest to midwives and midwifery fans.

Friday, July 17, 2009

Nurses Stand with Obama; Are Midwives Next?

by Dawn Durain, CNM, ACNM Vice President

I was trying to find some news coverage on the Sonia Sotomayor hearings on Wednesday afternoon, when suddenly there was President Obama on the White House steps surrounded by women! This being an atypical sight, I quickly unmuted. As it turned out, the people accompanying the president were mostly nurses and members of the Congressional Nursing Caucus—nurses in the Rose Garden! Nurses were being praised by the president for their dedication, ability to convey complex information to patients, and skills in caring for women in labor and their nervous husbands—all of this from the personal experiences of President Obama no less.

The occasion of the speech was, of course, to mark a significant step by Congress toward health care reform. I encourage you to read the Senate and House legislation and the president’s speech for yourself. I find the recognition of the work of nurses refreshing—more refreshing than the recent spate of TV shows featuring nurses for sure! I found myself hoping for the impossible though. Would the president mention nurse-midwives when he spoke of his experiences when his daughters were born? He didn’t. Would he mention the importance of nurse practitioners, certified nurse-midwives (CNMs), and certified midwives (CMs) as primary care providers when he spoke of the need for coordinated health care? He didn’t do that either. But, the legislation he referenced does, thanks to the hard work of our ACNM staff and midwives around the country who are talking and talking and talking to their representatives in Congress. Wednesday felt like a giant step forward. And maybe next time the White House will invite a midwife to the Rose Garden!

On a personal note, I’d like to give a shout-out to Keisha Walker, one of the nurses President Obama introduced who was there with him. She is a graduate of the University of Pennsylvania Graduate School of Nursing and worked on two projects in my Public Policy class at UPenn. She was passionate about nurses being involved in the political process and about the ability of nurses to have an impact on reproductive health care policy. She is currently at Johns Hopkins as a nurse researcher in their MPH program and clearly still involved in health care policy. Way to go, Keisha! Who is next in line to talk to the president about midwifery?

Wednesday, July 8, 2009

WRA Reminds G8 to Pay Attention to Moms

As world leaders come together at the G8 meetings in Italy this week, the White Ribbon Alliance (WRA) has launched a new video and an Atlas of Birth to draw attention to the problem of maternal death during childbirth.

According to WRA, maternal death is the greatest health inequity of the 21st century. Every minute, a woman dies while giving birth. In fact, more women die in the developing world from pregnancy than from any other cause.

Earlier this week, certified nurse-midwife Anne Hyre, director of the ACNM Department of Global Outreach, joined WRA delegates to present a petition to the US Ambassador-at-Large for Global Women’s Health Issues from millions of health care workers urging action at the G8. What can you do to help? Join WRA (it’s free!), and remind world leaders of their promise to correct the scandalous state of global maternal health. Visit the White Ribbon Alliance online to learn more about how you can take action for the cause.

Image source: White Ribbon Alliance

Left to right: Catharine Taylor (WRA Board Member & Director of Maternal, Child Health and Nutrition at PATH); Anne Hyre (Director of Global Outreach at the American College of Nurse-Midwives); Betsy McCallon (Deputy Director of White Ribbon Alliance); Melanne Verveer (U.S. Department of State's Ambassador-at-Large for Global Women's Issues); Rachel Vogelstein (U.S. Department of State, Senior Policy Advisor); Jen Klein (U.S. Department of State).

Thursday, July 2, 2009

CNM/CM Medicare Reimbursement Legislation Included in House Health Reform Bill

Senate Medicare bill (S. 662) has 18 co-sponsors and counting!
by Laura Jenson, CNM, MS

So, the best thing about making that first phone call to my representative’s health legislative aide was finding out how easy it is. Sure, I had made quick phone calls in the past to legislators’ offices asking that they support this or that bill, my zip code is 60623, OK, thank you very much, bye! But I had never phoned a health legislative aide (or “health LA” if you want to sling around some jargon) with the intention of having an in-depth conversation about legislation until this winter . . .

When I first spoke with the health LA for my representative, Luis Gutierrez, about H.R. 1101, she wasn’t even totally sure what a midwife was. I honestly kind of stumbled through that conversation and then followed up with a couple of e-mails with letters of support for the legislation from various organizations like ACOG, the ANA, the National Perinatal Association, and the National Rural Health Association. I called her back a couple of times to check in, and then to my great surprise, Rep. Gutierrez’s name showed up a few weeks later on the co-sponsor list for the bill! (Love www.opencongress.org/ – you can get loads of information about a bill; the old standby, http://thomas.gov/ is good, too). It was such a great feeling to see that my little amount of work made a difference, and now I’ve got a new little hobby.

Seriously. Once I started poking around looking for resources, I found that most everything you need is online, and ACNM has put it all in one place. You can go here to find information about the Medicare equitable reimbursement issue that’s so important right now, especially because of the health care reform legislation that’s being drawn up. If you want to find out who your elected officials are, just go here. (I had to go to the USPS site first to find my four-digit zip code extension to figure out who my one representative was.) There are also loads of people on the ACNM Government Affairs Committee (or the “GAC”) who would love to help with any questions you have about this process—e-mail me at laurajenson@gmail.com if you’re interested in finding out who’s in your region.

Why get involved? Because more phone calls means more legislators signing on as cosponsors, and more co-sponsors means our bill has a better chance of being attached to some larger health care legislation. The Medicare reimbursement issue is a top agenda item right now—let‘s make this happen! The legislation has already been included in the House health care reform package (go team!), and now it’s important that it be included in the Senate version. If you’ve read this far, how about taking a couple more minutes to give your Senators a call? Go here to learn more.