Wednesday, December 23, 2009
Thursday, December 17, 2009
An interesting study in the December issue of Birth explores American nurse-midwives’ attitudes toward planned homebirth and their impact on a woman’s choice of birth site. The findings suggest that, as a group, nurse-midwives have a “moderately favorable” attitude about planned homebirth and that their education and practice experiences may greatly influence their patients’ maternity care choices.
Factors that positively influenced nurse-midwives’ attitudes were clinical and educational experiences with planned homebirth, exposure to planned homebirth, and younger age. The study also identified barriers that had a negative impact on attitudes toward planned homebirth, including financial and time constraints, inability to access medical consultation, and fear of peer censure.
As health care providers, we sometimes underestimate the influence we have on women. When I was seeing patients at the Baltimore Birth Center, I was acutely aware of how my opinion could influence a patient’s choices. The way I presented out-of-hospital birth to my patients was a big factor in their decisions. Of course, my goal was to educate patients and assist them in the decision-making process. I always wanted women and their families to make the choice that was best for them. But when I read the study in Birth, it made me revisit the issue of the attitudes we have and whether we are objective in the information that we present to women. When I was primarily working at the birth center, I don’t ever remember offering the option of homebirth unless the woman specifically requested information. Was I doing my patients and their families a disservice?
It’s worth noting that many certified nurse-midwives (CNMs) and certified midwives (CMs) have a strongly favorable attitude toward planned homebirth. According to CDC data, CNMs/CMs attended nearly 4,000 homebirths in 2006. But as a group, we have some work to do to decrease the barriers to homebirth practice and to seriously examine our personal views. If we are not comfortable with out-of-hospital birth, our patients will not view it as a viable option. And true informed choice cannot happen if a woman is not aware of all her options.
Wednesday, December 16, 2009
Have you ever taken one of those online quizzes that matches you with the political candidate who most shares your views? So many people are surprised to find they match with a political candidate they never considered. It’s easy to cast a vote in favor of the candidate who gets the seal of approval from family members, friends, or the media rather than to objectively evaluate your beliefs and the candidate’s stances. Unfortunately, many women choose their birth care provider in the same manner.
That’s why I’m thrilled about a new online quiz that helps women objectively evaluate the type of care provider who will best meet their needs. Created by ACNM and Jones Public Affairs, Inc. and funded by the A.C.N.M. Foundation, Inc., the quiz was in development for more than a year and has passed the careful scrutiny of a panel of maternity care experts. This is more than your average purely-entertainment-factor online quiz.
The name of the URL that hosts the quiz, www.delivermybaby.org, was chosen to appeal to a broad range of childbearing-aged women (hat-tip to ACNM Graphics Designer Simone Christian!). Our hope is that millions of women will take the quiz and be surprised to find they match with a midwife. Here are some ways you can help spread the word:
- Post the link on your website or blog.
- Share the link on your social networking profiles, including Facebook, Twitter, and any other site where you’re active.
- Take the quiz at www.delivermybaby.org and if you’re impressed with your experience, consider writing your own blog post about it.
Thursday, December 10, 2009
Comments are what make a blog come to life. A blog without comments is no different than a magazine article, an online newsletter, or a plain old webpage. That’s why every comment we receive at Midwife Connection puts a smile on my face. Long, short, positive, negative—I love them all. Here are a few of my favorites.
About Should a Pharmacist be Able to Refuse to Fill a Prescription?
“But to the pharmacists in question, it is forcing them to participate in the murder of another human. Which should not be forced on anybody.”
“I agree with you, Amie. I cannot understand asking an individual to drive across town, to another town, to another county, etc... to have access to birth control.”
About What Mammography and Continuous Electronic Fetal Heart Rate Monitoring Have in Common
“My mom died from a VERY aggressive breast cancer at 47 yrs old. She was diagnosed at 42. Cancer is not akin to low risk pregnancy. I think women should start screenings in their 30's.”
About It’s Time to Fight for Preemies
“My son was born at 34 weeks, suffered from undetected chronic brain bleeds, and will now never live completely independent. I get tired of the blase attitude towards these late preemies (34-37wks). They are likely to do better but bad things can still happen.”
About BJOG Study Finds Homebirth as Safe as Hospital Birth
“What an elegant study! And unsurprising conclusion. It will be nice when practice begins to catch up with the evidence. Thank you for posting this midwife-friendly piece.”
-home birth CNM
Wondering what makes a good blog comment? Try listening to Grammar Girl’s How to Write a Great Blog Comment.
Tuesday, December 8, 2009
Chair, ACNM Government Affairs Committee
Here in WA State, a prescription refusal issue is working its way through the legal system. Many people are calling it “Refuse and Refer” claiming that it is appropriate for a pharmacy or a pharmacist to refuse to fill prescriptions to which they object on religious or moral grounds, and refer clients elsewhere. A few claim they should be able to refuse with no responsibility to refer at all.
A bit of history: In 2007, at the urging of Governor Christine Gregoire, the WA State Board of Pharmacy adopted two sets of rules governing pharmacy and pharmacist responsibilities to protect patients’ access to lawful prescription medications. Under these rules, a pharmacy can accommodate a pharmacist who objects to dispensing a medication as long as the pharmacy ensures the prescription is filled at that pharmacy in a reasonably timely manner.
Soon thereafter, two pharmacists and a pharmacy challenged these rules, arguing that that filling prescriptions with which they morally disagree violates their constitutional rights. Specifically, the issue was Plan B, as they considered it an abortion-producing drug. However, there are many other drugs that need to be filled in a timely manner, and whose efficacy (and therefore the patient’s health) is compromised by delay, such as drugs treating mental health and HIV.
One could also argue – how is this any different than health care providers being restrained in their practice to follow certain rules? If I am not an advocate of circumcision, should I be required to perform it?
Ultimately, however, I believe this is an access to care issue. I realize that for these pharmacists, it is a religious issue. But should a woman have to drive an extra 50 miles to get her Plan B? Can she afford the extra cost of gas? Will the next pharmacy be open? Will there be another pharmacist who objects there? Will she have an unwanted pregnancy that could have been avoided had the prescription been filled at the objecting pharmacy?
Note: A special thanks to Ann Darlington, CNM, from Seattle for following this issue closely and for keeping us WA State midwives aware and at “the table” of this hot topic discussion.
Thursday, December 3, 2009
Science & Sensibility contributor, Andrea Lythgoe, has a great post up at her own blog. In The Doula Numbers Game, Andrea shows that many of us may be overestimating – and overstating – the beneficial effects of continuous support from doulas. She argues and I agree that using outdated statistics that yield “better” results could compromise our integrity. Moreover, doing so is not necessary to advocate for greater access to doulas.
Data from the Cochrane Systematic Review show more modest effects of doula support, but they still add up to “clinically significant” benefits, greater satisfacation, and no evidence of harm. Maternal-fetal medicine researchers who evaluated the evidence for a variety of obstetric interventions in the November 2008 issue of the American Journal of Obstetrics and Gynecology called doula support “one of the most effective interventions” (p. 446) for improving outcomes. And they did so without being wowed by the inflated early statistics. (They stuck to the Cochrane.)
It can be extremely difficult to look at research objectively. It is human nature to want to cherrypick the research that furthers our cause the most. We may try to find fault with statistics we don’t like and subconsciously ignore problems or limitations of statistics we do. But improving the safety and effectiveness of maternity care requires that we critically analyze the research, which means recognizing limitations and flaws in the studies we agree with and standing behind solid research even when we don’t like the conclusions. We need not worry. Even with a critical lens, research points to a need to radically reform our system to make it more mother-friendly.
Andrea finishes each post in her Understanding Research series with a familiar plea to practice, practice, practice finding and reading research literature. One of the skills we all should practice is to read the studies that seem to contradict our beliefs or biases. Often, these studies are flawed, and spending time reading them helps us hone our ability to spot methodological problems and logical inconsistencies in other research. Other times the research is valid, and we see circumstances where technology and medicine do in fact improve outcomes. Reading these studies can also shed light on important unanswered research questions.
I highly recommend that readers take a look at Andrea’s post for an example of thoughtful critical analysis of statistics on doula support in labor. It is hard to update our long-held beliefs or alter the ways we teach and practice. But this is just what we’re asking of our “medical model” counterparts. We should lead by example.
Tuesday, December 1, 2009
As National Prematurity Awareness Month closes, we’re digesting a lot of statistics. Today, in the US, more than 1,400 babies will be born prematurely. Between the early 1980s and 2006, the rate of premature birth rose by 36%. These are fascinating and disturbing statistics, but as a midwife who is actively engaged in research, there is one companion statistic that startles me even more: From 1992 to 2002, the average gestational age at birth in the US dropped from 40 weeks to 39 weeks.
It does not take a statistician to appreciate that a drop in the average time a baby is born by a full week over the course of just 10 years means something big has been happening. Over 4 million babies are born each year in the US. A substantial increase in the rate of prematurity would be needed to reduce the average time of birth by a full week.
Why the rise in prematurity despite advances in medical knowledge and technology? According to the most recent March of Dimes prematurity summit, the primary reason is not obesity or smoking, as you might expect—it’s labor induction. In 1990, the rate of inductions was 9.5%. By 2006, the rate more than doubled to 22.3%.
Research documents that preterm infants have an increased risk of being admitted to level 2 or 3 nurseries and that important brain development continues all the way to full-term. More recently, late preterm infants (born at 34-37 weeks gestation) have been shown to have a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia.
Certified nurse-midwives and certified midwives have a long history of reserving labor induction for the situations when it is absolutely necessary. The American College of Obstetricians and Gynecologists (ACOG) recently issued a statement calling for an end to inductions prior to 39 weeks unless there is a clear medical indication. Now that the US has enough preemies to impact a national statistic and a national medical organization, let’s support a re-examination of medical indications for labor induction prior to full-term and promote a renewed emphasis on waiting for spontaneous labor and birth.