10 Midwifery-friendly Ways to Spend Black Friday

by Melissa Garvey, ACNM Writer and Editor

Make Black Friday 2010 count by doing more than bargain hunting at o’-dark-thirty. Use these tips to spend your time and money updating your professional skills and making a difference for midwives.

1. Connect with other midwives and midwifery supporters via Facebook (both the ACNM page and the ACNM Student Midwives group) and on Twitter (@acnmmidwives and @acnmmeeting).

2. Watch advocates promote midwifery and student midwives show why they are becoming midwives on the ACNM You Tube Channel.

3. View FREE Annual Meeting sessions in the ACNM Live Learning Center, and earn free CEUs while you’re at it! Look for a green square that indicates the 2 free sessions.

4. Jump over to the Online Education tab in the ACNM Live Learning Center to register for Billing and Coding Modules 1 & 2 so you’re prepared for live modules 3 & 4 on December 7 and December 14, 7pm – 8pm EST.

5. Buy ACNM midwifery postage stamps to support the A.C.N.M. Foundation and promote midwifery with every holiday card, bill, and letter you send this season.

6. Submit a poster presentation for the ACNM 56th Annual Meeting & Exposition. General non-research submissions are due December 31. Research submissions to the Division of Global Health and the Division of Research are due February 15.

7. Start on your paper describing your successful collaborative practice model. It’s due to ACNM and the American College of Obstetricians and Gynecologists on February 1!

8. Flip through the November/December issue of the Journal of Midwifery & Women’s Health. If you don’t have a subscription, check out the new Share With Women Handouts (Weight Gain During Pregnancy and Omega-3 Fatty Acids During Pregnancy).

9. Apply for the A.C.N.M. Foundation Midwives of Color-Watson Basic Midwifery Student Scholarship.

10. Learn about the ACNM Department of Global Outreach and the ACNM Division of Global Health. Get involved by joining the division or registering for the Life Saving Skills workshop to be held in Tuscon, AZ, April 11 – 15, 2011.

How Insurers are Still Pulling Maternity Coverage from Pregnant Women’s Plans

by Melissa Garvey, ACNM Writer and Editor

As of 2014, maternity care coverage in the United States will take a step up. Under the Patient Protection and Affordable Care Act of 2010, health insurance plans will no longer be able to turn away applicants based on the “preexisting condition” of pregnancy. Maternity care coverage will also be mandatory for individual and small-group insurance plans as well as policies sold through state-based insurance exchanges. This is good news.

But until 2014, women will continue to get pregnant. About half will become pregnant unexpectedly and may have the added stress of no maternity care coverage. Plus, more women will try to conceive and discover in the second, maybe even the third trimester, that their maternity benefits have been cut considerably or have become significantly more expensive.

That’s exactly what happened to The Feminist Breeder—a blogger and birth advocate planning a home birth with a certified nurse-midwife under the coverage of Blue Cross Blue Shield. Here’s what happened to her after months of planning to conceive her third child:

…we found out that coverage we signed up for last year isn’t the coverage we actually have now because they keep decreasing it every year, and it’s going to get even worse in 2011. Starting in January, almost NONE of our homebirth expenses will be covered because of a massive deductible increase, and what is covered will cost us a ton more than we anticipated when we made the decision to start trying to conceive last January.

Even more women are blindsided by expenses they never knew to expect. My cousin is staring down the barrel of inflated health care bills because her maternity care will stretch across two calendar years, two deductibles, and two out-of-pocket costs. A recent Washington Post article features a woman paying $400 per month for an individual health plan who thought “it must be a mistake” when she discovered her plan required a special maternity rider in advance of the pregnancy in order to be eligible for childbirth-related coverage.

Where does this leave mothers until 2014? It doesn’t look good.

Rigging the Election: When it comes to elective induction, are women asking for it?

by Amy Romano, CNM

This post was originally published on Science and Sensibility for Lamaze International.

There is a growing movement, backed up by evidence, practice guidelines, and efforts by agencies including the March of Dimes, the Institute for Healthcare Improvement and the Joint Commission, to reduce elective inductions, especially those occurring before 39 completed weeks of gestation.

Media coverage of these efforts tends to frame the problem as too many women asking for early delivery with no medical reason and the solution as hospitals “saying no” to these women. But this woman-blaming paradigm is simplistic and flawed. New research shows that, not only have maternity care providers failed to convey the risks of early delivery to women, they may be offering or recommending elective deliveries despite the risks, and telling women they have a medical reason for induction but documenting the inductions as “elective”.

First, the evidence that educating women does help.

As reported in the July/August issue of the American Journal of Maternal/Child Nursing, researchers at St. John’s Mercy Medical Center in St. Louis, MO, studied the effect of a 40-minute educational intervention given in the context of hospital-based Lamaze classes. The intervention was an educational module about elective induction incorporating evidence and professional practice guidelines, taught along with the otherwise-unchanged Lamaze class curriculum. Researchers compared the elective induction rates between attendees and nonattendees in the 7-month period following the introduction of the new module. The content of the educational model was straightforward:

Specific risks of elective induction presented during the class included cesarean birth with longer postpartum recovery, pain, and potential complications as well as other associated risks such as longer labor, use of pharmacologic agents and their effects on the mother and fetus, and neonatal morbidity. Benefits included advance planning and timing with personal schedules. (p. 190)

Women were also given “talking points” to discuss with their provider if induction was recommended.

The intervention appeared to be very effective. The elective induction rate was about 37% in both attendees and nonattendees before the intervention and in nonattendees after the intervention. But 28% of women who attended the classes that included the educational content had elective inductions, a significant reduction indicating that the hospital would only need to educate about 11 first-time mothers to prevent one elective induction.

But, you might say, that still leaves more than 1 in 4 first-time mothers having elective inductions. What else might be driving this besides lack of education? Well, it might be this: the researchers also discovered that nearly 70% of women were offered elective induction by their doctors. And, not surprisingly, women whose doctors offered them elective induction were far more likely to choose elective induction, whether or not they were exposed to the educational intervention. In fact, the magnitude of the difference was much greater than with educational content. Roughly speaking, doctors would have to refrain from offering elective induction to just three first-time mothers to prevent one elective induction.

Prior to the educational intervention, when the hospital leadership were considering how to decrease the use of elective induction, most doctors believed that the problem was that uninformed women were asking for it, an assumption turned on its head by the research findings. In postpartum surveys, three-quarters of women who had “elective” inductions indicated that the physician suggested the option compared with only 25% of women who indicated that they initiated the request themselves. Class attendance had an influence on whether women chose to act on the option of elective induction, but the difference wasn’t huge. About 38% of women who attended the class and whose doctors offered elective induction chose the option, compared with 50% of those who were offered elective induction but didn’t attend the class.

The researchers conclude:

Although education provided in prepared childbirth classes can be helpful for women in making the choice of whether or not to have their labor electively induced, the physician is a powerful influence…It is possible that patients perceive the offer of the option for elective induction as a recommendation that they actually have the procedure, particularly if they are told they are due now, overdue, or their baby is getting too big. (p. 193)

And therein lies the problem: it turns out many women having “elective” inductions think they’re having medically indicated inductions. In a follow-up study by the same research team, published in the current issue of the Journal of Perinatal Education (full-text available to Lamaze members), the researchers report more of their findings from postpartum surveys as well as data gleaned from reviewing the medical records of each woman after delivery. They write:

The most significant discrepancy between the medical record and patient perception was related to macrosomia as an indication. For example, based on the medical record, macrosomia was the indication for 26.7% of inductions; however, 39.9 of patients noted that their physician told them they needed to be induced because “my baby was too big.” The next most common reason women believed they had an induction was that they were “due now or overdue” (20.3%), yet only 35 women (6.4%) who had an elective induction were 41 completed weeks of gestation and none were more than 41 3/7 weeks. The majority of women who indicated they were induced for being “overdue” were only 1 to 4 days past their estimated due date. (p. 28)

So what’s the take-home of all of this? How do we rein in the overuse of elective induction? Clearly, childbirth education that specifically addresses the risks, benefits, and evidence-based indications for induction helps. As we have seen, fewer women exposed to this educational content will choose induction. Researchers also found that women who had inductions were more likely to have reported feeling prepared and having the reality match up with their expectations if they had taken the classes. They were also less likely to report not knowing why they were induced compared with women who were induced but didn’t take the class. In other words, the class helped women have more fruitful conversations with their care providers.

But it is clear from this research – the first to explore these issues in depth with a combination of qualitative and quantitative approaches – that we have to change provider beliefs and practices to have a meaningful impact on induction rates. It’s time for more research on what happens behind the closed doors of prenatal visits, and for clear standards that tell doctors it is not okay to offer a major medical (often turned surgical) procedure to women as if it was benign or beneficial.

The Truth About Omega-3s During Pregnancy

by Robin Jordan, CNM, PhD

What pregnant woman wouldn’t want to grow a smart baby, one that has every last genetically programmed fully functioning brain cell, is ahead of the preschool pack, becomes the straight-A class president, and attends an Ivy League university?

That might be a stretch. But research indicates that women who eat adequate amounts of omega-3 fatty acids—specifically DHA and EPA found in many fish and fish oils—have babies who have higher cognitive, verbal, and visual functioning than babies born to women with lower intakes of these fatty acids.

Additional benefits of consuming adequate DHA and EPA in pregnancy are higher infant birth weight and a reduction in risk of preterm birth. Research also supports a reduction in pregnancy hypertension and postpartum depression, and we’re not even getting into the gamut of health benefits for the general population! (Okay, a short list: decreased cardiovascular disease, hypertension and dementia, to name a few).

It all sounds easy, right? But it may not be that simple.

Separating Fact from Fiction

There are plenty of areas of confusion on omega-3s during pregnancy. A recent study making the news rounds does not support the findings of improved mental and visual function in offspring whose mothers consumed DHA and EPA supplements. There may be reasons for these results—or lack of. The researchers tested babies only up to 18 months old, and women’s prior patterns of DHA and EPA consumption were not taken into account. Now here’s where it gets confusing: the ratio of omega-6 to omega-3 in the diet could have played a role in study findings. Omega-3s compete for binding spots in the body with omega-6s, primarily linoleic acid (LA). LA is found in foods containing corn, soybean and safflower oils (think crackers, cakes, soda), and beef--foods that are consumed in overabundance in today’s typical diet. DHA and EPA compete with LA for receptor sites in the body. So if a woman has a diet high in LA rich foods, then the DHA and EPA she takes in might not be used by the body. When people eat less omega-6s, they can make huge increases in their body’s omega-3s!

The Mercury Conundrum

What about fish? Isn’t it full of mercury? Only certain kinds of fish like shark, mackerel, swordfish, and tilefish are high in mercury. Many others are perfectly safe to eat. Just know what they are! Dr. Joseph Hibblen, a researcher with the US Department of Public Health has stated that the benefits of eating fish during pregnancy far outweigh any risks of eating safe fish during pregnancy. Based on his analysis of other studies, he concluded that the effect of not eating enough fish in pregnancy appears to be a 5-6 IQ point difference! The general guideline of “up to” two fish meals per week is being challenged by experts as too low, that pregnant women (and the rest of us!) should be eating more.

We don’t know everything about omega-3s in pregnancy; however, we do know enough to conclude that DHA and EPA are important to pregnancy and fetal health. Who knows the difference a few IQ points can make!

Midwives and other health care professionals, read Robin’s article on the omega-3 fatty acids DHA and EPA in the November/December issue of the Journal of Midwifery & Women’s Health.

Women, get more guidance on omega-3 fatty acids during pregnancy from this free Share With Women handout.

Evidence-based Policies Needed in Prison Populations

by Donna Jackson-Köhlin, CNM

One reality of midwifery practice in these times is that all of us will—if we haven’t already—care for women who are affected by the criminal justice system, whether they are incarcerated themselves, or the child, parent, or partner of someone who has been in the U.S. prison system. Thanks to the relationship between the community health centers where I practice with Baystate Midwifery and Women’s Health in Springfield, MA, along with the Hampden County Correctional Center, I have been able to provide obstetric and gynecologic care to incarcerated women inside a regional women’s jail for the past six years.

Caring for incarcerated pregnant women is demanding. Standards of care must be meshed with jail concerns around security, planning for the baby at/after birth, confidentiality concerns, and trying to facilitate normalcy in what is not a “normal” setting.

Shackling of pregnant women has received media attention, and for good reason. Few states have legislation in place regarding standards for prenatal care or restraints for labor/birth. Prison nursery programs that help foster bonds between mothers and infants are uncommon. The current practices at my facility in Massachusetts have been put into place due to a commitment to proactive policies, and good graces of the correctional medical and administrative staff. However, they are not part of state policy, and as such, they can be reduced or discontinued at any time.

It was with great interest that I received the report from The Rebecca Project for Human Rights/National Women’s Law Center, “Mothers Behind Bars: a state-by-state report card." I recommend that you read this document, consider what your past experience has been with this population where you practice, and think about what you can do to advocate for more humane, evidence-based beneficial policies and legislation that influence the family, community, and society long after a woman’s time in the prison system has passed.

The Facts About Late Prematurity

by Melissa Garvey, ACNM Writer and Editor



Did you know that November is Prematurity Awareness Month? More than half a million babies are born prematurely in the United States each year. More than 70% of those half a million premature babies—which translates to more than 350,000—are born late preterm, between 34 and 36 weeks gestation.

Often, late-preterm births occur as a result of pregnancy complications or health problems in the mother or fetus. However, the March of Dimes and other organizations, are concerned that many late-preterm births happen via induced labor or cesarean section at the request of the mother and/or health care provider without medical justification.

Why the concern? Although 99% of late preterm babies survive, a few weeks gestation makes a huge difference in infant health. Here are the facts.

Late preterm babies are:

• six times more likely than full-term infants to die in the first week of life (2.8 per 1,000 vs. 0.5 per 1,000).


• three times more likely to die in the first year of life (7.9 per 1,000 vs. 2.4 per 1,000).


• usually between 4½ and 6 pounds and may appear thinner than full-term babies.


• at higher risk than full-term babies for newborn health problems, including breathing and feeding problems, difficulties regulating body temperature, and jaundice.


• at increased risk for learning and behavioral problems. At 35 weeks, a baby’s brain weighs only two thirds of what it will weigh at 40 weeks.
  

Learn more and take action by joining the March of Dimes Fight for Preemies. You can also learn more about the prematurity in your state by viewing the March of Dimes premature birth report cards.

Empowering Incarcerated Women during Pregnancy, Birth, and Motherhood

by Cheryl Hanna-Truscott, CNM

Mandi and Gabriel (3 days old)

Photo by Cheryl Hanna-Truscott, CNM: www.protectivecustody.org

"I’ve gone through a lot being here in prison. Early on when I first got here, I worried about a lot of things. One of them was, ‘Am I going to get to keep my baby?’"

In the mid-1990s, I first heard about a new program at our state women’s prison that would allow non-violent, incarcerated pregnant women to maintain custody of their infants while serving short prison sentences. I was intrigued, never having given much thought to women convicts, let alone pregnant ones. Healthy maternal-infant attachment could be promoted during this critical time in a protective, supportive, and safe environment.

“Being in the Residential Parenting Program has just given me a second chance, you know? I didn’t really have a place to send my baby to. I was blessed to be able to keep my baby here and it just shows me that I have a second chance.”

The program began in 1999, and in 2003, I asked if I could do a portrait photography project about the prison nursery. Even with my professional background as a nurse-midwife and expertise in child sexual abuse evaluations, I was surprised that administrators and mothers welcomed me. Prison is a closed, off-limits, censored, and locked-up environment. Prisoners are unseen, disenfranchised, and voiceless.

“Nobody I knew was with me when I gave birth. Nobody. But, gosh, the one officer was so great. I can’t think of her name…but, she, my gosh! I was leaning over the officer. I was slobbering, crying, and she didn’t care about her uniform. I wish I could think of her name so I could thank her.”

When I began this work, I expected to find the unit crawling with researchers interested in promoting maternal-infant health in such a vulnerable population and was aghast at the paucity of available information. Today, my photography project continues; although it is anecdotal and personal, it validates conclusions of current research efforts made by: Dr. Mary Byrne, Marie-Celeste Weisenburg (PhD candidate from UW with pending participatory action research), Chandra Villaneuva with the Women’s Prison Association, and the National Women’s Law Center with the Rebecca Project for human rights.

There is a great need to focus more attention and resources to maternal-infant health issues among this growing population. Both prison-based nursery and community-based programs have a place in our public health and safety system. We midwives like to say that we change the world one baby at a time. Through my work, I know that midwives are also the best-qualified providers that can make a huge impact on empowering incarcerated women.