Midwife Connection Goes on Vacation

Midwife Connection is taking a holiday break. We will return to our regularly scheduled postings on January 4, 2011. Season’s Greetings and best wishes for a happy, healthy, and prosperous New Year from your friends at the American College of Nurse-Midwives.

Midwifery Care from the Client’s Perspective

by Melissa Garvey, ACNM Writer and Editor

Our friends at Science and Sensibility have an interesting post that should be generating more discussion. The post explores certified nurse-midwife Mary Ellen Doherty’s study in the Journal of Perinatal Education called “Midwifery Care: Reflections of Midwifery Clients.”

Doherty conducted her study to describe the experiences of women who chose midwives as their health care providers throughout the lifespan. She and her team interviewed 12 women who had received prenatal, birth, postnatal, well-woman gynecologic, contraceptive, and primary health care services from midwives.

Five themes emerged from the data. As a member of the ACNM communications team, I’m particularly interested in two of them: 1) decision to seek midwifery care and 2) midwives as primary health care providers throughout the lifespan.

What Makes Women Choose Midwives?

That’s the million-dollar question here at ACNM. We exist to support and promote certified nurse-midwives and certified midwives. We know midwifery patients are extremely satisfied with their care. But how do we get a woman who has never considered a midwife to realize what she’s missing?

The women in Doherty’s study said they chose a midwife because of:

• a brochure from a midwifery practice along with one from ACNM that exuded “competence, confidence, compassion, and kindness.” (Go, ACNM Communications Department!)
• the recommendation of friends who had already given birth and had a positive experience with midwifery.
• an obstetrician’s recommendation.
• an insurance company’s recommendation.
  

Midwives as Primary Health Care Providers

All 12 of the women in this study discovered that midwives provide services beyond prenatal, birth, and postnatal care. Just among this sample of 12 women, midwifery services included:

• Contraceptive care
• Treatment for vaginal infections
• Flu shot administration
• Throat culture
• Annual exam
• Pap smear
• Treatment referral and support for postpartum depression
• Other health care referrals and recommendations for both patient and family members
  

Because this study was a phenomenological study, small sample size is not considered a limitation. However, Doherty notes that because her study focused on a “self-selective and purposive sample,” its results are not representative of all women. The majority of women were Caucasian, highly educated, married to their child’s father, and self-identified as “middle class.” Still, there’s a lot to learn from their answers…

…and a lot to add! Here’s where you chime in. What made you decide to choose a midwife? And what health care services do you receive from your midwife?

Hit the Holiday Sales at ShopACNM.com

by Melissa Garvey, ACNM Writer and Editor

Looking for the perfect gift for that special student, midwife, or parent in your life? Visit ShopACNM.com for unique gifts that promote and support midwives.

Now through December 15, all ACNM logo wear and ACNM and midwife branded products are marked down 15% for ACNM members. Log in with your ID and password; then enter promotional code HOL1 at checkout to receive your discount.

Not a member? Join now, or support ACNM with your regularly priced purchase.

Do You Really Know Kegels?

by Alyce Adams, RN, BSN, "the Kegel Queen"

Midwives are experts at applying low-tech, low-cost health care strategies that promote self-care and help women avoid the dangers of unnecessary interventions. Every midwife is familiar with the cesarean epidemic and with the safe, simple approaches that can keep birthing women out of the operating room.

But many health care providers and consumers don't know enough about another surgical epidemic affecting women. Each year, 200,000 US women have surgery to treat urinary incontinence or pelvic organ prolapse (POP). Eleven percent of women in this country will have this type of surgery by the time they're 80 years old — that's a lifetime risk of one in nine. Of those who have surgery to treat prolapse, one third will end up back in the operating room at least once.

Millions more will suffer without any treatment at all: 50% of women will experience urinary incontinence at some point in life, and 50% of mothers will have some form of POP.

Kegel exercises — when performed correctly — are a highly effective treatment for urinary incontinence and POP. The exercises are simple, promote self-care, and they're completely safe. The only side effect is better sex! But most people don't realize how effective kegels can be to solve these health problems without surgery, because they don't have the facts about correct kegel technique.

Check out these popular kegel myths. Do you have the facts?

Myth: Kegels are intentional contractions of the pubococcygeus (PC) muscle.
Fact: Correct kegel technique involves the entire pelvic floor, not just the PC.

Myth: Women should do kegels whenever they think of them — at a boring meeting, at a red light, or waiting in line.
Fact: There are three reasons this approach to kegels doesn't work. First, effective kegels are sustained, high-intensity muscle contractions. Real kegels require your full attention. If you're trying to drive and do kegels, you'll either do weak, useless kegels or crash the car. Second, you must relax the pelvic floor fully after each kegel contraction. This complete relaxation requires your full attention as well. Finally, research shows that women who do kegels "whenever" simply don't end up doing them. Doing kegels on a regular schedule and connecting kegels with preexisting daily routines is the way to succeed.

Myth: Women should do 200 kegels a day, or more.
Fact: Too many kegels can lead to hypertonic pelvic floor muscles and pain with intercourse. A few dozen kegels a day is all you need — then far less for maintenance over time. Correct kegel technique takes just a few minutes a day.

Myth: Truly effective kegels require a kegel device.
Fact: Devices make kegels complicated, messy, and inconvenient. Study after study shows excellent kegel results with no devices at all.

When done correctly, kegels can eliminate prolapse symptoms, stop incontinence, and transform women's sexual health. Get the facts!

When it Comes to HIV, Every Woman is at Risk

by Jan Kriebs, CNM, MSN, FACNM, Assistant Professor and Director of Midwifery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine

Today is World AIDS Day – a reminder that HIV and AIDS are part of life for 33.3 million people around the world. Women are 15.9 million of those infected.

I have worked with woman who are pregnant and HIV-positive for almost two decades. You cannot tell who they are by looking at our waiting room. Some are poor, inner-city women without jobs. Some are women with homes and careers. Some come alone to their visits, afraid of anyone finding out they have HIV. Some come with their husbands, sisters, or best friends. Since we have had access to highly active antiretroviral medications, none of the women who knew they were positive for HIV in early pregnancy and who took medication throughout their pregnancies, have transmitted HIV to their child at birth.

Our pediatricians report that the young children they see in the pediatric HIV clinic have mothers who were not diagnosed, did not seek care, or were unable to manage their medications.

In the United States, where recommendations for universal HIV testing have been in place for years and where a full range of medications are widely available, babies are still born who will carry the virus for their entire lives. Part of the problem is a woman’s fear. What will I do if I am positive? Who will want to be with me? Part of the problem is our collective unwillingness to believe that ANY woman might be infected as well as our failure to decrease the barriers to testing.

The most common cause of HIV in women is sexual activity; it is responsible for more than 80% of new infections. As midwives we must recognize that pregnant women are an at-risk population. It is easy to think that “our” patients are safe, but it isn’t true. We may also think that women who are privately insured, who live in safe communities, and who are married cannot be at risk. But risk is a tricky topic. These women may not be at high risk, but that is not the same as no risk.

The theme chosen for World AIDS Day this year is Universal Access and Human Rights. For the families, women, and children seen by midwives, access begins with testing. If you do not know your status, you cannot seek care.

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.

Do Flashy Campaigns Make a Difference for Breast Cancer?

by Melissa Garvey, ACNM Writer and Editor

October is National Breast Cancer Awareness Month, and one Facebook campaign has already gone viral. It’s not a campaign imploring people to donate to breast cancer research. Instead, women are using their Facebook status updates to reveal where they like to put their purse.

As you can imagine, this leads to all sorts of sexual connotations–for example, “I like it on the couch,” or “I like it in the kitchen.” It’s similar to a previous campaign that encouraged women to post their bra color as their status update. It’s eye-catching, and people like it. But is it really making a difference for breast cancer?

According to the National Breast Cancer Coalition, these flashy campaigns do nothing for the millions of women who are struggling or will be diagnosed with breast cancer. In fact, NBCC has started an alternative approach by setting a deadline to end breast cancer by January 1, 2020. It’s different, well thought out, and bold. But is it possible?

If you had to choose between the Facebook “I like it” campaign and the NBCC deadline, which would you say holds the most potential to make a difference for women with breast cancer?

Houston Midwives Honor Rep Green at B.I.R.T.H. Fair

by Lynneece Rooney, CNM

Texas Representative Gene Green (D-TX) was honored at the 9th Annual Bringing Birth Information and Resources to Houston (B.I.R.T.H.) Fair earlier this month. An award honoring his support of women’s health was presented to him by certified nurse-midwives Melanie Dossey, Jackie Griggs, and Pat Jones, with hundreds of advocates in attendance.

Representative Green is the first and only federal legislator who represented Texas as a co-sponsor of the Midwifery Care Access and Reimbursement Equity Act of 2009 (H.R. 1101). (H.R. 1101 was part of the Patient Protection and Affordable Care Act of 2010; the law will raise Medicare reimbursement of certified nurse-midwives from 65% to 100% of the physician fee schedule.)

Greenhas shown continued support of women’s health care issues by sponsoring and co-sponsoring numerous women's health care related bills in the past, including the Medicaid Birth Center Reimbursement Act; Heart Disease Education, Analysis Research, and Treatment for Women Act; Birth Defects Prevention, Risk Reduction, and Awareness

How to Brand Midwifery

by Melissa Garvey, ACNM Writer and Editor

This week I came across an interesting post by Sam Ford about the problem many midwives and their supporters struggle with every day. How do you clearly communicate what a midwife is? It’s a loaded term with all sorts of cultural baggage and preconceptions, which typically triggers associations like home birth and no pain control.

Ford’s post didn’t grab my attention merely because of the subject matter. Many people who have come before him have astutely pointed out that the midwife brand needs a makeover. In fact, ACNM members say that limited public awareness of midwifery is the number-one barrier to practice. What impressed me is that Ford actually took a stab at evaluating why existing advocacy campaigns and PR initiatives have not made a large impact on the US public.

The biggest hurdle to overcome is that many have painted midwifery in extremes: as only for parents who completely oppose medical intervention, almost as eschewing all that modern medicine and technology has given us.

A thoughtful follow-up post at Babble.com further articulates the problem:

As a culture, we tend to see only the extremes. We love a good, clear fight, even at the expense of facts. When it comes to birth, there are “the crunchies” and there are “the medicalized maniacs.”

In between these two extremes is where you’ll find the majority of modern midwives. What does that look like? It depends. Midwives serve as primary care providers, giving annual exams, reproductive health services, and family planning counseling to women of all ages. Most midwives work in hospitals. Some work in birth centers or homes. They can order medications, ultrasounds, and epidurals. They exercise those privileges when needed or when requested by the mother. Most midwives spend a longer amount of time with their patients—just like nurse practitioners tend to give longer annual exams than OBGYNs.

How do you boil that down into a brand? It’s complicated. Try choosing a picture to represent midwifery. Should the midwife be a woman or a man? Should s/he be wearing a white lab coat, scrubs, professional attire, or casual dress? Should his or her patient be a teenager, a pregnant woman, or an older woman going through menopause? Even among ACNM staff, there are wide variations of opinion on this topic.

It’s almost as if there’s too much information to shove into a brand. At ACNM, we’re pouring resources into raising public awareness of midwifery. We just launched Evidence-Based Practice: Pearls of Midwifery. Last year we released midwifery postage stamps We’re vamping up our media relations and social media efforts. But there’s still more work to be done.

In your view, what is it that defines midwifery? Do you think it’s possible to rebrand midwifery in America?

Overcoming Barriers to Safe Maternity Care in Afghanistan

by Annie Clark, CNM, MPH

The majority of women in Afghanistan are constricted by traditional customs forbidding them to travel without a male companion.

Last month, NPR’s Morning Edition posted a story about midwifery in Afghanistan with Renee Montagne reporting from the remote region of Badakshan along Afghanistan’s northern border. The story provides a snapshot of the situation in Afghanistan where the maternal/infant health statistics are among the worst in the world. According to UNICEF, the estimated infant mortality rate is 165 per 1000 live births, and under-five mortality is as high as 257 per 1000. (You can also watch an excellent video summarizing the situation in Afghanistan here.)

A recent study undertaken in four Afghan provinces indicates that the country still has one of the highest maternal mortality rates in the world—estimated at 1600 deaths per 100,000 live births. Montagne reports on a USAID initiative to address these appalling statistics by recruiting and training midwives in rural areas. She personalizes the account with an illustrative example of midwife Farangis Sultani, who was chosen by her Village Health Council to participate in an 18-month community midwife training program and then return to serve her community and receive a salary.

In just six years, midwife training programs have increased the number of midwives in Afghanistan from 467 in 2002 to nearly 1700 in 2008 (2300 was the total number of midwives reported to me when I was in Afghanistan earlier this month). The objective is to train a total of 5000 midwives. This has not been an easy undertaking for a number of reasons, including the fact that up to 86% of Afghan women are illiterate, making it difficult to find candidates who meet the required prerequisites for midwifery training. The majority of women in Afghanistan are also constricted by traditional customs forbidding them to travel without a male companion. Consequently, few women in rural villages manage to deliver outside their own home. There was opposition to the concept of a midwife traveling alone to the home of a laboring woman, let alone staffing a clinic at night.

The NPR story highlighted the efforts of Jhpiego, an affiliate of Johns Hopkins University, which has been implementing a USAID-funded project to train community midwives. Jhpiego helped combat cultural barriers to training by promoting the establishment of Village Health Councils. When confronted with the problem and the possible solution, Village Health Councils independently selected young women candidates for midwife training and agreed to some flexing of cultural norms.

There are many additional donors and NGOs who are involved in efforts to address the high maternal and child mortality and morbidity rates in Afghanistan, including UNICEF, the World Health Organization (WHO), Merlin, Aga Khan, and University Research Company/Health Care Improvement Project.

Did you know that ACNM, as a partner with Jhpiego on the USAID-funded ACCESS project, helped launch the Afghan Midwives Association in May 2005? Find out more about the grant-funded ACNM Department of Global Outreach at www.midwife.org/global.cfm.

How to Present Evidence-based Midwifery Care Like a Pro

by Melissa Garvey, ACNM Writer and Editor

This week we launched an exciting project that has been in development for more than a year. Evidence-Based Practice: Pearls of Midwifery is a professionally developed presentation featuring nearly 100 fully referenced slides to assist midwives and their advocates (expectant moms, active dads, other health care providers, everyone!) in explaining the science and art of the midwifery maternity care model. Designed to showcase the evidence-based foundation of midwifery practice, Pearls of Midwifery emphasizes the proven benefits of physiologic labor and childbirth for mothers and their newborns.

Pearls of Midwifery is a long-overdue resource. In the words of ACNM President Holly Powell Kennedy, CNM, PhD, FACNM, FAAN, “Despite the recent plethora of information on evidence-based maternity care practices, there continues to be an underuse of many beneficial interventions while some harmful practices persist. We must continue sharing the evidence with our clients and other health care providers to ensure that all women receive the safest and most effective maternity care.”

Evidence-Based Practice: Pearls of Midwifery includes suggested speaking notes for each slide and a checklist that can be printed and shared.

Pearls of Midwifery is free to ACNM members and available for nonmembers to purchase in the ACNM Live Learning Center for just $69. Where do you plan to use this new resource?

Title V Turns 75

by Elaine Germano, CNM, DrPH, FACNM, ACNM Senior Education Policy Analyst

2010 marks the 75th anniversary of Title V of the Social Security Act, the only national program that focuses solely on improving the health of all mothers and children. To celebrate, the Health Resources and Service Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) is hosting a commemorative event next week—Wednesday, October 20, in Washington, DC—to highlight the past, present, and future of the program.

Many midwives have served in MCH bureaus at the state and local level, and midwifery practice is often strongly supported by government officials in those bureaus. For more information, resources on Title V, a 75th Anniversary widget, and ideas for community service projects, visit www.hrsa.gov/mchb75.

HRSA is also calling for YouTube video submissions about maternal child health programs that have impacted your life, community, or country. Submission topics related to midwifery include:

• Adolescent health
• Family-centered, community-based, coordinated systems of care
• Maternal child health research
• Obesity
• Oral health
• Prenatal and perinatal care
• Women’s health
  

How are You Celebrating National Midwifery Week?

by Melissa Garvey, ACNM Writer and Editor

We’ve been thrilled with the updates rolling in about how midwives and their supporters are celebrating National Midwifery Week across the country. Check out these highlights and make a comment to tell us how you’ve been celebrating.

On Sunday, October 10, Andrea Bendewald will give a unique “Blessing the Hands” to the remarkable midwives of Los Angeles who work tirelessly serving women and families. A dedicated group of more than 300 midwives and supporters, including Ricki Lake and Carrie Ann Moss, will gather at Golden Bridge Yoga. The event honorees are Peggy O’Mara, editor and founder of Mothering magazine, and Congresswoman Lucille Roybal-Allard (D-CA), who is a consistent supporter of women and infants’ health and is the congresswoman who introduced the Maximizing Optimal Maternity Services for the 21st Century Act (MOMS 21—H.R.5807) to promote evidence-based maternity care.

Governor Beshear proclaimed Midwifery Week in the state of Kentucky.

Where’s My Midwife? is hosting daily activities throughout the week, culminating with the National Walk for Midwives on Saturday, October 9. New York City, San Francisco, and Seattle midwives are also hosting Miles for Midwives walks.

The Morgan Library and Museum features a photograph of the pioneering nurse-midwife Mary Breckinridge in their current exhibition "Anne Morgan's War: Rebuilding Devastated France." You probably know Breckinridge’s story—many consider her the founder of nurse-midwifery in America—but before creating the Frontier Nursing Service, which brought midwives on horseback to women in the rural mountains of Kentucky, she volunteered with Anne Morgan's civilian relief organization in the devastated regions of France. She was one of the group's most distinguished volunteers, drawing on her wartime experience to make a huge difference in people's lives (and the very future of prenatal and infant care) back home.

An International Approach to Mainstreaming Midwifery in America

by Peter Johnson, CNM, PhD, FACNM

As we celebrate Midwifery Week—a time to recognize our profession and celebrate our achievements—I am struck by the good work midwives are accomplishing globally. National Public Radio aired a story last week that highlighted the work of my organization, Jhpiego, that is taking place in the far northern region of Afghanistan. While listening to Renee Montagne’s interview with a young Jhpiego-trained midwife, I felt proud, but it also reminded me of the work left to be accomplished both around the world and here in the United States.

Jhpiego, which serves to “innovate to save lives of women and their families,” has been doing creative work for nearly 37 years and has always maintained close ties to ACNM. Our nearly 800 midwives, nurses, physicians, and public health professionals strengthen midwifery education in war-ravaged countries like Afghanistan and Liberia, support care to women and families living in urban slums of Kenya, and prepare midwives to reduce the mother-to-child transmission of HIV in Southern African countries. The great majority of these professionals are native residents in the countries where we work.

My travel building cherished relationships with new colleagues from around the world has convinced me that we have more in common than one may think. For example, we all seek to build a stronger health care system that respects the autonomous role of the midwife. We all want midwives and other health care professionals to have the best possible work environment and access to the equipment and supplies needed to do their jobs. We want midwives to have a quality education that forms the foundation for life-long learning and growth.

Even our challenges, while apparent on a different scale in low resource countries like Afghanistan, are largely the same. We all struggle to find the resources to educate our midwives and offer them a living wage for their services. We work to develop autonomous regulatory structures that provide midwives with a framework for optimal practice. We strive to optimize midwives’ work environment so that they can maximize their effectiveness in practice. Even in America, where midwives often serve the most vulnerable of society’s women, these struggles are apparent. There are far too few of us because of our inability to overcome these challenges, and women suffer because of it. Let us use this week to celebrate midwifery globally while mobilizing our midwives here at home to overcome our shared challenges. Let us reflect on the lessons learned by midwives around the world that can “mainstream” midwifery practice in America.

Does Health Care Reform Do Anything for Midwifery?

This post originally appeared on RH Reality Check in honor of National Midwifery Week.

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

Most midwives would agree that The Patient Protection and Affordable Care Act has several concrete benefits for the midwifery profession. The act establishes reimbursement for certified nurse-midwives (CNMs) at 100% of the Medicare Part B fee schedule, which means that as of January 1, CNMs will be reimbursed at the same rate as physicians. The law also recognizes freestanding birth centers under Medicaid, which allows birth centers to receive reimbursement for their facility fees.

But since these parts of the legislation have not yet gone into effect and do not affect all midwives, does health reform really mean anything for the thousands of US midwives and their patients?

The answer is yes! To the prospective midwifery student, I can now say that more money will be available for graduate nursing education and that there will be more help with loan repayment for midwives who practice in maternity care shortage areas. When I am asked how reform legislation has impacted midwifery practice thus far, I can say it has brought the evidence forward as we move towards some major changes and improvement in care for women and infants.

There is a new focus on evidence-based practice, which I believe is the direct result of health care reform legislation. A dialogue is taking place among the stakeholders in this country about how we can do better for mothers and newborns. This year, Childbirth Connection published two reports in addition to hosting a symposium called Transforming Maternity Care: A High Value Proposition. One of the reports, the Blueprint for Action, reinforces the importance of evidenced-based maternity practices. The American College of Nurse-Midwives is about to release a PowerPoint presentation entitled Evidence-Based Practice: Midwifery Pearls, to help midwives spread the facts about evidence-based practice. Evidence-based practice in maternity care is definitely in the limelight. Also, the National Institutes of Health (NIH), discussed vaginal birth after cesarean (VBAC) at a Consensus Development Conference.


But there is still more work to be done. Passage of the “Maximizing Optimal Maternity Services for the 21st Century Act" (MOMS 21) is the next step to help move this nation forward as we create a focus on maternity services. If the bill passes, there will be expanded federal research on best maternity practices and support for the education of a more culturally diverse interdisciplinary maternity care workforce. There will also be a national consumer education campaign to inform women about evidence-based maternity care practices.

For midwives, this legislation has brought renewed hope to a system of care that spends more than double per capita on childbirth than other industrialized countries, yet ranks far behind almost all developed countries in perinatal outcomes. For years midwives have been the champions of reducing risks in childbirth and eliminating disparities in communities of color. We have fought hard over the past several years to have federal legislation address concerns of midwives and the women we serve. A major barrier for women who want a midwife has been inadequate reimbursement for services. We know that midwives provide health care services to women of all ages and play a significant role in access to quality, affordable primary care, gynecology, family planning, and maternity services. Passage of MOMS 21 will enhance the viability of midwives as well as increase the incentive for hospital and physician practices to employ them.

The times, they are a changing, and we have renewed hope that the four million women who give birth in this country will have many safe, affordable maternity care options—and that the care they receive will be based on the evidence of best practices.

Happy National Midwifery Week! Have You Thanked Your Midwife Yet?

It’s National Midwifery Week 2010! To help you celebrate, we’ll be posting more frequently this week. Check back often and don’t forget to take advantage of our National Midwifery Week resources.

Birth, Trust, and Cultural Divides
by Lorene Gilliksen, CNM

As I celebrate my daughter’s 26th birthday, I’d like to acknowledge the help I received during my pregnancy from Mei Ka Chin, my midwife. Emily is my only child, so I suppose I am 26 years postpartum.

When I was pregnant, I worked at North Central Bronx (NCB) Hospital as a staff midwife. Mei Ka was a lead midwife there, and my friend and neighbor. As a patient, I felt confident and well-cared for because I knew that I had Mei Ka’s complete attention.

We are all thankful for midwives who listen to women and extend the values of midwifery into communities worldwide. Mei Ka is special because she listens beyond and across cultural infrastructures. She puts the dislocated, fretful, and disenfranchised at ease. Only later, as I worked at a hospital that served immigrants to the Midwest, did I think about Mei Ka’s special skills. As I attended the births of women from several continents, I thought about the courage required to give birth in a foreign city, without one’s mother, and without one’s mother tongue.

As current research on pitocin and trust reminds us, a woman needs to feel safe in order to labor. Childbirth generates a ripple effect of trust. These ripples of trust are a woman’s confidence in her body’s ability to do the work, the relationship she has with her partner, the web of immediate family support, and wide social networks. Midwives facilitate the effectiveness of these relationships. Mei Ka recognizes how each ripple contributes to a woman’s sense of safety.

Mei Ka has devoted her life to being present with women. (The word midwife means “with woman.”) She is now in Shanghai bringing new life into one of the world’s biggest cities. Mei Ka Chin wears a cell phone around her neck. She’s on call all the time. She was on call 26 years ago. She is on call now. Thanks, Mei Ka!

ACNM Members: Read the full version of Lorene's essay in the upcoming fall issue of Quickening.

Trail-Blazing for Midwives: An Unexpected Encounter

by Michelle Grandy, CNM, MN, President, Washington ACNM State Affiliate

Pictured in center: Michelle Grandy, CNM, and Congressman Jay Inslee

You never know where opportunities will arise to support midwifery. My most recent unexpected opportunity happened as I was backpacking with my daughter in the great outdoors of Washington State.

We heard a few men down the trail talking about taking a group photo. One voice was particularly boisterous in the otherwise quiet wilderness. As we rounded the corner, the group said, "Great! Here is someone who may be willing to take our photo."

I replied, "For you, I could do that."

After snapping their photo with a magnificent mountain range in the background, one of the men made a comment about "My chief of staff…"

"What do you do?"

"Well, I'm a congressman,” he answered.

"What is your name?"

"I'm Jay Inslee."

I jumped into gear and began talking about our recent ACNM Annual Meeting in Washington, DC, and how we'd missed talking with him personally but met Megan, his health legislative assistant. I asked if he'd heard of the MOMS 21 bill. He stated that he had not. I kicked it up a notch and began discussing the bill, using personal references to my practice at the University of Washington. I mentioned that one component of the bill would support certified nurse-midwives (CNMs) billing while supervising residents in medical schools.

A week later, I sent a follow-up e-mail that included a photo and a copy of the MOMS 21 bill to Congressman Inslee and Megan. Shortly after, I was notified that he signed as a cosponsor for the bill!

Interested in learning more about MOMS 21? Visit the ACNM website or contact Kathryn Kravetz Carr at kkccnm@gmail.com.

Let’s Play Catch Up!

by Melissa Garvey, ACNM Writer and Editor

We’ve been quiet at Midwife Connection lately, so let’s pick up the pace again by catching up on the latest ACNM news.

• Flu season is on the way. ACNM, CDC, and other professional organizations issued a joint statement on the importance of seasonal flu vaccination—especially for pregnant and postpartum women.
  
  
• Collaborative practice between midwives and physicians is in the spotlight. ACNM and the American College of Obstetricians and Gynecologists are calling for papers on successful collaborative practice models between midwives and physicians. Winning submissions will receive monetary awards and may be published in Obstetrics & Gynecology.
  
  
• Free updated midwifery fact sheets are available. Two of our most popular fact sheets—Essential Facts about Midwives and CNM/CM-Attended Birth Statistics—have been updated and are available online.
  
  
  
• National Midwifery Week is October 3 – 9. Host your own event or join in one of the many celebrations across the country during National Midwifery Week. ACNM has a webpage with tools to help you celebrate, and Where’s My Midwife? is organizing the National Walk for Moms and Midwives.
  
  

Remembering Women Who Were Widowed in Pregnancy on 9/11

As we approach the anniversary of 9/11, now is an appropriate time to revisit a study published in the March/April 2008 issue of the Journal of Midwifery & Women’s Health called “The Lived Experience of Widowhood in Pregnancy.” This groundbreaking study examined the experiences of women who were pregnant when their husbands were killed in the 9/11 attacks or while serving in the US military during the Iraq and Afghanistan wars.

This was the first study to examine the experiences of pregnant widows. (Most previous studies of widowhood have focused on women in their 60s or older.) Authors examined the experiences of 10 women who lost their husbands during pregnancy. Using 8 themes that emerged from the data analysis, the authors described the emotions and challenges experienced by these women, including their struggles with loss, emotional trauma, depression, and creating a support system for their birth. The study offers strategies that midwives and other women’s health care providers can use in helping these women cope with their loss and impending motherhood.

Approximately 7 million women in the United States become widows every year. It is not known how many women are pregnant at the time of their husband’s death. However, the authors emphasize that we need only look at recent historical events to see that the number of widows of childbearing age is rising.

Supporters Join Forces to Save Terre Haute Midwives

by Melissa Garvey, ACNM Writer and Editor

A group of midwives at Union Hospital in Terre Haute, Indiana, have been notified that their employment contracts will not be renewed this year. It’s a familiar situation—one that we saw play out in Wilmington, North Carolina, about this time last year.

The midwives’ last scheduled day at the hospital is October 29, but a dedicated group of supporters is refusing to stand by as the date approaches. Prompted by outrage, their love of midwifery, and a little help from Where’s My Midwife?, Friends of Wabash Valley Midwifery have organized to fight for their community’s midwives. They are on their second letter to the hospital and their third action meeting. Meanwhile, their Facebook group has grown to 113 members who are prepared to picket if the group so decides.

Want to show your support for Terre Haute midwives? Here’s how to help:

• Join the Friends of Wabash Valley Midwifery group on Facebook and stay tuned to updates and calls for action.
• Organize or participate in a Where’s My Midwife? Walk for Moms and Midwives on Saturday, October 9, during National Midwifery Week.
• Sign the Save Our Midwives! petition.
• Help spread the word by sharing this post, the Friends of Wabash Valley Midwifery group, and the Walk for Moms and Midwives with coworkers, friends, and family.
  

ACNM Responds to ACOG’s 2010 VBAC Recommendations

On July 21, 2010, the American College of Obstetricians and Gynecologists (ACOG) released a revised practice bulletin on vaginal birth after previous cesarean section (VBAC). Today, ACNM released its response to the revised practice bulletin. Read on for an excerpt from the response, or read the full statement here [PDF].

ACNM’s philosophy is that all women—including those who have had a prior cesarean birth—should have access to information, counseling and birthing options provided by vigilant, skilled clinicians within a coordinated maternity care delivery system. While integrated resources should be made available in all settings, immediate access to emergency delivery solely to safeguard against the potential risks associated with TOLAC (trial of labor after cesarean) should not be the focus. Rather, risk associated with TOLAC should be considered within the spectrum of perinatal benefits and risks associated with nulliparous women in labor. Uterine rupture, a rare, often unpredictable complication of both trial of labor after cesarean as well as repeat elective cesarean delivery, is a primary factor underlying the ACOG recommendations. Yet the risk of uterine rupture associated with TOLAC is similar statistically to that of other obstetrical emergencies for a woman experiencing her first birth. Furthermore, it should be noted that the benefits of labor and vaginal birth are often omitted from this discussion. The focus is exclusively on risk, which does not yield a complete picture. Provided with the latest evidence and comprehensive counseling, women must be allowed to make decisions regarding TOLAC and give birth in the settings that best meet their individual needs. It is unclear how these fully informed women will be at liberty to choose a TOLAC when facilities continue to refuse them this option, claiming compliance with the 2010 ACOG guidelines.

ACOG’s 2010 practice guidelines may help to expand access to TOLAC for women with certain clinical presentations. However, ACOG’s continued recommendation that TOLAC be undertaken at facilities capable of immediate emergency deliveries virtually assures that the 2010 guidelines alone will fail to appreciably increase access to TOLAC and VBAC in the U.S. The NIH VBAC consensus statement recommends that “hospitals, maternity care providers, health care and professional liability insurers, consumers and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor” (p. 37). Only a long-term, system-wide, concerted effort based on quality evidence and further research in all settings will accomplish this goal. ACNM welcomes this important and necessary collaboration.

Read more [PDF]

Access to Midwifery Care Improves Maternity Outcomes

by Tina Johnson, CNM, MS, ACNM Director of Professional Practice & Health Policy

The Patient Protection and Affordable Care Act will bring millions of newly insured citizens into the health care system. In order to meet the country’s needs, leaders are calling for high value, evidence-based solutions. Let’s start with the health condition that affects 100% of all Americans...childbirth! How can we provide high quality, high value maternity care for all women and families? The answers are in the evidence: midwifery care improves maternal and newborn outcomes and patient satisfaction, reduces health disparities, and saves money and resources.

The U.S. grossly outspends every other nation per capita on health care, yet our maternal and newborn outcomes lag far behind those of other developed nations. Childbirth is the number one reason for hospitalization, and its related hospital charges surpass those of any other health condition. Resource-intensive interventions like labor induction, epidural analgesia and cesarean section are overused, often without indication or consideration of alternatives, resulting in increased risk of maternal and newborn harm.

Cesarean section is the single most common operating room procedure in the U.S., and the rate is steadily climbing. Incredibly, in 2007, nearly one-third of American women delivered their babies by cesarean section. Maternal mortality has risen dramatically, and glaring racial disparities in maternal and neonatal outcomes persist.

How can we reverse these disturbing trends? Ensure that all women have access to maternity care providers and practices that support the normal processes of birth. Labor support, freedom of movement, intermittent monitoring, alternative birth settings, vaginal birth after cesarean...all have been identified as evidence-based practices that are underused.

Midwives truly are the experts in supporting healthy vaginal birth in all settings. Midwives caring for low-risk women improve infant mortality rates in both hospitals and birth centers when compared with physicians caring for equally low-risk women. Midwife-led models of group prenatal care reduce preterm and low birthweight rates and improve patient satisfaction. Birth centers provide improved outcomes for even the most at-risk women, reducing preterm birth, low birthweight and cesarean section rates, and reducing costs to our health care system. Skilled midwifery care is the gold standard among nations with the best maternal and neonatal outcomes, and has been identified as essential to reducing maternal mortality worldwide.

It’s time to bring that message back home. The time is now to promote and support midwifery in America—and to follow the evidence.

This post was originally published on the the Center to Champion Nursing in America (CCNA) blog. Visit CCNA to join more conversation about this post.

Labor Induction: The Back Door to Reducing Cesarean Rates?

by Melissa Garvey, ACNM Writer and Editor

A study in the July 2010 issue of Obstetrics & Gynecology underscores why the midwifery model of care—a model which minimizes interventions—should be the standard of care for women. Researchers set out to investigate the link between labor induction and cesarean birth, and discovered some telling findings.

This retrospective study examined the electronic hospital clinical records of nearly 8,000 women who had never given birth, were pregnant with only one baby, experienced head-first (specifically, vertex) presentation of the baby at birth, and were between 37 and 42 weeks of pregnancy. Of the group, 43.6% underwent induction of labor—39.9% of which were elective. That means that instead of being medically necessary, the labor induction happened because the woman and/or her health care provider chose to induce labor.

Many women and health care providers opt for elective labor induction. In fact, it may be a factor in why the latest CDC statistics show a 140% increase in the rate of labor induction between 1990 and 2007. Elective labor induction may seem like an attractive option when a woman is uncomfortable near the end of her pregnancy or is trying to plan for a vacation or important event. One study showed that most women don’t perceive labor induction as a safety hazard even at just 37 weeks of pregnancy.

But here’s the rub: researchers estimate that 20% of cesarean births among the women studied could be attributed to labor induction. After adjusting for confounders, for example, obesity and high blood pressure, labor induction was associated with a two-fold increase in the risk of cesarean birth.

Researchers also found a significant association between obesity and risk of cesarean birth. What do you think? Could the answer to reducing our 31.8% cesarean birth rate be reduced by a healthy lifestyle and avoiding unnecessary induction of labor?

For more information on when to allow labor to start on its own and when labor induction is medically necessary, check out the Journal of Midwifery & Women’s Health “Share With Women” handout on induction of labor.

Pregnant? This Caffeine Shot is for You…Maybe

by Melissa Garvey, ACNM Writer and Editor

The American College of Obstetricians and Gynecologists released a Committee Opinion this month entitled Moderate Caffeine Consumption During Pregnancy. The Committee Opinion examines a long-standing debate: is maternal caffeine consumption related to spontaneous miscarriage?

Caffeine raises a woman’s levels of catecholamines—hormones released into the blood in response to stress—and crosses the placenta to her unborn child. Sources of caffeine include coffee, tea, soft drinks, and chocolate.

Most studies on the relationship between caffeine and miscarriage have significant limitations, including small sample size and recall bias. The new Clinical Bulletin explores the results of several recent, higher-quality studies. The good news is that they found no link between moderate caffeine consumption and miscarriage. However, the results regarding higher levels of caffeine consumption are not black and white. The Committee Opinion states:

“Moderate caffeine consumption (less than 200mg per day) does not appear to be a major contributing factor in miscarriage or preterm birth. The relationship of caffeine to growth restriction remains undetermined. A final conclusion cannot be made at this time as to whether there is a correlation between high caffeine intake and miscarriage.”

Nutrition research can be especially challenging due to the difficulty of isolating various nutrients and controlling for confounding factors. For example, are the women consuming large amounts of caffeine in these studies getting a good night’s sleep? Are they using caffeine to keep up with a high-stress job?

What are your thoughts on this Committee Opinion? If you’re expecting, will it change your caffeine habit? Midwives, will this affect the advice you give to your patients and clients?

Midwife Develops iPhone Application for Expectant Parents

by Melissa Garvey, ACNM Writer and Editor

If you’re an ACNM member, you may remember Sandie Mulcrone, CNM, from the Spring 2008 and Spring 2009 issues of Quickening. I first interviewed Sandie after she successfully pioneered her way to a new hospitalist position at Advocate Christ Medical Center in Oak Lawn, IL. One year later, Sandie contacted me to share how she started her own business to improve women’s access to breastfeeding equipment. This summer, she’s at it again with yet another pioneering idea: iBabySono.

iBabySono is an iPhone application that allows expectant parents to store, sort, display, and share their baby’s ultrasound photos via iPhone, Facebook, and other online channels. Parents simply download their ultrasound pictures, then use iBabySono to upload the images and create virtual scrapbooks, calculate baby’s age, post images to Facebook, and send e-mail attachments to friends and family.

“Expectant moms and dads are experiencing one of the most exciting times of their lives,” says Sandie. “This is their future, a little person who represents their hopes and dreams. iBabySono lets them share that excitement and that joy with everyone they love from the earliest possible stages of their baby’s development.”

iBabySono is $2.99 in the iTunes app store and comes with a $10 discount for use at Sandie’s business, Perinatal Home Medical Supply.

What are some of your favorite apps for expecting and new parents or families?