|February 19, 2003|
Volume 5, Issue 4
|Midwifery Today E-News|
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THIS WEEK'S ISSUE
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Quote of the Week
According to the medical model, life is a problem because it is full of risk and in almost constant danger, an assumption easily accepted if one's professional career is spent surrounded by pathology, suffering, and death.
- Marsden Wagner, MD
The Art of Midwifery
When a laboring woman urinates while she is pushing, I think, "Thank goodness, that will get the bladder out of the way to make more room for the head." I have the same thought when I see stool. Then I know that mom is pushing effectively and that the baby's head is moving lower and closer to being out. Getting rid of any stool makes that much more room for baby, and it is that much less stool that mom has to pass later when the perineum is sore.
- Lori, Midwifery Today Forums
All Birth Practitioners: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to firstname.lastname@example.org.
Epidural analgesia (EDA) has been reported to prolong labor. A study examined the concentration of plasma oxytocin and the progress of labor in women with and without EDA. Thirty-four full-term women in spontaneous labor were included, 17 with epidural and 17 controls, matched for cervical dilation and parity. Oxytocin was measured by radioimmunoassay before analgesia, 60 min later and after placental discharge. No oxytocin augmentation was given during the first hour. EDA during labor was associated with a fall in plasma oxytocin. There was no difference in plasma oxytocin levels between the groups at inclusion. One hour later, oxytocin concentrations had decreased in the epidural and increased in the control group. The change in oxytocin levels between the first and second sample differed significantly between the groups. No difference in cervix dilatation between the groups 1 h after inclusion was noted, but women with EDA had a longer labor compared with those without, especially those with epidural and oxytocin augmentation during the later phase of the first stage of labor.
- Acta Obstet Gynecol Scand 81 (11):1033- (2001)
A study titled "Racial Differences in Prenatal Care Use in the United States: Are the Disparities Decreasing?" and published in the December 2002 American Journal of Public Health, used all U.S. birth records from 1981 to 1998 to explore trends in early and adequate prenatal care use for African American and white women. For the 18-year study period, the percentage of pregnant African American women who received adequate prenatal care as measured by the month care began and the number of prenatal visits in the first trimester rose from 26.9% to 44%, an improvement of 64%. Among white women, the percentage receiving adequate prenatal care rose from 33.6% to 50.2%, a 50% increase. Overall, the racial gap in adequate care use has narrowed steadily since the 1980s, but the study revealed that the gap is actually widening among white and African American mothers 17 years of age and younger.
The study also found that
A study by Giblin, Poland, and Ager (Journal of Community Health 15 (6), 357-368 ) found a clear association between the level of tangible/behavioral, emotional, and informational support of expectant fathers and prenatal care use and health behaviors exhibited by the expectant mother. The study shows that women were more likely to participate in prenatal care and quit risky behaviors if the expectant fathers provided them with all three of those types of support. Thus, the informational support of the expectant fathers is as essential as emotional and behavioral support. Informational support is exhibited by the roles of information provider and information seeker.
Also, research conducted by Westney, Cole, and Munford (Journal of Adolescent Health Care, 9, 214-218 ) suggests that the expectant mother is more strongly influenced by input from her partner than from any other significant person, including other relatives and healthcare professionals. This research suggests that expectant fathers were most influential in getting the expectant mother to comply with medical protocol and exercise good health behaviors.
A recent report, "WHO antenatal care randomized trial for the evaluation of routine antenatal care," (The Lancet, May 2001) concludes that for women without previous or current complications, a reduced number of prenatal visits, including goal-directed, effective activities, does not increase risk for themselves and their babies and may reduce the cost of pregnancy-related health care. This multicenter, randomized, controlled trial compared the standard model of antenatal care with a new model that has fewer clinic visits and emphasizes actions known to be effective in improving maternal or neonatal outcomes. There were two elements to the trial: not just fewer prenatal visits but also a set of specific, scientifically evaluated activities.
Fifty-three clinics were randomly allocated to the new model or to standard care. Women in new model care clinics were evaluated according to obstetric history, present pregnancy, and general medical condition to receive basic prenatal care, or more intensive care if appropriate. Twenty-three percent of women received the intensive model of care, and all women were included in the final analysis.
The new model consists of a set of specific activities implemented on a four-visit schedule. In fact, the women had an average of five visits, and in the control clinics the average was eight. Activities were familiar prenatal care activities in three general areas: screening, therapeutic interventions, and education ... The primary outcomes studied were low birth weight, preeclampsia/eclampsia, severe postpartum anemia, and severe treated urinary tract infection.
All primary outcomes were essentially the same in both models, except for preeclampsia, for which the authors report "the rates were clinically similar, but an increase in risk of up to 56% cannot be ruled out." Rates of eclampsia were essentially identical.
Women expressed concern about the reduced number of prenatal visits but were more satisfied with the length and content of the individual visits. Providers' responses were mixed. Costs were reported to be possibly lower. More referrals were engendered by the new model of care.
Perhaps the biggest concern is that government and third-party payers may use the study as a reason to reduce the access of vulnerable populations to prenatal care, a course that midwives should resist. In countries where economics does not permit access to prenatal care for the poor, the new model might be used to expand prenatal care in a beneficial manner while making the best use of available funds. The worst outcome would be a situation in which a frightened teen mom calls, anxious to be seen, only to be told, "Your medical card will cover only four visits. You can come in but you will be billed for it yourself." This kind of outcome would seriously decrease the quality of maternity care and increase complications.
- Marion Toepke McLean
Excerpted from "How Many Prenatal Visits?"Midwifery Today Issue 59.
To read the entire article, purchase Midwifery Today Issue 59. To order, click here.
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