|July 2, 2008|
Volume 10, Issue 14
|Midwifery Today E-News|
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In This Week’s Issue:
Quote of the Week
Farmer: "What are you talking about? Just lay them eggs!"
— From a Danish newspaper
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The Art of Midwifery
Affirmations…can be powerful tools. Simply alter those used with clients to a midwife's perspective. For example: Women are the product of millions of years of successful childbirth, babies know how and when to be born, I accept and embrace the mysteries and unknowns of the labor/birth process…. One could simply pick a few affirmations that particularly resonate, alter them to fit a midwifery perspective, write them on cards and read them before bed or put them around your living area or in your birth bag where they will periodically catch your eye. The idea is to create your own culture of trust in birth and to immerse yourself in it.
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Research to Remember
A study of 380 primarily poor African American and Latino children in Boston found a 12% prevalence of infants and toddlers with vitamin D deficiency and 40% with levels below an accepted optimal threshold (30 ng/mL). The prevalence did not vary between infants and toddlers or by skin pigmentation. Those who were breastfed only without supplementation were 10 times as likely as bottle fed babies to have vitamin D deficiency. On x-ray, three vitamin D-deficient participants (7.5%) showed changes related to rickets and 13 (32.5%) showed evidence of demineralization.
— Archives of Pediatric and Adolescent Medicine 162(6), June 2008
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Animal vs. Human Birth
The protocols in the world of animal husbandry to protect an offspring at the time of birth—no strangers, dimmed lights, freedom of movement, familiar environment, unlimited nourishment, respectful quiet, no disruptions—are done without hesitation because to do otherwise invites "unexplained distress" or sudden demise of the offspring. These thoughtful conditions are the norm, along with careful observation to determine when to use the technological expertise in true emergencies. When we have veterinarians in our childbirth education classes, they always start to smile and nod when I tell this story. These are givens—instinctive givens, even, for animals of all descriptions!
Yet what are the "givens" for the human who births not in a barn, but in a "modern and advanced" hospital? In many cases, 100% the opposite! Usually a minimum of a dozen strangers pass through the world of the laboring mother in her first 12 hours in the hospital—security officer, patient transporter, triage secretary, admission clerk, triage nurse, resident and/or doctor on call, admitting nurse, first shift nurse, break nurse, additional nurse at delivery, doctor or midwife plus possibly students, anesthesiologist, pediatrician, etc. Bright lights in the triage and labor rooms are challenging to dim. Mothers are tethered to monitors or IV poles and are moved through a bright hall with unfamiliar sounds to a new room in a building devoted to illness/trauma that most have visited once briefly if at all. They receive poor quality "clear liquids only." They are exposed to voices of others in the hall or chatting by the attendants during contractions and endless disruptions throughout! But then, do we ever find that we have an offspring experience "unexplained distress?" Of course, and at frightening rates! Yet, oddly, many of these disruptions are promoted as minor inconveniences or necessary to "protect" the baby.
Curiously, while veterinarians commonly have to defend interventions in light of the additional cost and the risks associated with interfering with nature, providers caring for human mothers within the medical system more commonly are forced to defend why they did NOT intervene! Consider the high rates of inductions, epidurals, artificial rupture of membranes, immediate cord cutting, cesareans and the vigorous defense necessary to fight for anything different, especially if time is involved (time to go into labor, to progress, to push, to allow the cord to stop pulsation or to get "done" bonding). I've recently seen outstanding CNMs and obstetricians sacrifice their own political reputations and suffer departmental reprimands for births with great outcomes where they protected the mothers' yearning for privacy, allowed extended pushing time with great vital signs or, during a healthy normal birth, followed their intuition and honored the mother's begging to check heart tones frequently by hand during pushing instead of what the mother considered the massive intrusion of wearing the monitor belt. Interventions are considered to be the ultimate protection from litigation in human care, yet they contribute mightily to the high rates of distress in mothers and babies!
In animal husbandry, the first line of defense for protecting the unborn is to protect and nurture the nutritional needs and comfort of the birthing female. In the case of institutionalized birth for humans, however, in spite of evidence to the contrary, the norm is to act as if the nutritional needs and the comfort of the birthing mothers are of concern to, at most, the marketing and public relations department! It's an affront to common sense that as a society we are currently more accepting of the needs of foaling mares, whelping poodles and high-producing cows than of our birthing humans. From the high rates of fetal distress, meconium staining and breastfeeding problems, the consequences are clearly devastating to our infants, just as any decent horseman would predict.
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The US now ranks 41st among 171 countries in the latest UN list ranking maternal mortality, with a maternal mortality ratio of 11 deaths per 100,000 live births, one of the highest rates among industrialized nations.
— US House Resolution 1022, "Reducing maternal mortality both at home and abroad"
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Question of the Week
Q: A lot of women these days seem to be getting their labor induced because they have oligohydramnios, or too little amniotic fluid. How is this determined? And how accurate is the test that is done to show that this "problem" exists? Is it a real problem? If so, what causes it?
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Question of the Week Responses
Q: Do you think that baby formula milk should be available by prescription, readily available or what? Basically, I mean when breastfeeding doesn't work, and a mom has tried everything in order to be successful at it, or had a medical or other reason for being unable to breastfeed?
— Jessica A Bruno
A: Marketing of infant formula has changed parenting practices around the world; the WHO says that 1.5 million babies die each year because they are not breastfed. Researchers Rogan and Chen (Pediatrics 2004) calculated that lack of breastfeeding causes at least 720 infant deaths a year in the US. Formula is the first step towards infants developing diabetes, obesity, lymphomas and leukemias, and other chronic diseases. The general public doesn't know this because in the US, profit is more important than health. The information is being kept from the public to sell product. (Google: "HHS toned down breast-feeding ads" for the August 31, 2007, story about this from the Washington Post.)
Breastfeeding provides health benefits to mothers as well, reducing risk for breast and endometrial and ovarian cancer and diabetes, and also delaying fertility.
In the ideal world, every city with a level III NICU would have a milk bank certified by the Human Milk Banking Association of North America.
We don't live in an ideal world; human milk is not available for every baby. Currently, women who are HIV+, HTLV-1 and HTLV-2+, alcoholics or illegal drug users, or are receiving cancer chemotherapy are discouraged from breastfeeding. Rare infants with galactosemia should not breastfeed; they need special formulas to survive. In these situations, the babies need to be fed. That means using formula.
I would like to see women without medical contraindications for breastfeeding sign an informed consent before using formula to indicate awareness that the health course of both their lives will be changed when they choose not to breastfeed.
Before that happens, every mother must have access to accurate and practical information and encouragement about breastfeeding after the baby is born. This means that every birth hospital and center would implement the 10 Steps to Successful Breastfeeding (from WHO/UNICEF), whether they apply for Baby-friendly status or not. This also means that every business and place of employment would implement recommendations from the Business Case for Breastfeeding (free from DHHS/HRSA 2008). This also means that the WIC program would stop giving away formula.
The US has a lot to do to increase breastfeeding initiation and rates of exclusive breastfeeding. The goal is exclusive breastfeeding for about six months, and a gradual introduction of solids after that time, with breastfeeding continuing up to at least one year and, thereafter, for as long as mother and baby find the relationship rewarding. To achieve that goal, breastfeeding must be supported (practical advice and encouragement) and protected (legislation in place to honor breastfeeding in the workplace, outside the home, in the legal system). We have made strides in the past 10 years, and still have far to go.
To put all of the responsibility on women to initiate and sustain breastfeeding when the cultural norm for infant feeding in the US is formula is unfair. Breastfeeding needs to be honored by our culture so that everyone assumes the baby will be breastfed.
— Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC, CCE, CIMI
A: This is the first I've heard of any movement toward making infant formula available by prescription only. Presumably the intention is to make clear to parents that the decision not to breastfeed has serious medical consequences. A worthy sentiment, but even leaving aside certain practicalities (imagine all the substandard foodstuffs currently fed to minors that would then have to be regulated), I have a problem with any type of regulation that undermines the judgment of mothers. The variables that play into any one mother's decision are far too numerous and individual for any such regulation to accommodate fairly. If we want to get the message across that formula feeding should always be the last resort, we must continue to insist that every mother should have affordable access to a qualified lactation consultant, that formula-makers have no place on the maternity ward, and that our legal and social environment must be 100% supportive of nursing moms.
— Megan O'Connor, LMT
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Think about It
In 2002 and 2005, following the devastation of the Tsunami in Indonesia, terrorist bombings in Bali led to the collapse of the tourist industry, resulting in economic devastation, mass poverty, and malnutrition on the island. As a result, the poorer families on the island lack the money needed to receive the health care they need in pregnancy and birth. When a mother is malnourished from poverty and then gives birth, there's a far greater chance she will tear, and without proper medical attention, the mother can bleed to death, which explains the high maternal mortality rate in Bali today.
In 1999, Midwife Robin Lim set up a birth clinic for women to come and receive prenatal care, as well as to give birth in a safe, compassionate environment commensurate with their ability to pay. To learn more, please visit the Web site of Yayasan Bumi Sehat: www.BumiSehatBali.org
Bumi Sehat began receiving 50 mothers per year and offering them a safe place to birth their babies. By 2007, that number jumped to 600, and projections are 750 to 800 births in 2008 with the same number of staff and facilities. Based on the numbers of women that come for prenatal visits every week, 2008 has already stressed the facilities at Bumi Sehat beyond maximum capacity. With a policy at the clinic that no woman is ever turned away, building a new facility in the same village that can accommodate all the requests for help has become critical. 100% of every dollar sent will directly go to funding the purchase of land, building and supplying the new clinic, and buying a much needed ambulance.
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***Note: Please only use the online method of donation for group donations over $10, as the fee for donating through PayPal costs $.30 per transaction and 3% of any amount donated.
Join my heart and turn it into A Million Mother's hearts, manifesting safe and proper care for mothers and babies in Bali! One Million Mothers CAN create a miracle—we DO make a difference. Please pass this to your childbirth classes, teachers, mother's groups, breastfeeding friends or mothers everywhere. The mothers on the island of Bali DO feel your caring. I make sure of that. Contact me directly, if you can help me spread this word to a million more mothers!
— In gratitude!
[Editor's Note: To read more letters about the effects of the tsunami, visit this tsunami news page from 2005.]
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The Commonwealth Court of Pennsylvania in May reversed the September 2007 decision of the Pennsylvania Board of Medicine to order Lancaster County midwife Diane Goslin to cease and desist from the practice of midwifery. Goslin, a Certified Professional Midwife, serves many Amish women there.
The Commonwealth Court in its decision said that "practicing midwifery cannot be construed to be the same as practicing medicine and surgery." The Board had ruled that Goslin had violated the 1985 Medical Practice Act by practicing medicine without a license, in part because she is not a nurse-midwife.
This is a monumental victory for women, babies, and the women who attend them! To learn more or to make a donation to help pay for defense costs, go to: http://www.savehomebirth.com/home
[Letter reprinted by permission]
Douglas H. Kirkpatrick, MD
I am a practicing OB/GYN in southern California and Fellow of ACOG and recently was informed by midwife colleagues of your recommendation and encouragement for the AMA to lobby Congress for a law banning out of hospital birth. Funny that I had to hear of this decision from outside sources and was never approached by my college to see how I or my local colleagues felt about it. I have grave concerns regarding my organization taking such a stand. I think we are all agreed that ACOG has a statement regarding patients' rights to informed consent and informed refusal. Yet, it seems with every decision our organization moves further away from that basic tenet.
ACOG's little "guideline" paper on VBAC in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds if not more hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let's be honest, to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If you think this is untrue you are, sadly, out of touch with real clinical medicine.
As to out of hospital birthing, please give me the courtesy of an explanation as to the data you used and the process by which an organization which is supposed to represent me came to this conclusion. Any statement saying that it is as simple as patient safety and that one-size fits all hospital birth under the "obstetric model" of practice should be applied to all patients is, putting it nicely, not really in line with what best serves all our patients. In many instances, hospitals are not safe, certainly not nurturing and have a far worse track record for disasters than home birth. Even when emergency help is nearby this is true. The focus of all of us in medicine should be on reigning in trial lawyers and tort reform and lobbying Congress for that. The best interest of the college members and the patients we serve would be for my organization to spend its time and energy on something that has true benefit.
Removing choices from well-informed patients and caring doctors and midwives is wholly un-American.
So please send me detailed information on how ACOG decided outlawing homebirth was a wise thing to do. You must have scientific data to take such a drastic stand. Please make it available to me so that I may share it with like-minded colleagues. I would also like to know the process by which this came to pass. Who first raised this issue and why? What committee reviewed all the data and did its due diligence in interviewing those of us with long-standing experience in backing midwives who perform out of hospital births? There must be a fine, non-confidential paper trail you can share with your members. Specific names of committee member who voted for this would be enlightening and I am requesting this information. I would like to know the background and expertise regarding out of hospital birth for each member who had a hand in the decision to go to the AMA.
We live in an odd era where once something is said or recommended by a legitimate organization such as ACOG it has deep ramifications never intended, such as becoming fodder for trial lawyers trying to squeeze the lifeblood and dignity out of your members. Or forcing women to travel hundreds of miles in labor to find a supportive facility. Or even worse, to have them arrive in a VBAC banned hospital and refuse surgery. Can this be the best we can do for our patients? Remember, your VBAC statement was meant to be only a recommendation but quickly became the rule by which hospital administrators, risk managers and anesthesia departments of smaller hospital banned this option for thousands of women. An option, that in proper hands, was the safe and accepted standard of care for 30 years. In fact, you still have an ACOG VBAC brochure that recommends this option!
For those of us working at smaller hospitals where VBAC was banned due to lack of emergency help (anesthesia, OR crews, etc.) there is a big question that has perplexed us, that no administrator seems to be willing or able to answer. That question is: "If a hospital cannot handle an emergency c/section for VBACs, and most emergencies are for fetal bradycardia, hemorrhage (i.e., abruption) or shoulder dystocia, not for ruptured uteri, then how can they do obstetrics at all?" For they seem to still be able to have a maternity ward without in house anesthesia. Will someday ACOG, in their great wisdom but seeming disconnect from reality, make a "recommendation" that little hospitals stop providing obstetric services? Will this better serve women and their communities throughout America?
I am frightened and angered by what you have done in my name. Now I ask you to defend your position in encouraging the AMA to lobby Congress for another restriction on the freedom of choice that belongs to women and their families. Those choices include midwifery and the right to have the most beautiful and life changing event occur wherever best fits their desire.
Midwives are well trained and required to have obstetrical backup. They have very special relationships with their patients and want the very best outcomes for them. They do not need me or you to police them. We have a habit in our country over the past 40 years of thinking we can legislate out stupidity. All that has done is erode the individual freedoms that belong, by birthright, to each of us. I would hope you trust your Fellows to know their specialty, their colleagues, and what is best for the patient as an individual.
These decisions do not belong to politicians or faceless committees. You should have more faith in your members to give balanced informed consent. Again, my recommendation to you is to put all your considerable energy into changing our legal malpractice system. Those of us actually practicing medicine and caring for patients know this to be the greatest threat to the mission and responsibility we have chosen to undertake.
I look forward to your response and possibly the beginning of a meaningful dialogue.
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