Book 1 by Stephanie Penland

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 – 14

New Life — A Woman-Centered Birth

A Woman’s Confidence, her ability to give birth, and to care for her baby, are either Enhanced or diminished by each person who gives her care, and by the environment that she gives birth in.

The

Beginning Weeks 1 â&#x20AC;&#x201C; 14

Birth Should be

Amazing, Fulfilling

and Empowering

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Dedication This thesis is dedicated to my husband who supported me, encouraged me and never gave up on me in any area of my life. I also dedicate this book to all the women whom have ever had to say, I wish I knew then, what I know now, about their birth. And to every mother who has had a baby and wanted to finish school, to keep going, it is worth it in the end. With the guidance and aid of my midwife Maria Iorillo, the love and support of my husband Michael Penland, mom Catherine Byrd, doula Christina Beiser and encourager Jackie Page, my birth team, I had a perfect birth in spite of the challenges. A big Thank You to the Academy of Art University and teachers, Erik Adams, Ariel Grey, Hunter Wimmer, Phil Hamlett, Marc English, Jeremy Stout, Jennifer Sterling and many more for guiding me and working through tough times in life and design, for always encouraging me and challenging me to greater heights.

It's not about Home-Birth vs Hospital Birth It's about Evidence Based Practices

The debate about heath care in the usa goes far beyond coverage. Addressing quality health care for all women on the basis of nondiscrimination and equality is key. Maternal health care services must be improved for all women, and those most affected by current disparities in health care. Amnesty International Deadly Report 2010 shows the human cost of this failure and highlights the urgent steps needed to reduce maternal mortality and morbidity rates in the usa .

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Forward These books are intended for the pregnant mother to learn and make educated decidions about her heath care during and after the birth of her baby. They provide Evidence Based Resources for practices and procedures and a way for her to share and engage those around her in a conversation about why she has chosen the type of birth she wants, be it a home-birth or a hospital birth. I am not an expert but the articles I have included are from experts that are rich in information and content. I am a mother who has gone through this process of giving birth. New Life is an easy read with uplifting stories and statistics but also presents comprehensive and straight forward information that appeals to the heart and the rational mind. Upon approval of my thesis in July of 2009 I was 7 months pregnant. I had hoped to have a home-birth but due to unforeseen events I did not. I labored 36 hours at home, then another 8 in the hospital. This was a blessing in disguise as I got both the home and hospital birth experiences. I had all the stereotypical bad doctors, as well as some fantastic nurses. Through the help of my birth team, my midwife, husband, mother and encourager Jackie, my entire birth experience was not only fantastic but empowering. This thesis focuses on the woman while pregnant and her choices in maternal care, with an emphases on natural birth, feeling safe and having alternatives during labor and finally postpartum care. The research is based on a central theme of a woman-centered birth backed by scientific research data provided by the cdc, w.h.o, March of Dimes, Stanford, Harvard, Amnesty International, and many other noteworthy organizations.

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Title Page book

section

k The Beginning l The Middle m The Arrival n The Postpartum o The Birth Story 01 New Life â&#x20AC;&#x201D; A Woman-Centered Birth 02 Evidence Based Birth 03 A Woman-Centered Model of Maternity Care 04 Choosing a Hospital or ob/gyn 05 q & a for your ob/gyn or Doctor 06 Choosing Home-Birth & Midwife 07 Choosing Birth-Center 08 q & a for your Midwife 09 Choosing a Doula 10 q & a for a Doula 11 The History of Child Birth in the usa 12 The Finance of Health Care 13 Failure to inform â&#x20AC;&#x201D; The usa's Maternity Crisis 14 Accountability and Lack of Supporting Data 15 Exercise for Pregnancy 15 When is that Baby Due?

The are two Essential human needs in this life, Love and Peace! When these two vital elements are not provided for in the home, a life-long search beings. Home is the central system in which human development occurs. The main function of the home should be designed very carefully. When families execute plans to provide positive growth, that is needed by each person living in that home, the results can be Glorious.

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Excerpt 01 start | The Dignity and Sanctity of the Home — The Home Experience By Devi Titus Dignity The dignity of the home is seeing and experiencing it’s worth by those who are touched by it. Webster says dignity is worthy of recognition due to a change in character and appearance. Combining worth together with character and appearance defines dignity. A home that has dignity sets standards of order and creativity with the godly characteristics of love, honesty, and loyalty. The sanctity of the home is it’s purity in heart and purpose — which is, its wholeness and holiness in tone and mood. Home is a duet of devotion and worth — devotion to God while valuing one another. Home is the sanctuary for the human soul to be recharged, renewed, refreshed, and restored. Home is the Basis for Human Society One of the most widely read books of all time is The Decline and Fall of the Roman Empire. In his book, Edward Gibbon gives Five Basic Reasons Why Great Civilizations Wither and Died. These are as true today as when Gibbon wrote it in 1788. Five Basic Reasons Why Great Civilizations Wither and Died k The undermining of the dignity and sanctity of the home, which is the basis for human society. l Higher and higher taxes: the spending of public money for free bread and circuses for the populace. m The mad craze for pleasure: sports becoming every year more brutal, more immoral. n The building of great armaments when the real enemy was within — the decay of individual responsibility. o The decay of religion; faith fading into mere form, losing touch with life, losing power to guide the people. end |

Excerpt 02 start | Birth Matters by Ina May Gaskin It matters because it is the way we all begin our lives outside of our source, our mothers’ bodies. It’s the means through which we enter and feel our first impression of the wider world. For each mother, it is an event that shakes and shapes her into her innermost core. Women’s perceptions about their bodies and their babies’ capabilities will be deeply influenced by the care they receive around and during the time of birth. No matter how much pressure our society may ring upon us to pretend otherwise, pregnancy, labor, and birth produce very powerful changes in women’s bodies, psyches, and lives, no matter by which exit route — natural or surgical — babies are born. It follows then that the way that birth care is organized and carried out will have a powerful effect on any human society. A society that places a low value on its mothers and the process of birth will suffer an array of negative repercussions for doing so. Good beginnings make a positive difference in the world, so it is worth while to provide the best care for mothers and babies throughout this extraordinarily influential part of life. Birth also matters because the journey through pregnancy and birth offers an irreplaceable way for women to explore their deepest selves — their minds, bodies, and nature. Such a journey of self-discovery can help them prepare for the hard and under appreciated job of motherhood in a world now full of historically unique and complex challenges. There is a sacred power in the innately feminine capacity of giving birth. It is one of the elemental, continuing processes of nature that women have the chance to experience, and it is the one act of human creation that is not shared by men. end |

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Excerpt 03 start | Interview Maria Iorillo 2012 No matter where they have their baby, with a midwife or with their ob in the hospital I want women to come from their birth experience feeling likee, WOW! I just gave birth and I feel so empowered. If I can do that, I can certainly take on mothering. This is an important piece I've learned about myself about how courageous I am, how strong I am and I work. Because then they can take that with them for the rest of their lives. What you take away from your birth experience is something you take for the rest of your life. And unfortunately what we are coming up against now is women coming off of their births with ptsd, post traumatic stress disorder because it was so terrifying, things weren't explained to them, they weren't treated with kindness or respect or informed of what was going on and birth becomes very scary for them. Midwifery often sounds too crazy for people to consider. So we need to go all the way back to step one and get people interested in natural childbirth and really help people understand why it is a powerful thing to do and why it's worth while. The question usual is, Why would you do a natural birth if you have drugs to take away the pain? Once we get more women interested in natural childbirth they will start asking the right questions. end |

We should ask the question

What are the Basic Needs of Pregnant Women? From Conception, During Birth, Through Postpartum

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Excerpt 04 start | Deadly Delivery Maternal Heath in the usa by Amnesty International 2010 The total amount spent on health care in the usa is greater than in any other country in the world. Hospitalization related to pregnancy and childbirth costs in the usa, are $86 billion a year; the highest hospitalization costs of any area of medicine. Despite this, women in the usa have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries. For example, the likelihood of a woman dying in childbirth in the usa is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain. More than two women die every day in the usa from pregnancy-related causes. Maternal deaths are only the tip of the iceberg. Severe complications that result in a woman nearly dying, known as a near miss, increased by 25 percent between 1998 and 2005. During 2004 and 2005, 68,433 women nearly died in childbirth in the usa. More than a third of all women who give birth in the usa — 1.7 million women each year — experience some type of complication that has an adverse effect on their health. African-American women are at especially high risk; they are nearly four times more likely to die of pregnancy related complications than white women are. Even for white women in the usa, however, the maternal mortality ratios are higher than for women in 24 other industrialized countries. These rates and disparities have not improved in more than 20 years. Maternal mortality ratios have actually increased from a low of 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While some of the increase may be due to improved data collection, the fact that maternal mortality ratios have doubled is a cause for concern. At the time of writing, reform of the health care system was a priority for the usa's administration and major changes were under consideration. However, under the existing system, the way the health care system in the usa is structured and financed is failing to ensure that all women have equal access to the health care they need. Although women in Active Labor cannot legally be turned away from a hospital regardless of their ability to pay, they may later be billed for thousands of dollars for medical care. Half of all births are covered by private insurance.

However, policies that exclude coverage for maternal care are not uncommon and pregnant women may also find that they cannot get private health insurance because pregnancy is regarded as a pre-existing condition. About 42 percent of births are covered by a government-funded program for limited categories of low income women. Medicaid, however, complicated bureaucratic, requirements means that the women eligible for public assistance experience significant delays in receiving prenatal care. Women, and above all, the ones from low incomes, can face considerable obstacles in obtaining maternal health care, particularly in rural and inner-city areas. Doctors may be unwilling or unable to provide maternal health care because of the high costs and low reimbursement fees involved or because of cumbersome reimbursement procedures via Medicaid. Women interviewed by Amnesty International also cited lack of transport to clinics, inflexible appointment hours, difficulty in taking time off work, lack of child care for other children, and the absence of information in languages other than English or interpreters, are the major barriers to health care. Again, discrimination proved to be an additional barrier for African American, Indigenous, Latina and immigrant women and any who did not speak English. The usa's governmentâ&#x20AC;&#x2122;s failure to ensure that women have guaranteed lifelong access to quality health care, including reproductive health services, has a significant impact on the likelihood of having a healthy pregnancy and delivery, and postpartum care. Prenatal care is expensive, and if youâ&#x20AC;&#x2122;re undocumented or uninsured itâ&#x20AC;&#x2122;s a luxury instead of a basic right. Susan Moskosky, Director of Office of Family Planning, Office of Population Affairs, Amnesty.

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Prenatal care is very expensive, and if you are undocumented or uninsured it is a luxury instead of a basic right. The usa's government has failed to ensure that women have a guaranteed lifelong access to quality health care, including their reproductive health services. This has a significant impact on the likelihood of having a healthy pregnancy and delivery. Susan Moskosky, Director of Office of Family Planning, Office of Population Affairs, Deadly Delivery Maternal Heath in the usa by Amnesty International 2010

Key Recommendations k The usa's government should ensure that health care services, including sexual and reproductive health care services, are available, accessible, acceptable and of good quality throughout an individualâ&#x20AC;&#x2122;s lifetime. l The usa's government must ensure that all women have equal access to timely, quality maternal health care services, including family planning services, and that no one is denied access to health care services by policies or practices that have the purpose or effect of discriminating such as ethnicity, age, gender, race, ability to pay, indigenous status, or immigration status. m The Office of Civil Rights, within the Department of Health and Human Services, should undertake investigations into laws, policies and practices that may impact equal access to quality health care services. n State governments should ensure that pregnant women have temporary access to Medicaid while their permanent application for coverage is pending presumptive eligibility and that Medicaid provides timely access to prenatal care. Cases where a woman receives prenatal care before eligibility is confirmed, the states should ensure that Medicaid reimburses retroactively for services provided. o Federal, state and local governments should ensure that an adequate number of health service facilities and health professionals, including, nurses, midwifes and physicians, are available in all areas. Particular emphasis should be given to medically under served areas, including by expanding community health care center programs, such as the Federally Qualified Health Center, fqhc. p The Department of Health and Human Services should, in collaboration with affected communities and the medical community, develop and implement comprehensive, standardized, evidence-based guide lines and protocols for maternal health care services.

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q Health care providers should ensure that sufficient, accessible information is available to all women so that they can make informed decisions about their personal health care. r The usa's congress should direct and fund the Department of Health and Human Services to establish an Office of Maternal Health with a mandate to improve maternal health care and outcomes, and eliminate disparities. s Washington, d.c, and each of the 29 states that do not currently have a maternal mortality review committee should establish one. Committees should receive ongoing funding to collect, analyze and review data on all pregnancy-related deaths and address disparities. Efforts at state level should be coordinated nationally by the cdc in order to identify and implement best practice. k t State and federal authorities should devise and implement programs to data collection and analysis in order to better identify and develop responses to issues contributing to maternal deaths and complications. This may also include requiring all states to report maternal deaths and morbidity to federal agencies, including the cdc, on an annual basis and standardizing data collection tools. end |

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k Designer Stephanie Penland l Photographers 01 Isaiah Beiser Photography 02 Tres Photography 03 Stephanie Penland 04 Catherine Byrd 05 Istock Photography m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

These books are intended for the pregnant mother to learn and make educated decisions about her heath care during and after the birth of her baby. They are a resource and a way for her to share and engage those around her in a conversation about why she has chosen the type of birth she wants, be it a home-birth or a hospital birth.

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 – 14

Evidence Based Birth

Did you know that many women in the United States and other countries receive maternity care that is not based on best evidence? Unfortunately, evidence-based maternity care is hard to come by

sometimes. Research has shown that it takes — on average — twenty years for evidence to make its way into clinical practice. This means that it is very possible that you — as a maternity patient — may sometimes receive standard care that is outdated, carries no benefits, and may increase your risk of harm.

Evidence Based Care should be

The most up-to date

Practices & Procedures

sect ion 01 Evidence Based Birth

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Evidence Based Birth In our society today it is accepted that a healthy baby is more important than a good birth. People are placing their trust in their providers to keep them safe. It is interesting that home-birth is higher in second time moms who are refugees from a previous, traumatic, hospital birth experience, showing that the hospital was inadequate for meeting their needs, inflexible and incapable. A 2008 survey of 2,792 mothers through The Fairfax Essential Baby website highlighted traumatic and unsatisfactory experiences of women giving birth in an overstretched system. A particularly alienating feature of this system is its one-size-fits-all service, which dismisses the special needs of individual women. The features of current maternity services include conflicting information and advice, which result from staffing arrangements that cannot secure a known caregiver once the woman has been admitted to a hospital. Having a constant stream of unknown caregivers undermines the trust women have in the care received and decisions being made. start | Evidence Based, December 3, 2012 By Rebecca Dekker, phd, rn, aprn — givingbirthwithconfidence.org What is Evidence Based Birth and Why Should You Should Care? Have you ever been told that you have to do things a certain way when you are giving birth? That your care provider may or may not allow you to do something? As a nursing professor, I teach my students to always ask the question, Why? Why do we do things a certain way? Is there any evidence to back this up? It is okay — and it’s even best — if you ask What’s the evidence for that? When you are told you need to do things a certain way during pregnancy and birth. When I got pregnant for the first time, even though I was a nurse, I really didn’t know that much about labor and delivery. I read a few baby books, took the brief hospital class, and looked through my old ob textbook a couple of times. I thought that was all I needed to know — because my care providers would guide me through labor and delivery, and they knew what was best, right?

sect ion 01 Evidence Based Birth

I ended up having a pretty typical labor and delivery in the hospital — a vaginal birth of a 6 lb 8 oz little girl — along with iv fluids, continuous monitoring, strict bed rest, nothing to eat or drink for 24 hours, Pitocin and an unwanted epidural for failure to progress, vacuum extraction, and finally — immediate separation from my healthy baby after birth so that she could be observed in the nursery for several hours. A few years later, when I became pregnant again, I started thinking about everything that I had experienced in the hospital. By this time, I had finished my research doctorate and I was in a full-time nurse faculty position, teaching nursing students and doing research. As a teacher, I was talking every day with my students about evidence-based practice. Meanwhile, as a researcher, I was discovering new evidence for how to best take care of people with heart disease. Then one day, I started to get curious. I had always had a gut feeling that there was something wrong about my first birth. I was a completely healthy, low-risk pregnant woman who was in great physical condition. I was as healthy and strong at 9 months pregnant as I am right now. So why did I get the feeling that something was wrong about the care I received? Was my care really based on best evidence?

For those of you who don’t know, evidence based care means that your healthcare is based on the most up-todate medical evidence about what works best. Evidence-based care also means that you are informed accurately about risks and benefits of different options, so that you can make the best informed medical choices for your unique situation. Using the resources at my university, I began to read the medical evidence for the care I received at my first birth. Imagine my surprise when I learned that much of the care that I received has been shown by medical evidence to be harmful to healthy pregnant women and their babies!

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Amazed by the evidence I was uncovering, I googled evidence-based care during labor and delivery. I was stunned to find that nobody else was really blogging about this the way I thought it could be done. The evidence exists out there â&#x20AC;&#x201D; but in order to read the evidence you need an expensive subscription and you need to have research skills in order to decipher the evidence. I happened to have both the subscription and the skills. I thought to myself, Wouldnâ&#x20AC;&#x2122;t it be great if I could blog about the evidence about birth options so that pregnant women all over the world can access and understand this information? At Evidence Based Birth, my main goal is to write articles that review the highest quality medical evidence for certain birth practices. For your sake, I always have at least two experts review my articles, and I try to write the articles in as non-biased a way as possible. I donâ&#x20AC;&#x2122;t want to insert my personal opinions into these articles. Instead, I would like for the evidence to speak for itself, and then let you and your care provider decide how you want to use that evidence for your unique situation. I realize that educating people about the evidence is not enough. Real life stories can give people the courage to put evidence into motion. I publish testimonials, written by women and care providers, that promote the use of evidence-based practice. Why should You care about Whether or not Your Birth is Evidence-Based? Nursing students are in a unique position to observe what is going on in the maternity care system with a fresh, unbiased view. I asked a nursing student who is currently in her ob clinical rotation to share her impression about why you should care about evidence-based birth: Kara Lester, a bsn nursing student, writes, As a nursing student currently in my ob rotation, I have met many pregnant mothers throughout the semester. Some are well-educated, while others have more limited knowledge about pregnancy. It is so important for women to be active participants in their care because it gives them autonomy within the healthcare setting. Women who are aware of the evidence and options available will have more confidence when it comes to voicing their thoughts and feelings to healthcare providers.

sect ion 01 Evidence Based Birth

Also as healthcare providers, we need to empower women to get more involved in their care by giving them the facts and letting them decide what option is best for their situation. During one of my clinical rotations, I sat through a birthing class with a first-time pregnant couple and saw firsthand that as their knowledge grew, so did their confidence. As the couple became more engaged, they started to feel more comfortable in their decisions. It was really neat to see their transformation from being quiet and anxious to calm and confident. Witnessing this reminded me that as an active participant you really can have an influence on the care you receive — and ultimately the outcome of your stay. Your Next Steps You have already taken a great first step by learning what evidence-based care means. However, here’s a little secret I’m going to tell you. Even though we have evidence for many treatment options, this evidence is not always used in practice. Sometimes your care providers might not know about the evidence, or they might choose to ignore the evidence. Why? We don’t know exactly why, but there are many possible reasons. It may be that some care providers are too busy and do not have time to keep up with the most up-to-date research. Or maybe they can’t access the evidence. Or maybe they just prefer to do things the way they have always done them.

So ask your care provider about the evidence. Whenever a treatment option is suggested, ask, What’s the evidence for that? What are the risks? What are the benefits? Are there any other options that I should consider?

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Ultimately, I believe that the power to move towards evidence-based care is in your hands — the hands of pregnant women and their families. This past Labor Day, nearly 10,000 women in the usa rallied on the streets to raise awareness for the need for evidence-based maternity care. In 2013, we expect those numbers to double. I encourage you to educate yourself about evidencebased care and then get involved at the local or national level with campaigns like ImprovingBirth.org, an organization dedicated to promoting evidencebased maternity care in the usa Who knows? Maybe, if enough women stand up to demand the best care — evidence-based care — we can make birth safer and better for us and our babies on a national scale. Rebecca Dekker is an Assistant Professor of Nursing and teaches pathopharmacology to undergraduate nursing students. She recently received the Marie Cowan Promising Young Investigator Award from the American Heart Association, and she is principal investigator on a research grant from the National Institutes of Health. In 2012, Rebecca foundedEvidenceBasedBirth.com and joined the executive board of ImprovingBirth.org — a non-profit organization dedicated to promoting evidence-based care for women, their babies and families. end | start | In the first place, do no harm — Bringing the Hippocratic Oath into the 21st Century In order to bring science-based maternity care to all childbearing women, we must bring an end to flat earth obstetrics. True mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Our present system of obstetrics for normal childbirth does not do well in this regard. The scientific literature — vital statistics records, textbooks and published research — all make it clear that routine obstetrical interventions and conducting normal birth as a surgical procedure are more dangerous for healthy women than the use of normal or physiological principles.

sect ion 01 Evidence Based Birth

For the last century, an unscientific form of interventionist obstetrics has dominated maternity care in the United States, to the detriment of child bearing women and the taxpaying public. In spite of spending more money that any other country in the world, the United States is 30th in maternal mortality and 22nd in perinatal mortality. The five countries with the best outcomes spend only a fraction of the money we do. They all have national maternity care policies that depend on physiological management. Over the last hundred years organized medicine has purposefully dismantled the infrastructure for providing physiologically-based maternity care and replaced it with interventionist obstetrics. Medical and surgical procedures originally intended to treat life-threatening complications are routinely used on healthy women with normal pregnancies, without having been proven safe or more effective than physiological management. This unregulated medical experiment introduces artificial risk and serious complications. In the last three decades the medicalization of childbirth has expanded exponentially. Institutional memory of normal childbirth is now absent for obstetricians, the nursing profession and medical educators. Defensive medicine rules the day. This creates an asymmetrical burden of risk that falls unfairly on the childbearing woman, in which the mother is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of litigation for the obstetrician. Premature and/or artificial termination of normal pregnancy through induction of labor, surgical incisions, instruments or cesarean section has become the statistical norm. Childbirth for healthy women in 21st century America is typically accompanied by the routine use of continuous electronic monitoring 93%, inducing or speeding up labor with artificial hormones 63%, epidural anesthesia 63%, episiotomy, instrumental delivery and/or cesarean surgery 72%.

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America is typically accompanied by the routine use of continuous electronic monitoring 93%, inducing or speeding up labor with artificial hormones 63%, epidural anesthesia 63%, episiotomy, instrumental delivery and/or cesarean surgery 72%. Obstetrical medicine rejects out of hand the social model of childbirth used world-wide to the great advantage of childbearing families. While publicly promoting itself as virtuous beyond compare, the obstetrical profession is frequently disrespectful and dismissive of the concerns of childbearing women and their families. It does not provide truly informed consent and resorts to threats of legal force if parents do not quickly comply with obstetrical advice for risky medical and surgical interventions that frequently turn out to be unwarranted. For society, flat earth obstetrics is an economic issue. Most Americans are not directly affected by this dysfunctional system â&#x20AC;&#x201D; that is, we aren't presently expecting a baby and do not have to worry that we will become a casualty of over treatment. However, we are all negatively impacted by the economic damage resulting from artificially inflated maternity care costs. The current practice of obstetrics misdirects scarce economic and human resources that could more properly be used to treat the ill, the injured and the elderly. Seventy percent of maternity care expenses equal to 2.4% of our total GNP are artificially inflated by unneeded medicalization and preventable complications. The bill for this failed medical experiment is passed on to the public and to employers through the increased cost of health insurance and the Medicaid tax burden. Economists identify our inflated health care costs as compared to other countries as a major reason why many industries are outsourcing manufactured goods and replacing service jobs with off-shore workers. This means that every American has a stake in reforming our maternity care policies so the United States can remain competitive in a global economy. Worldwide, the global economy depends on the use of physiological principles and low-tech, low-cost methods for providing normal birth services. To remain competitive in a free market economy, the usa must also utilize these efficacious forms of maternity care to meet the needs of healthy families.

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k Designer Stephanie Penland l Photographers 02 Edited by Tres Photography 03 Stephanie Penland m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

A Woman-Centered Model of Maternity Care

When the focus of maternity care is on the woman, her heath, her needs, and her preferences, harm to the mother and the baby can be greatly decreased. The midwife is one of the best kept secrets of this age. And those that discover who the midwife is and what she offers finds not only amazing maternity care but a friend, an encourager, and a relationship like none other.

sect ion 03 A Woman-Centered Model of Maternity Care

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A Woman-Centered Model of Maternity Care The midwifery model of maternity care rests on the assumption that all things maternity related are both normal and natural. The process is a woman-centered model of care. When the focus is on the woman, her heath, her needs and her preferences, harm to both mother and baby can be greatly decreased. The midwife is one of the best kept secrets of this age. Each state in the usa has it's own credentialing system, so be sure to check out what your state says regarding midwifes. The laws and insurance companies are always changing things up so it's good to research these things and know what your rights are. Family Planning is a major part of having a baby. Peter Schlenzaka did research in the last decade about midwifes and amazingly he found that there were far less medical interventions used, less complications, had fewer medical emergencies, and a significantly reduced infant and mother mortality rate especially when compared to the procedure of a c-section within the midwifery model of maternity care. Certified Nurse-Midwife cnm This person is trained and licensed in both nursing and midwifery. They have earned at least a bachelor's degree and are a part of the American College of Nurse Midwifes. Midwife This can be a general term as well as a person who is independently trained in midwifery. Self-studied, have an apprenticeship, or attend a midwifery school or college or university program. Just because they don't have the nurse title after their name doesn't mean they are not fully capable. They most likely have education and training in emt certifications and much more so be sure to ask them about that and research their experience. American Direct-Entry Midwife dem This person is trained in a credited midwifery program, can also be with a self-study, apprenticeship, a school or a college program. Certified Midwife cm This midwife has at least a bachelor's degree from an accredited institution and are certified under the American College of Nurse Midwifes, and they are trained.

sect ion 03 A Woman-Centered Model of Maternity Care

start | Bring The Midwifes Back â&#x20AC;&#x201D; 2011 by Crystal Wolf Around most of the United States the perception of birth is something to be feared, that it is painful, and that women must be rescued from it. On the television, whether it be movies or a real life hospital show, the majority of what we see are women in pain, screaming, blaming their partner for putting them in this situation, asking for drugs and wishing they didn't have to go through this horrible experience. We can add to this scene that the birthing woman is laying on her back, hooked up to machines, pushing when someone other than herself is telling her to push. The sad part of this is that this depiction is only one side and it does not have to be the most common view. Furthermore the scary part of this view is that it has encouraged the medical community to go overboard with interventions to save the birthing mother. These interventions, when used at unnecessary times cause more harm than good. Doctor's are trained minimally about natural childbirth and few have seen many natural births. They are also supported in performing caesareans and must defend not doing one. If I could wave a wand and change this atmosphere, the medical community and the natural world could merge and live together peacefully as well as support one another. Childbirth should be seen as a miracle, and moment in time, or a woman who can be in a state of ecstasy and bliss instead or in spite of the pain. Hospitals would have to bring midwifes back into the hospital scene and reserve the doctor's role for the small percentage of women that need their expertise. If a doctor is very attracted to birth in all forms, then he or she could train with a midwife to be skilled in both avenues thoroughly. Midwifes are natural birth advocates that have been doing what the medical community says is impossible for decades! If you compare notes between hospital births and births at home or in birthing centers the differences are astounding. All of the things that have had a strong place in the medical community are bypassed in the natural scenes. The medical doctors rarely view natural birth. By natural childbirth I am referring to a woman giving birth without drugs or interventions and on her own. This does not mean that she would be alone; she may be surrounded by care givers that give position suggestions, massage pains and shower her with love or motivate her at times of plateau. What it does mean is that she is not told what to do, she is left in control and holding the power.

k The Beginning

midwifes are natural birth advocates that have been doing what the medical community has said to be impossible for may decades!

If you compare notes between hospital births and births at home or in birthing centers the differences are astounding. All of the things that have had a strong place in the medical community are bypassed in the natural scenes. The medical doctors rarely view natural birth. By natural childbirth I am referring to a woman giving birth without drugs or interventions and on her own. This does not mean that she would be alone; she may be surrounded by care givers that give position suggestions, massage pains and shower her with love or motivate her at times of plateau. What it does mean is that she is not told what to do, she is left in control and holding her power. Midwifes do a better job at the normal deliveries than we do. For a normal, low risk woman, it's overkill going to a doctor. It's just too much. The doctor's not really excited about things when they are normal, Business of Being Born. Dr. Moritz supports midwifes and what they do and is part of the movement that I would like to see, where the two communities merge and work together. Crystal Wolf, Bring the Midwifes Back 2011

sect ion 03 A Woman-Centered Model of Maternity Care

In the video, The Business of Being Born Dr. Michel Odent, and ob /gy n researcher says Today, most obstetricians, most of them have no idea of what a birth can be like. He is referring to a natural childbirth and birth in general, saying that they are lacking this experience and therefore are not the first choice to have as a support during this birthing process. To go further, some ob/gyn residents at Bellevue Hospital Center in nyc responded to the question How often do you get to see a fully natural childbirth, with Rarely, and Almost Never. This loudly speaks of the doctor's role in childbirth what-so-ever; how can one choose a doctor that has rarely assisted the kind of experience and birth most women claim they want to have? It's worrisome because most women go to a doctor without asking questions and assume that the doctor should be trusted because they have a degree. So, women are putting themselves in situations where they do not know what is going on or what to expect; where they will easily go with whatever the doctor says blindly. Here I would like to call on all women to help educate our birthing mothers. I have a desire to bring the traditional community back into the birth community! By this I am thinking of when women learned how to breast-feed because they watched all of their aunts, and mothers do it; and they had advice from their grandmothers. Women that have experienced what the maiden has yet to experience can teach her what she has to look forward to as well as help out when the baby arrives and give advice during the postpartum period. What I enjoy in both communities the natural and medical is when one acknowledges the necessity of the other and appreciates their role. Dr. Jaques Moritz ob/gyn does this throughout the documentary and one of his most powerful statements was when he said Midwifes do a better job at the normal deliveries than we do. For a normal, low risk woman, it's over kill going to a doctor. It's just too much. The doctor's not really excited about things when they're normal, The Business of Being Born. Dr. Moritz supports midwifes and what they do. He is part of the movement that I would like to see, where the two communities merge and work together in harmony instead of against each other. end |

k The Beginning

The Midwifery Model of Maternity Care is appropriate for 60 â&#x20AC;&#x201C; 70% of all pregnant women in the usa. How can one choose a doctor that has rarely assisted the kind of experience and birth most women claim they do not want to want to have?

It's worrisome because most women will go to a doctor without asking any questions. They are assume that the doctor should be trusted because they have a degree. Women are putting themselves in situations where they do not know what is going on, or what to expect; where they will easily go with whatever the doctor says blindly. I am calling on all women to help educate our birthing mothers.

colophon

k Designer Stephanie Penland l Photographers 01 Isaiah Beiser Photography m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Facts for Choosing a Hospital or an ob/gyn

When you choose a hospital to birth at you are giving them permission to care for you how they see fit. An ob/gyn is first and foremost a medical doctor, that means your ob/gyn is first, a specialist in obstetrical gynecological problems.

Evidence Based Care should be

The most up-to date

Practices & Procedures

sect ion 04 Facts for Choosing a Hospital or ob/gyn

k The Beginning

Facts for Choosing a Hospital or an ob/gyn Regardless if you know this or not, you are making a choice when you go to the doctors or the hospital for maternity care. It is a choice that most women do blindly because that is the status quo. You are giving the hospital permission to care for you how they see fit. The ob/gyn is first and foremost a medical doctor. That means she or he is a specialist in obstetrical gynecological problems. That's why you go to an ob/gyn doctor to asses and then care for problems and issues. They are in the business of preventive care of disease. Second to that they help to manage pregnancy, labor, and birth. Obstetrics directly deals with issues of pregnancy including fetal embryonic development. Gynecology in practice deals mainly with the female reproductive system and women's heath issues. start | www.sciencebasedbirth.com Choosing Evidence Based Practices Flat Earth Obstetrics is a term used to describe the way the current medical system treats birth, referring to the medical Dark Ages, in which contemporary medicine has forgotten or ignored traditional knowledge base and physiological principles necessary for normal labor and safe, spontaneous birth. Flat earth obstetrics is the belief that medical and surgical interventions are necessary in every birth, despite evidence that such a policy is harmful. The problem with the current form of obstetrical care in the United States is the uncritical acceptance of an unscientific method Ââ&#x20AC;&#x201D; the routine use of interventionist obstetrics for healthy women with normal pregnancies. Medicalizing normal childbearing in healthy women makes childbirth unnecessarily and artificially dangerous. Obstetrics has been rated as the least scientifically-based specialty in medicine. Dr. Ian Chalmers 1987 Assume as a given that no one in the obstetrical profession is purposefully making childbirth hard for women. Medicalized childbirth may be well intentioned. However, interventionist obstetrics does not properly acknowledge the normal biology of spontaneous childbearing nor meet the practical needs of healthy women and their babies. end |

sect ion 04 Facts for Choosing a Hospital or ob/gyn

Services May Include

k Prenatal Care l Labor and Birth Care m Annual gynecologic exams, pap smear test and breast exam n Contraceptive counseling o Sexually transmitted disease treatment p Pap test and treatment, colposcopy, cryosurgery and cone biopsy q Acute and chronic medical conditions such as endometriosis r Infertility diagnosis and treatment q Menopause management

A gynecologist will receive four years education and be certified by the abog American Board of Obstetrics and Gynecology. Their list of education includes oncology, and ultrasonography. Benefits of an Obstetrician There are a great number of women that have specific medical issues or family history that would lend them to be candidates for a hospital birth. They may need extra care that only an obstetrician can provide. k ob/gyn has specialized training to manage complications such as preclampsia or placenta previa which are very serious complications and need medical attention. l They have access to medical technology such as ultrasound and genetic testing, though midwifes can have these done. m Specialized surgical training if a cesarean birth is necessary. Disadvantages of an Obstetrician When a doctor is basically trained to manage and control complications the use of medical interventions is greatly increased, as these are the doctors tools in problem management. You as a patient are considered through this view, so your preferences, respect and care are vastly different then the doctors view. Some examples may include:

k Increased risk of an episiotomy, induction or assisted delivery l Increased chance of cesarean birth m Birth location at hospital rather than birth-center or home n Higher cost for prenatal health care and birth

k The Beginning

Promoting Maternal Choice The obstetrical profession has recently begun promoting the 'maternal choice', or medically unnecessary cesarean as the ideal form of childbirth. Scheduled surgery permits the practice of 'daylight obstetrics' while maximizing the physician's time and economic compensation. Many doctors predict that within the next 10 â&#x20AC;&#x201C; 15 years, scheduled cesarean delivery will replace spontaneous vaginal birth as the obstetrical standard. Unfortunately, this major abdominal surgery is also associated with a 2 to 4-fold increase in preventable maternal deaths and many delayed or downstream complications. Maternal mortality associated with vaginal birth is rare â&#x20AC;&#x201D; only one out of 16,666. To put this number in perspective, auto accident fatalities for women of childbearing age are one out of 5,000, so it is more than 3 times safer to give birth normally than to travel in a car. However, when cesarean sections are performed, the maternal death rate jumps to 1 out of 3,225 or six times more dangerous than normal vaginal birth. To put elective cesarean in perspective, consider that terrorist-related deaths for Israeli citizens is only one per 10,000, making scheduled cesarean surgery three times more dangerous to childbearing women than living in the midst of the Israeli-Palestine conflict and 6 times more dangerous than normal birth. In addition, there are some serious, sometimes fatal problems for babies delivered by cesarean, such as surgical lacerations, surgery-related prematurity and respiratory distress. To assume that normal biology is itself dangerous is a serious misunderstanding of normal childbearing. This regrettable attitude held by the obstetrical profession culminates in the politics of the pre-emptive strike and the hair trigger. For healthy women, the greatest risk associated with normal labor and birth is not the rare unpreventable complication of normal biology but the frequent preventable complications stemming from the routine use of electronic monitors, iv's, immobilizing laboring women in bed, routine use of uterine stimulants to accelerate labor,narcotics, anesthesia, surgical procedures and surgical instruments. Obstetrical intervention makes normal childbirth into a war zone for healthy women and their babies.

sect ion 04 Facts for Choosing a Hospital or ob/gyn

Instead of the optimal conduct of the many normal cases as proclaimed by the obstetrical profession as its forte, interventionist care routinely exposes healthy mothers and babies to unnecessary physical and mental suffering and increased rates of preventable death and disability. A medical care system that over treats three-quarters of its patients 3 million each year is both expensive and dangerous. For a profoundly wasteful and dysfunctional system, obstetrical reformation is long overdue. Consider this: If planes landing at usa airports crashed five times more often than when they landed at airports in England, Japan or Sweden, we would demand an inquiry of our air traffic control system, since the laws of aerodynamics are the same worldwide. Each year in the usa about 8 million mothers and babies 'fly' the united service of interventionist obstetrics. Only a fraction â&#x20AC;&#x201D; under 30% â&#x20AC;&#x201D; need and benefit from highly medicalized obstetrical management. Isn't it time to inquire why the universal laws of normal childbirth, which are the same worldwide, are being routinely suspended by American obstetricians and, as a result, American mothers and babies are crash landing at an alarming rate? The Better Way, Evidence-based Maternity Care Preserving the health of already healthy mothers and babies is the primary role of maternity care. Approximately 70% of pregnant women in the United States are healthy and have normal pregnancies. That is about 3 million normal births annually. Physiological principles provide the safest and most cost-effective form of maternity care. According to the World Health Organization, w.h.o., it is the preferred standard for healthy women. w.h.o. refers to this as the social model of childbirth. In the usa, it known as family-centered or mother/ baby/father-friendly maternity care. These protective and preventive methods include a commitment not to disturb the natural process. This minimal-intervention approach includes continuity of care, patience with nature, one-on-one social and emotional support, non-drug methods of pain relief and the right use of gravity. Obstetrical intervention is reserved for complications or if medical assistance is requested by the mother.

k The Beginning

The scientific basis for physiological management of pregnancy and normal childbirth is supported by a consensus of the up-to-date scientific literature. Physiological management is actually protective for both mothers and babies, reducing the episiotomy /operative delivery rate and its associated complications, from approximately 72% to approximately 5% with an identical, or even slightly improved perinatal mortality rate. Reliable scientific evidence establishes physiological management the safest and most cost-effective form of maternity care. Scientifically speaking, this is not a controversial finding. The scientific literature is neither lacking nor incomplete, nor the subject of methodological disputes. To become familiar with this body of knowledge is to redefine the politics of this controversy. The real question is how best to care for healthy women with normal pregnancies. The choice is between more of same — the ever-escalating, ever-more-expensive model of obstetrical intervention — or actively engaging the public in the reformation of our maternity care policies and rehabilitation of obstetrical practices. Scientific, humanist and economic factors all call for the rehabilitation of obstetrics as it is applied to healthy women with normal pregnancy. This would make way for a science-based system — maternity care that is safe, cost-effective, family-friendly and physiologically sound. A rehabilitated policy would integrate the classic principles of physiological management with the best advances in obstetrical medicine. This would create a single, evidencebased standard for all healthy women used by all maternity care providers — gps, family practice physicians, obstetricians, and professional midwives. Recovering of institutional memory & reestablishing physician expertise in physiological management: To create single, evidence-based standard for all practitioners would require the obstetrical profession to recover its institutional memory of normal childbirth and to reestablish physician expertise in physiological management and socially-based childbirth services. In a rehabilitated maternity care system, physicians who provide care to a healthy population would be required to either:

sect ion 04 Facts for Choosing a Hospital or ob/gyn

› › ›

Utilize the successful strategies of physiological management themselves Cede the care of healthy women to those who do, Obtain truly informed consent for substituting medicalized obstetrical care with its well-documented dangers

Fully informed consent would require true transparency relative to the documented consequences of medicalized labor and normal birth conducted as a surgical procedure. Scientifically correct information must be routinely provided to healthy women on the short and long-term limitations and complications resulting from the medicalization of labor — i.e., drugs, anesthesia, and medical interventions and procedures that abnormally limit mobility or confine the laboring women to bed. The benchmark for transparent informed consent should be this same level of information about complications that is reported to physicians in the scientific literature and obstetrical trade papers Failure of efm and c-sections to Prevent Cerebral Palsy Informed consent as provided by obstetricians must identify the well-documented failure of continuous electronic fetal monitoring efm and increased use of cesarean section to reduce the rate of cerebral palsy and other neurological disabilities. According to the scientific literature, there has been no change in the incidence of cerebral palsy since the advent of fetal heart rate monitoring. The increasing use of cesarean delivery triggered by worrisome fetal monitoring data has not resulted any reduction in the cp rate. In an attempt to identify babies at high risk for cp, a non-reassuring heart rate pattern as picked up by efm has a 99.8% false positive rate. A physician would have to perform 500 c-sections for abnormal efm tracings to prevent a single case of cerebral palsy. Management strategies determined by health status of the childbearing woman: Under a rehabilitated system, management strategies would be determined by the health status of the childbearing woman and her unborn baby in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider family practice physician, obstetrician or midwife. At present, who the woman seeks care from obstetrician vs. FP physician or midwife determines how she will be cared for. This illogical situation must be corrected.

k The Beginning

Recognizing and protecting the ethical and constitutional rights of competent adult women to have control over the manner and circumstances of pregnancy and normal birth. Hospital labor and delivery units must be staffed by professional midwives to assures that physiological management remains the standard used by all practitioners and is taught to medical students. This system frees obstetricians from many routine duties, thus permitting them to be the highly trained experts their education prepared them to be. This plan will require economic incentives for current l&d nurses who wish to retrain for hospitalbased midwifery practice to do so at minimal expense to themselves: Standard arrived at through an interdisciplinary process. This interdisciplinary process must include the traditional discipline of midwifery as an independent profession and must integrate the input of childbearing women and their families into the process. It is especially important to include testimony from those families who had complications following episiotomy, instrumental delivery or cesarean surgery or who found it virtually impossible to arrange for a subsequent normal labor and birth after a cesarean vbac. Mutually respect: In the reformed or social model of maternity care system, professional midwives, family practice physicians and obstetricians would all enjoy a mutually respectful, non-controversial relationship.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

q & a for your ob/gyn or Doctor

How are you to know what questions to ask during your prenatal appointments if your doctor does not provide you with the questions? This booklet provids for you here a list of questions and reasons why they are important.

sect ion 05 q & a for an ob/gyn or Doctor

k The Beginning

q & a for an ob/gyn or Doctor

You should ask your doctor many of the same questions you ask your midwife. These questions are specific to the techno-medical model of maternity care, in other words, for your ob/gyn or doctor. 01 Who can be with me throughout the birth, father, partner, family, children, a doula, or a midwife? A mother-friendly place will allow whomever you want in your room. They should also let you decided whom you donâ&#x20AC;&#x2122;t want there, such as strangers, unknown doctors, or nurses, male or female. 02 How do you allow for culture and beliefs to be recognized? If the place you are interviewing is mother-friendly then they will recognize your needs, and beliefs, such as rituals you might want to perform after the baby is born, or not having men in the room for religious reasons. 03 Can I walk around during labor and labor in whatever position I am most comfortable in? You should listen to your body and be able to push your baby out however your body is telling you to do it, squatting, standing, or laying. Mother-friendly facilities almost never put a mother on her back with her legs up in stirrups for the birth. You should have a choice and if you don't seriously consider a different facility that will allow you to birth normally. 04 How do you make sure everything goes smoothly when the nurses, doctors, midwifes or agencies need to work with each other? Make sure you can bring your birth team, including your partner or midwife with you if you are moved to another place to labor. Find out also what the plan will be to keep in touch with you after the baby is born, incase complications arise and what help they have for breast feeding. 05 How do you help mothers stay as comfortable as they can? There are some are very good reasons why a completely natural birth is not possible for every woman, so it is good to know what they can do to help comfort you or what you can bring or do with your birth team. It is also helpful to have a doula or advocate to prevent medical interventions and medications that aren't necessary. It's wise to choose a birthing place that has amenities like a shower, comforts, or other laboring devices.

sect ion 05 q & a for an ob/gyn or Doctor

06 What happens during a normal labor and birth in your hospital? This will help › Mothers who have had a c-section can often have future babies normally. Look for a birth you to understand if your chosen hospital is place in which 6 out of 10 women, 60% or more at high-risk for interventions like a c-section. of the mothers who have had a c-section go You should find out the procedure they use for on to have their other babies through the birth giving you drugs, consent forms, who and canal, vbac vaginal birth after c-section. when they are asked. If they provide motherfriendly care, they will tell you how they handle every part of the birthing process. For example 07 What medical devices or procedures do you use on women in labor? This seems will they let you birth for 10 hours or is it their like a no-brainer but you need to ask this. Only practice to administer drugs to aid in delivery medical devices proven to be medically useafter only 4 or 6 hours if your not dilating to ful during labor should be used. You need to their schedule. know that not everything the hospital uses is scientifically proven to benefit you during labor. American College of Obstetrics and Gynecology › They should not use oxytocin, a drug to start or speed up labor for more than 1 in 10 women, which is only 10% of births. › They should not do an episiotomy on more than 1 in 5 women 20%. They should be trying to bring that number down. An episiotomy is a cut in the opening to the vagina to make it larger for birth. It is not necessary most of the time and has proven to cause more harm. › They should not do a c-section on more than 1 in 10 women, 10% if it’s a community hospital. The rate should be 15% or less in hospitals which care for many high-risk mothers and babies. A c-section is a major operation in which a doctor cuts through the mother’s stomach into her womb and removes the baby through the opening, then closes it up.

› Electronic Fetal Monitor Keeping track of the babies heart beat 100% of the time causes unnecessary medical interventions, cdc 2009 Statistics Data Report. Keeping track every half hour or so is much better. › The bag of waters should not be broken unless there is a medical reason to do so. › They should not tell you that you can not eat or drink during labor unless you specifically need a medication or procedure before hand that won't allow this. › They should not have you shave your vaginal area, unless this is something you want to do. It is uncomfortable, degrading, and not medically necessary. › They should not give you an enema.

k The Beginning

08 Besides using drugs how do you help the birthing woman release the pain of labor and delivery?

› › › › ›

Changing your position Shower, Bath, Birth Tub Music Acupuncture Massage

09 Do you circumcise baby boys? Unless it is for religious or specific medical reasons the cdc, and w.h.o. agree this should not be done because it is medically unnecessary, creates pain and complications later on. 10 What if my baby is born early or has special problems? A mother-friendly facility will help encourage mothers and families to touch, hold, breast-feed, and care for their babies as much as they can. There may be a medical reason you shouldn’t hold your baby. 11 How do you help mothers to breast-feed? It is best to breast-feed within the first hour of birth. There should be a lactation consultant there to help you. If you have to be away from your baby for some reason they should show you how to bring on your milk, and keep your milk producing. Newborns should only have breast milk unless a medical condition prevents them from having it. They should allow and encourage you to stay with your baby all night and feed baby whenever baby wants.

Pacifiers should not be given so as not to create nipple confusion. Each facility will have it's own policy on breast-feeding so it's good to know the rules and guidelines they abide by before you are in that situation. 12 How much time do you allow for prenatal visit? If the answer is about 15 minutes this might be a warning sign. 15 minutes is not nearly enough time to adequately answer all of the questions, comments and concerns you have. It also doesn't allow for you to create a close bond or friendship with your care giver. Often times offices are over worked and have more patients then they can handle to allow for this. You might also ask how many patients do you have giving birth around my due date and how much personal attention can you give me? 13 How do you handle routine phone calls? They should always call back and be very helpful and considerate with an answer to all of your questions and concerns. 14 Are you part of a high-risk practice? If you don’t get a straight answer this is a warning sign. Legally they have to provide you with their statistics of procedures and use of interventions so don't take no for an answer.

sect ion 05 q & a for an ob/gyn or Doctor

First Stage of Labor

15 Do you consider maternal age as a risk 18 Can I eat and drink during labor? The short factor during pregnancy and labor? There answer is usually yes, and if so your in good is a growing population that is having babies hands. Though most hospitals want to limit you later and later. Yes there are more risks to the incase you decided to have medication or need older mother especially first time moms, but if it on an emergency operation so they can say no. medically you are in perfect health you have options besides the hospital birth. 19 How do you feel about having a natural or unmediated birth? The common answer 16 Under what circumstances would you is every birth is different and you should be recommend the following prenatal tests prepared for anything to happen. You never or procedures? know what will happen so lets just cross that bridge when we get there. They should be sup › Ultrasound how many and what stage portive in this, give you aids and guides to › Maternal serum alpha-fetoprotein help you cope with the pain such as breathing, › Chorionic Villus Sampling cvs yoga, and relaxation techniques. Crossing that › Amniocentesis bridge when you get there basically means they don't support natural birth. 17 How do you feel about labor support such as a doula or massage therapist joining 20 What are non pharmacological comfort my birth team? Most hospitals will only allow measures do you support? an appointed nurse midwife to perform any medical treatment or help during the labor or › Freely changing positions after the birth. You might want to consider an › Walking around alternative to a hospital if you want options that › Water therapy, shower or tub are not directly given to you through their staff. › A birth ball It's good to note that even midwifes that work in › A doula a hospital have to abide by all the same regula› Other things you haven't thought of? tions the doctors do as well as the nurses. They are legally bound by the institution they work 21 Under what circumstances would you for, and can only offer support accordingly. recommend an epidural or narcotics? Again this answer will probably vary. A good answer will give you specific examples, such as you've labored 30 hours, are exhausted and can't go on, you need rest to regain your strength and the epidural will help you do that.

k The Beginning

22 When would you like me to come to the 26 To ripen the cervix do you routinely use cytotec or prostaglandin gel before you birth-center or hospital? Usually not when induce? You really should do the research on your water breaks. A good time to go is when this and other medications as just because the contractions are four minutes apart lasting something is approved or not approved by the for one minute for at least one hour. fda for labor doesn't always mean it is right for you or safe for you and your baby. 23 What are your recommendations if my water breaks before contractions have begun or has not broken even after they began? 27 Do you believe in active management of first stage, progress less than 1 cm an Should I call and stay home until contractions hour will call for artificial rupture of memstart? Come to office, hospital, birth-center to branes, arom or pitocin? If everything is monitor baby? fine with you and your baby you should be able to labor at your own pace. Having a mid24 How long after my water breaks would wife or doula there to help advocate for you if you let me stay at home? This depends on your not progressing. It's perfectly normal for the color of the water that comes out. If there someone to progress several cm's forward or is meconium in the water you will have about backward based on circumstances happen36 – 72 hours before you may be in danger of ing in the room or where they are at. certain complications like infection. 25 Do you recommend induction if my labor 28 What non-medical ways of stimulating the labor do you recommend? There are doesn’t start on its own by my due date? a lot of alternatives used around the world, There is a trend to have labor artificially indcheck them out and know them before hand. uced especially after the due date. One thing to know is that going beyond a due date is › Herbs normal, and often times it's miscalculated. › Nipple stimulation There is a growing concern for delivering › Castor oil babies too early and there is evidence that the › Intercourse for spontaneous labor historical outlook of 40 – 42 weeks is actually › Rupture of membranes perfectly normal. Your doctor or midwife can › Acupuncture help determine if the baby is in distress.

sect ion 05 q & a for an ob/gyn or Doctor

Second Stage of Labor

29 What is your protocol regarding...

31 What percentage of women in your practice give birth in the lithotomy position, › iv's on their backs with legs raised? Will › Continuous monitoring I be able to choose the position in which › Internal fetal monitoring I will give birth such as side lying, all fours, › Artificial rupturing of the membranes or squatting? This is a huge problem with arom at a specify amount of dilation hospitalized births as it is easier for the doctor › Assisted vaginal delivery forceps or to sit on a stool and watch as the baby comes vacuum extraction out. It's much more difficult for you the one in › Episiotomy labor but the medical system is not designed to help you so if they won't let you birth in the 30 Are you supportive of vbac, vaginal birth position you want then that is huge red flag after a cesarean? What is your vbac rate? that they are not a women-centered practice. What are your standard protocols for vbac mothers? There is much controversy over this 32 Can I keep my placenta and delay the cord topic in your practice. The ama, American cutting? What storage do you have for me? Medical Association, says that it is dangerous I talk about this later in the book but it is also to do a vbac, while there is growing evidence good to delay the cutting of the cord allowing of the opposite. Remember a doctor or practice for the blood and the baby to still be connected. has to abide by medical restrictions, laws and The placenta is very useful for the mother both probably most important, insurance compaafter the birth and later on in her lifetime. nies. Research the facts and find a doctor that will help you.

k The Beginning

Postpartum

33 Can my baby remain with me at all times 36 Will you or someone from your staff help support me to establish and then continue from the moment of birth? There has been to maintaining breast-feeding? The hospital a trend in the past to whisk the baby away, permight provide a lactation support person. Take form any medical procedures on them the docwhat they say and if it doesn't work then find tors deem fit and keep the baby away from the another one. Remember every support person mother. There is evidence now that supports is different and may use different methods. You keeping the baby with the mother the entire should never be forced to do something that time. You have to make your voice heard and is extremely uncomfortable and painful. You known what you want. A helper like a doula, should always be treated with respect, asked during birth can advocate for you when there and worked with. is confusion. 34 Do you support skin to skin contact with 37 What percentage of women in your overall practice are given pitocin or some other me and my baby immediately after birth? medications following the birth of the This is actually a very important question as baby? There are some very good reasons to there is growing evidence that skin to skin give medications after birth but remember that immediately after birth is beneficial for the medications do pass through the milk. Know baby in many areas of connection, brain dethe risks and reasons. . velopment, and a lot of hospitals do not have a procedure or practice in place to provide for this. A good hospital will be open to this and 38 How long will I stay in the hospital, or the may already have a plan for it. birth-center after the birth? Hospitals use to keep women for 10 days to make sure there were no complications as some very serious 35 Can I delay newborn procedures such as things can happen after birth. If you have a vitamin k shot, and eye ointment? Rememmidwife she will visit you at home every couple ber it is your right and responsibility as a parent days to make sure you are doing well. If you do to know what these procedures are, harm they not have a midwife and you only have two visits may cause or help they may prevent. Tell your in 6 weeks after the birth to check on you, this birth team and your doctor your wishes. If you may not be adequate care to determine if you keep your baby with you the entire time it is are healthy or not. easier to know what is being done to them.

sect ion 05 q & a for an ob/gyn or Doctor

Backup Doctor

39 If you are in a group practice when can I meet your partner? It might not be possible to meet everyone that is on the team but you can probably manage a doctors visit or meeting with the important people who will give you the most care. 40 What is your personal perspective on the routine and emergency hospital interventions? This may sound redundant but each person has their own take on this and it's good to know who is all for it and who is better at finding other alternatives in case your doctor is not available. 41 How likely is it that one of your partners will be the one to attend my birth? Most hospitals work on an schedule, on call or not so it is entirely possible your doctor won't be there for the birth which is why it is so important to meet the other doctors on staff.

k The Beginning

In the usa, only about 5% 5 of births are attended by midwifes, compare that to 75% 75 of births in Europe. cdc National Vital Statistics Reports 2011

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Choosing a Home-birth & Midwife Ultimately a good birth experience is one where a woman feels empowered by the process, and part of that process is giving up control, it's the surrender. You prepare and prepare for birth and then when your ready to give birth you just need to let it go. Because you just don't know what is going to happen. You need to be ready to make big decisions, and be flexible and change gears a little bit so that way you can stay in a positive space but still deal with whatever is going on. My main job is help facilitate your natural process. 2012 Interview, Midwife Maria Iorillo â&#x20AC;&#x201D; Wise-Woman Child Birth

Birthing Women need to

Feel Relaxed, Loved

& Safe with Labor

sect ion 06 Choosing a Home-birth & Midwife

k The Beginning

Choosing a Home-Birth & Midwife Where you have your baby is your choice. Regardless if you know it or not, this is a choice. You need to choose where to deliver your baby at; you need to feel safe and know that it was your choice, not something mandated to you by doctors, midwifes, family, friends or the government. Many women are electing to choose to have their babies at home with a midwife. The home is a safe, and comforting place that can aid and relax you during birth. If you are part of the 60 â&#x20AC;&#x201C; 80% of women who have low-risk pregnancies this is an option for you. 01 Who can be with me throughout the birth, father, partner, family, children, a doula, or a midwife? 02 I am healthy and have had healthy pregnancy. 03 I am considered low-risk by my health care provider. 04 I want to labor, birth and meet my baby in a safe and familiar environment that is under my control. 05 I am concerned about the discomfort of the trip to the hospital 06 I want to avoid an unnecessary cesarean section. 07 I want to have access to my partner, family and support people at all times during labor, birth and the postpartum period. 08 I want to be with my baby continuously from the moment s/he arrives in the world. 09 I believe pregnancy and birth are normal, natural functions and not an illness to be medically treated. 10 I believe in my bodyâ&#x20AC;&#x2122;s ability to give birth to the baby I have conceived, grown and protected. 11 An extensive study published by British Medical Journal shows that planed home births are as safe as hospital births for low-risk women in the United States.

sect ion 06 Choosing a Home-birth & Midwife

The World Health Organization recommends that the cesarean section rate for undustrialzied nations should not exceed 15%. A safe range, as determined by w.h.o. experts, is 10 â&#x20AC;&#x201C; 15%. The thought of a home-birth for some can be scary or dangerous. But for others itâ&#x20AC;&#x2122;s a liberating and exiting way to birth. Noteworthy organizations such as the cdc, the w.h.o, Amnesty International and many other originations all suggest home-birth is not only safer than a hospital birth, it benefits the mother and baby with a higher rate of success; by using less medical interventions and medications and empowering women, making their own decisions about their body. There are still are a lot of people who want to discredit anyone or any organization having to do with the home-birth advocates so find out what the research is saying, who's agenda it advancates, and if the statistics are reliable. From what I found there is always two sides to every story. That is why this book focuses on facts and information, bringing knowledge and heart together and dispelling fear. Home-birth can allow a mother to be in the comfort of her own home. She can choose what or who enters her environment, what and when to eat. She has her support group and chooses to have lights on or off, soft rugs or a bed or a couch. When at the hospital she does not have a choice on how bright it is, or how loud, or the temperature. At home she can labor at her own pace and is not on the timetable of the doctors or nurses. She can eat and drink, or use any type of birthing method of her choice. The midwife will be there by her side watching and attending her if she wishes. The midwifes job is to watch for warning signs of potential problems and let her birth how she wants. In-effect the midwife sits on her hands and lets you get on with it. Trust me, this is not only amazingly empowering while giving birth but during the labor you will find your own strength, your own power from within to birth how your body wants you too. I f there is an emergency or the birthing woman wants to go to the hospital for whatever reason the midwife is ready and there is a plan set up for this. This is a choice, even if it's an emergency. It is best to preplan a route to the hospital, drive it a few times during traffic and both weekends and days, about 20 minutes distance is good.

k The Beginning

My midwife, Maria Iorillo had told me there was about a 20% chance for transfer for first time moms. And of those 20% only about 2% were emergencies. Being a transfer from a home-birth, non-emergency, but medically necessary, honestly, was not fun at all. I'm so glad the back up hospital Maria works with was welcoming, understanding and we didn't get any flack for transferring. When I first started researching birth I was drawn to the idea of having my baby in water. Having been a very busy person, always on the go before I got pregnant. Now I moved to a slower, and calmer, pace. Water was so relaxing. And though I could not have my water-birth in the hospital I was able to labor in the shower for a long time, while they accommodated me. I loved the time I spend in water, all the heaviness I felt gone. When I approached my doctor about this she seemed indifferent, said that my hospital didn't allow for a full or partial water-birth anymore and I should check out my options. She was pregnant at the time and upon returning from maternity leave she urged me with more conviction to again check out my options. Thus, a thesis, and a new outlook on birth began. My home was not perfect for a Home-birth, being a smallish studio apartment. We had set up the birth tub and it did fit but there wasn't much room. Maria had assured me it would do nicely. A week before I gave birth we ended up moving to the building next door. I asked my midwife, my mentor, and my mom if I was crazy and they all thought it was fine. We now had a two bedroom apartment just across the street so we didn't really have to pack. A week later I went into labor. Having labored for 36 hours at home I was free to move about, relax, and use all my tools during the birth. I was not embarrassed or ashamed to be naked. In fact, it felt more natural than having the restrictions of clothing on and mind you I am a very conservative person, but birth isn't conservative, it's messy, it's hard, and it's natural. It is true that I ended up having to go to the hospital after 36 hours of hard labor, acupuncture, homeopathic and squats just could not bring the contractions back. Maria my midwife suggested that we talk and pray about going to the hospital to receive the proper medication that would bring the contractions back, and so we did.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Choosing a Birth-Center

birth-centers saved the usa health care system $30 million in 2009. So in a nutshell c-section rate of 6% + great infant outcomes + ridiculously low cost = Top Notch Care!!!

sect ion 07 Choosing a Birth-Center

k The Beginning

Choosing a Birth-Center A Birth-Center is another good choice outside the hospital. You will most likely have a private room with lots of accommodations. You can have children with you or family members, often times they let you birth in water and not just labor in water. It is a holistic approach to medicine, though they do have ivâ&#x20AC;&#x2122;s, oxygen and infant resuscitation, drugs and interventions. Sadly many birth-centers are having to close their doors mostly due to laws and regulations putting restrictions on them that are often times unfounded and harmful. Many that are still standing are there to aid the low income person and are often over crowded and underfunded. But there are a lot of birth-centers that are quite nice. That is why it is so important to visit a birth-center and see for yourself first hand what the facility offers. A lot of insurance companies will cover the cost of a birth-center, some won't. Ask your midwife, and your doctor questions about the facility, about insurance, and what is right for your family. It is important to take with you the questions you would for the doctor and the midwife and find out which ones apply to them. All birth-centers are different, their procedures, and their practices can all vary. Some are attached to the hospital so they might be on a different floor but still operate under the same regulations as the parent hospital. And if that hospital is at high-risk for c-section then that birth-center is also at high-risk if you transfer. Often times it is not possible to birth at home. Perhaps you cannot have a tub in your apartment or your place is small or you live with your parents. I was in a one room studio and was planning a home-birth in that apartment. Perhaps you would feel more comfortable in an open environment with all the equipment but still that home feel. Whatever the reason a birth-center is worth checking out and considering.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

q & a for your Midwife

Be ready to be honest and give her your medical and family history. She to know needs everything so that she can to give you a fair, and honest assessment of your pregnancy, and what she can offer. During your interview, ask the midwife what her specialties are, what her preferences, limitations, and beliefs are. These answers will help you make a decision that is right for you.

sect ion 08 q & a for a Midwife

k The Beginning

q & a for a Midwife First and foremost a midwife is looking for honesty. You might think well that’s a no-brainer but it really isn’t. Honesty invites trust, and trust invites friendship, and a bond between the two. There are reasons why you may not be entirely truthful to your midwife, or at that first interview. Perhaps you had an abortion and not told your husband, or you have herpes or know your a high-risk patent but don't want that to be known. Without all the facts, both the good and bad the midwife can't make a professional assessment of the type of care that you need. There can be ways to arrange a copartnership with your doctor if you are high-risk. There are lots of good options but don’t hide any information from your midwife in fear, she won't work with you. There could be religious, or in some cases philosophical reasons women choose midwifes but might not be a good fit for them. The laws and regulations are always changing regarding midwifery. Unfortunately many states in the usa prohibit the practice of midwifery and home-birth. Research your states laws and your rights. Your midwife can also help you find this information and will know them herself. You should agree to all the midwifes procedures and protocols. She knows her capabilities and is trained to spot red flag situations. She wants to keep you and baby healthy and will make decisions based on that. The protocols can include everything that happens in her office regarding your pregnancy. She might require you to take prenatal vitamins and stick to a healthy diet, and help you to make one if you don’t already. She may use herbs, homeopathic, acupressure or non invasive alternatives to medications and procedures. Do your research on the midwife you are interviewing. Find out her specialties, and limitations. And be ready again to be honest and give her your full medical and immediate family history.

sect ion 08 q & a for a Midwife

Midwifery Model Provides The most important thing you can do to be respectful and professional is to pay your midwife on time. They are offering to you a service of care that is far beyond a simple check up. So find out from your insurance what they will cover and count the cost. For example, perhaps your midwife charges $4,000 for the entire birth from your first visit to the last which is several weeks after the birth. If you donâ&#x20AC;&#x2122;t deliver with her she might give you back a percentage. k Comprehensive prenatal care and postpartum care. l Continuous support and monitoring during labor and after the birth. m Prenatal counseling to build confidence, trust, and comfort. n Acknowledgment of hopes, fears, and expectations of birth. o Working together to experience the beauty and power of birth. p Postpartum support for breast-feeding and family bonding. q Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle. r Providing the mother with individualized education, counseling, a nd prenatal care, continuous hands-on assistance during labor, the delivery, and postpartum support. s Minimizing technological interventions. k t Identifying and referring women who require obstetrical attention.

k The Beginning

Midwifery Model Questions â&#x20AC;&#x201D; Experience 01 What is your philosophy regarding pregnancy and birth and your role in it? Every midwife is going to have a different answer to this. You should ask this even of your ob/gyn. 02 How many births have you attended? Sometimes this is important. You might want a more experienced midwife who's been to a 1,000 births, or you might be ok with her being newer with really good references. 03 What percentage of women successfully have a natural birth under your care? This is also good to ask as well as what do you consider to be a natural birth, and how would you react if I changed my mind. 04 What is your rate of transfer to hospital? This data should be easily assessable and provide you with a comparison between care options. Generally it should be pretty low for emergency transfer. Such as my midwife has a 12% transfer rate, mostly first time moms and less than 2% of those were actual medical emergencies, most were not emergency. 05 Who is your back up obstetrician? Usually midwifes work with a hospital for when they have transfers. Not all hospitals will allow your midwife into the birthing room so find out the facts first. 06 Will I be able to meet or interview them? Meeting the person who will most likely take care of you at the hospital is good planning. Feel free to discuss any and all parts of your birth plan with them. Most will want you to have at least one doctors appointment with them before taking you on. 07 Breast-Feeding? Most midwifes have lactation consultant they work with that they will send to your home at no cost to you to help aid in this. 08 Under what circumstances do you recommend the use of pitocin? This is a good general question for all medical interventions, medications and practices regarding hospital transfer.

sect ion 08 q & a for a Midwife

09 How long will I stay in the hospital or birth-center after the birth? This of course can not be known until birth occurs and if you have complications but is still a good hypothetical question to ask. 10 For home-birth midwifes â&#x20AC;&#x201C; How long will you stay with me after my baby is born? Each woman and midwife relationship is different so the answers will vary but generally they should stay to make sure you are properly taken care of and have no complications. 11 How many are in a group practice? It is helpful to know if your midwife works alone or with others. Generally it's good to have two midwifes at a birth; one to take care of the baby and the other for the mother but not entirely necessary. 12 Can I meet your partners? Again it is a good idea to meet anyone and everyone who can potentially give you care. 13 What percentage of moms end up with a c-section? It is good to know this incase you are in that emergency situation and the facts and details about this. 14 What percentage of moms end up with an epidural? Knowing how many women transfer to the hospital and why will help you make better decisions. 15 What percentage of babies are transferred to nicu? Usually this number is very low, I would be worried if it was as much as or worse than the hospital you are transferring too. 16 What is the mortality rate for moms? For babies? Generally this too is very low and can help you determine if this midwife is for you. Check out the cdc statistics on hospital mortality rates. 17 Do you have hospital privileges? At what hospitals? When choosing an obstetrician or midwife, you are simultaneously choosing a hospital. It is important to check into the regulations and protocols of the hospital as they influence the outcome of your birth. Some hospitals will be more accommodating of natural birth than others. The c-section rates of hospitals are often available and are a good indicator of the birth culture in that institution For better or worse, most home-birth and birth-center midwives in our country don't have hospital privileges. However, if they need to transfer a mother to a hospital, they can stay with her as support. Find out what hospital your midwife would transfer you to if that were necessary.

k The Beginning

18 If you have children, what were your birth experiences like? You could and should ask this question of either a male or female care provider. I might think twice if someone had elective c-section. On the other hand, I would give big points to anyone who had actually experienced natural birth for themselves as a supportive partner but especially as a birthing mother. They would be assured to have a clear understanding of the natural birth process. 19 How many midwives or obstetricians are on the team? Who are your assistants? Will I get to meet all of them? What is their experience? Can I be sure that you will attend my birth? You may not expect to deal with these issues. Your midwife or ob's answer, however, is a good indication of how supportive they may be of natural birth if unexpected circumstances arise. It will also tell you the breadth of their experience. Even in the world of natural birth, few birth attendants are comfortable handling breech babies or multiples. If you are preparing for a vbac's Vaginal Birth After Cesarean, there's a great resource for finding one even before you interview a doctor. The vbac Database lists hospitals across the country and indicates whether they allow or ban vbac's. 20 Do you deliver breech babies naturally? vbacs? Twins? Many groups of midwives or obstetricians may work on a team, alternating who is on call. This means that depending on when you go into labor, your own care provider may not be there. Being relaxed is vital to making your labor go smoothly, and having a birth attendant present that you are comfortable with will have a big impact. At the very least be sure that you can meet and talk to anyone who may potentially attend your birth. .21 How many births do you attend per month? Most home-birth and birthcenter midwives stay with a laboring woman for her entire labor and birth. Therefore, they can only attend around 5 births per month. Choosing a midwife that doesn't take on too many clients can help ensure that she will be the one to attend your birth and won't need to send her backup. Attendants who work in hospitals may attend multiple laboring women at once and are not present for the entire labor, so their birth count may be higher.

sect ion 08 q & a for a Midwife

Questions about Pregnancy & Prenatal Care

22 When do you do vaginal checks during labor? This is good to know as too many checks can introduce bacteria and checking is largely inadequate to determine when the baby will be born, unless you are at that 10 cm phase. There have been new ways and methods of checking dilation such as the red line that appears from the vagina to the top of the anus to help determine where your at instead of an invasive check with fingers. 23 What type of monitoring do you do during labor? How often? For how long? We now know that conscious monitoring with an efm causes more harm then good. You midwife usually will use a hand held device and monitor every 1/2 hour or so depending on how you are. She usually has an underwater doppler as well if you are in the tub. 24 Do you routinely use an iv or hep-lock? Knowing your midwife's capabilities and her preferences will help you to determine if she's right for you. Generally and iv is not needed at home but she should have one if you become dehydrated. 35 How long do you recommend I stay in the water at one time? Do I need to get out for monitoring? Again she will probably have a underwater doppler. If you get into the tub too early you might slow the progress of labor. 36 Are you comfortable working alongside a doula? Do you have particular doulas you recommend? I recommend hiring a doula that will focus on you and your needs. Your husband or partner is there for moral support but often times needs breaks and can't do everything for you. 37 How long can I labor without induction? This is good to know, she will explain all the conditions in which you might need to go to the hospital for pitocin. 38 When would you recommend induction? Do you use natural induction methods first? Some natural methods might be acupuncture, or homeopathic remedies. 39 How long can I labor without intervention after my water breaks? When your water breaks before you go into labor, this is called premature rupture of membranes, also referred to as prom. If you are at least 37 weeks gestation, this

k The Beginning

is called term premature rupture of membranes. Anything before 37 weeks would be pre-term premature rupture of membranes. If there is a color or odder of the you should let your care giver know and that is when the clock starts ticking, usually 24 â&#x20AC;&#x201C; 36 hours. Make sure what your midwife or doctor say about this is evidence-based. 30 Who attends a birth? Students, assistants, nurses, etc. This is good to know as you might not want unknown students there, or you might not care. 31 When do you feel amniotomy is indicated? Research evidence does not support artificial breaking of the waters amniotomy for labor induction. Artificial rupture of the membranes during labor does not shorten labor and is associated with a trend towards surgical birth. 32 Can I eat and drink during labor? This might seem a silly question but still important to ask. You should be allowed to eat or drink what you like. 33 What's your process for implementing a family's birth plan? This could be very important if you end up transferring to the hospital. 34 What positions are available during labor? While pushing? Generally your midwife will have lots of options for you and give you resources. 35 What are reasons you would initiate a transfer to a hospital if a home birth or birth center birth? Making sure she is ok if you want to transfer for a non-medical reason, like you just can't handle the pain and need meds is alright with her. 36 How long do you allow for delivery of the placenta? When do you cut the cord? Delaying cord cutting has been shown to be very beneficial to the new born and ask about keeping your placenta.

sect ion 08 q & a for a Midwife

Postpartum & Newborn Care

38 What postpartum care do you provide? When? How many appointments? Where? Generally midwives will come to your house on day's 1, 3, 5, and each week for about bout 6 weeks. However you might have to go into the office. 39 What does newborn care consist of? Under what circumstances would my newborn need to be taken away from me for treatment? It is always good to have the facts and know what could happen. 40 Are you comfortable with me declining bathing, vitamin K, heel poke, eye ointment, vaccinations? You need to find this out from your midwife and your pediatrician as well. Especially if you transfer to the hospital, once the doctor deliveries the baby these things are up to the pediatrician. 41 Can you help me initiate breast-feeding? Most midwives have lactation consultants to help you with this.

Backup Midwife

42 What is their perspective on routine hospital interventions? It's a good to know this because though they may be part of the same practice midwifes might have very different outlooks on these things then whom you've chosen. 43 How likely is it that one of your partners will attend my birth? Midwifes in training might be invited or you might have medical reason why two extra midwifes might be there. 44 How much time do you allow for each prenatal visit? Most midwifes offer about an hour for each visit and unlimited calls or emails.

k The Beginning

Without all the facts, both good and bad a midwife can't make a professional assessment of the type of care that you need. There are ways to arrange a copartnership with a doctor if it is found you are high-risk.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Choosing a Doula

You want a Doula that is non-judgmental, who will support you no matter what. Someone you feel comfortable being naked or sick or whatever infront of.

sect ion 09 Choosing a Doula

k The Beginning

Choosing a Doula Finding the doula who is right for your birth may take time and patience, but it's well worth the effort. The first doula you meet may be perfect, or you may not decide on which to choose until you meet three or four doulas. It is important to start looking around your sixth or seventh month, to provide you with plenty of time to consider your options. Ideally, hiring a doula isn't something you want to feel pressured over. The first step is finding a doula to speak with! Starting with any personal contacts is a good way to start your search. If you took a childbirth course, you may want to ask your instructor for a referral. She is likely to know at least a few local doulas, and she herself may be a doula. But don't feel obligated to hire her for your birth. Just because she's an excellent instructor doesn't mean she's your doula. If you have friends with children, be sure to ask them if they used a doula. You may want to ask your midwife or ob/gyn for recommendations, as well as your local birth-center even if you don't plan on having your baby at that center. Another place to find a doula is through the doula certification organizations. There are several, though you should be able to find plenty if you check out the largest ones, dona and cappa. Most of these organizations either have a referral list on their website, or you can email or call them for a longer list of local doulas. You can learn more about what approach your doula may take from reviewing the websites of certification organizations. start | The Association of Labor Assistants and Childbirth Educators, alace.org Beyond the doula organization referral lists, the internet has quite a few doula search engines. Search online with the words find a doula to find several doula referral sites. You may even be able to find a doula by typing into Google, or whatever your search engine of choice is, the word doula, along with your city or state name. Interviewing your Doula Once you've gathered a list of doulas, you'll want to start calling them. I have found it best to call several to ask the most basic questions, and then later, choose three or four from the list to meet with face to face. If the first doula you meet feels like the perfect match, I'd still suggest meeting with at least one other doula. Being able to compare the two will help

sect ion 09 Choosing a Doula

in making your choice. Also, make sure your partner meets the doula as well. It's essential that they also feels comfortable with your chosen doula. Some qualities to look for when deciding which doula to hire, experience and training often come second to which doula feels right. Listening to your gut is important when choosing a doula. For me, it was about bonding and falling in love with my doula, Stephanie of Nurturing Hearts Birth Services in Arizona says. It was like choosing my husband â&#x20AC;&#x201D; doesn't matter how much experience he had before I met him, what matters is how well we clicked and that I fell in love with him. Also consider what you are looking for in a doula. Everyone wants something a little different. Some people want a doula who will be a strong advocate. Others want a doula who will be involved physically a great deal, through massage and physical support. And still others want someone to just be there to provide a calm and centered atmosphere. I knew that I needed someone that wouldn't, try too hard, for me and my birth, Stephanie explains. I derive confidence by seeing the normalcy in those around me, so I chose a doula that I knew would smile for me through my labor, who wouldn't try too hard to do stuff, but that would just be there for me. Another important consideration when looking for a doula is their feelings on birth and how it will affect their support. You want someone that is non-judgmental, who you will feel comfortable with no matter what your requests or views on birth are. Kym Benner, a doula for over 17 years from Riverside, ca, encourages you to find a doula who will support your wants and needs, and not be concerned with her personal agenda. My philosophy is that this is your birth, your body, and your baby. You have the final say, and no matter what the doctor, nurses, and doula say, you make the decisions! I am there to support my clients in whatever they choose. If they want an all natural birth, then I will make sure that happens, but if they want every drug under the sun, then I will make sure that happens. It is not my birth, it is their's, and my beliefs do not come into play. end |

k The Beginning

start | Doulas of North America, www.dona.org As expectant parents, you are probably preparing extensively for childbirth and early parenting—attending classes, watching videos, reading books and articles, touring your hospital, practicing relaxation and comfort techniques, preparing a birth plan and discussing your hopes and concerns with your doctor or midwife and other parents. Such preparation improves the quality of your birth experience in many ways. You understand the birth process and know about your options for care, ways to cope with pain and the clinical measures commonly used to maintain safety and labor progress. In short, childbirth preparation takes many of the surprises out of labor and helps you to meaningfully participate in your care. Yet the journey through birth is unpredictable and stressful. Even wellprepared women or couples often find it difficult to apply their knowledge in the midst of intense labor. It helps to have guidance and reassurance from experts so you can relate the intense physical sensations and emotions of labor to what you already know intellectually. Your nurse, midwife or doctor will offer some guidance, but may be limited by their clinical duties and the needs of other laboring women in their care. And some are better than others in giving such support. To be sure you will get the kind of help you need in labor, consider having a birth doula. A doula is with you continuously through labor. She is trained and experienced in providing emotional support, physical comfort and non-clinical advice. She usually meets with you before labor to discuss your preferences and concerns. She learns the role you both want the father or partner to play. For example, some partners prefer to be the primary support person—with the doula there as a guide, errand-runner for beverages, ice chips, hot packs, warm blankets, partner’s food, helper often a woman needs two people helping during contractions and stand-in if the partnern needs a break. Other partners want to be with the woman they love to share in the joy of the birth of have you thought about having a doula at your birth? The doula is a constant — no breaks unless you are asleep, no shift changes, no clinical responsibilities or other women to care for. And she understands what you are going through. Her knowledge and experience reassure and comfort you and guide you in breathing techniques, positioning, massage and use of the bath, shower, birth ball, hot and cold packs and other comfort items.

sect ion 09 Choosing a Doula

As one grateful father said, I heaved a big sigh of relief when she walked in. I hadn’t realized how much pressure I had been feeling. A new mother said, I don’t know what we would have done without her. Your doula’s goals are to learn your preferences regarding the use of pain medication and any fears or concerns you have. In labor she helps you accomplish your wishes and allays your fears, but also helps you make adjustments if unexpected demands or complications arise. The continuous assistance of a doula throughout labor has been proven in numerous scientific trials to improve both physical and psychological outcomes of the birth. By alleviating the mother’s emotional stress which can have a negative impact on labor progress and the baby’s well-being, doulas reduce the mother’s need for pain relief medications. Most studies have also reported shorter labors, less need for oxytocin to speed labor and fewer deliveries by forceps, vacuum extractor and cesarean when doulas are present. In addition, the research has shown that women’s satisfaction with their birth experiences, their postpartum psychological state, success in breastfeeding and interactions with their newborns are all improved when a doula is present during childbirth. Research also shows that when doulas are in attendance, fathers take fewer breaks away from the mother, remain closer to her and touch her more. The doula seems to relieve the stress and some of the burden on the father, allowing him to comfortably give more support to his loved one. Whether you plan to birth at a hospital or at home, with medication or without, a doula can make a positive difference at your birth. If you are interested in learning more about doula care see page 37 for listings of organizations that train and support doulas. Penny Simkin is a physical therapist, childbirth educator, doula, birth counselor, doula trainer and author of books and articles for parents and professionals. She is a frequent presenter at conferences and workshops for maternity care professionals. end |

k The Beginning

Another important consideration when looking for a doula is their feelings on birth and how that will affect the type of support they will give. You want someone that is non-judgmental, who you will feel comfortable with no matter what your requests or views on birth are.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

q & a for a Doula

Do you like the sound of her voice? Yes! This is good because that is the voice of the woman you will hear during the labor and birth, you really want it to be pleasant for you.

Birthing Women Need

Help & Support

Choose Wisely

sect ion 10 q & a for your Doula

k The Beginning

q & a for your Doula

While the answers to your questions are important, you're really looking more to see how you feel with them on the phone. Do you feel comfortable? Do they sound like someone you could relate to? Do you like the sound of their voice? Yes, really! That is the voice you'll be listening to during birth, and you want it to be pleasant for you. Once you go through your list, arrange to meet face to face with two, or three, or four, of them. 01 Are you taking any new doula clients for the month I'm due? If she says no, ask her if she can refer you to any other local doulas. 02 What's your experience and training as a doula? This answer will vary greatly and there really is no right or wrong answer. 03 How would you describe your approach to birth as a doula? This answer will vary greatly and there really is no right or wrong answer. 04 What's your price? And can you provide me with references? Each doula will have their own pricing and regulations on cancellations. 05 What training have you had? 06 Are you certified? By what organization? What were the requirements for your certification? It is perfectly ok for you to ask these questions as you want someone with professional experience. 07 Tell us about your experience with birth, personally and as a doula. Just like asking your doctor and midwife these answers can tell you a lot about how she will support you. 08 What is your philosophy about childbirth and labor support? Her philosophy might be different then yours, this is ok, just keep looking. 09 May we meet to discuss our birth plans and the role you will play in supporting us through childbirth. Remember she will need to know what your plan is, and if there are any changes. 10 May we call you with questions or concerns before and after the birth? Usually Doulas have a good reputation for open communication.

sect ion 10 q & a for your Doula

11 When do you try to join women in labor? Do you come to our home or meet us at the hospital? This is good to know, as you could be in labor a couple days, or you might need to transfer. 12 Do you meet with us after the birth to review the labor and answer questions? She might want to be at your postpartum meeting with your midwife or doctor. 13 Do you work with one or more backup doulas to cover for times when you are not available? May we meet them? Always good to have a back up plan. 14 What is your fee? When you meet the doula and it is a good idea for both you and your partner to meet her, pay particular attention to your personal perceptions of the doula. Is she warm, kind, and enthusiastic? Is she knowledgeable? Does she communicate well? Is she a good listener? 15 Is she comfortable with your choices? Do you feel comfortable with her? You may want to interview more than one doula, make sure they are comfortable with what you want and what you need.

k The Beginning

Doulas give you support and care while you are laboring, that is focused on you. They have been shown to reduce the need for medications, c-sections and other interventions.

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Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

The History of Child Birth in the usa According to the cia the online World Factbook the usa infant mortality rate in 2011 ranked in 39th place. In 2012 that number has dropped to 48th place. The usa has the least amount of midwifes and one of the worst infant and mother mortality rates of all developed nations. What's wrong with this?

We have to ask ourselves are we going in the right direction with medical interventions, drugs, insurance companies and hospitals bureaucracy? CIA World Fact Book, https://www.cia.gov/library/publications/the-world-factbook/

sect ion 11 The History of Child Birth in the usa

k The Beginning

The History of Child Birth in the usa The history of birth in the usa is not pretty. The event of birth has been adapted to suit the doctors and the nurses rather than the motherâ&#x20AC;&#x2122;s comfort and ease of birth. For example, doctors appointments are limited to 15 minutes usually with the doctor asking the pregnant woman, Do you have any questions? Instead of giving them in-depth information and time to get aquanted. Or in the case of using ultra-sound to measure the pelvis of a woman to see if she is able to pass a child through the birth canal which is scientifically unfounded. Another example is how women are made to lay down in a lethargic position with their legs up, which is usually a dysfunctional position to give birth in as it makes the pelvis smaller and the woman canâ&#x20AC;&#x2122;t use her stomach muscles or gravity in a beneficial way. These are just a few examples that the medical system has adapted for business and procedure, not women and babies. Birthing knowledge that was once common and understood even doctors before the 20th century is being ignored by doctors of today. Doctors are good at what they do and we need them. What I am saying is that the medical profession treats birth as a medical problem, a procedure, when in fact it is a natural part of life We can compare the option for a natural child-birth to that of organic food. In the 20th century and for all of history organic food was normal. At one time pesticides were considered luxury. Then they became the norm and later we found out that they had serious consequences not only to our health but to the environment as well; people are now demanding that we go back to organic. Organizations like Slow Food Nation, and Farmers Market are examples of companies trying to fulfil this gap. According to the cia on their online World Factbook, the usa infant mortality rate in 2011 ranked in 39th place. In 2012 that number has dropped to 48th place. The usa has the least amount of midwifes and one of the worst infant and mother mortality rates of developed nations. We have to ask ourselves are we going in the right direction with medical interventions, drugs, and hostpitals?

sect ion 11 The History of Child Birth in the usa

We should be asking the question, What are the basic needs of women in labor, through out the entire birthing process from conception, and to care of the mother during postpartum. Then give women a choice as to what they want to do with their bodies, and for their families. My preliminary pool of 86 people, 17% considered natural birth to include an epidural, 10% considered labor to be painful and to be avoided, 7% people thought a cesarean section avoids complications and reduce pain. start | Excerpt from Midwifery & Childbirth in America by Author Judith Rooks The usa has a history of doing things it’s own way regardless of what the rest of the world is doing. Maternal medicine is no different. Whereas most of the world, developed countries have midwifes attending most births the usa does not. Countries like the United Kingdom, Sweden, and Japan all have a rich heritage in midwifery practice and are benefiting from that.The usa had midwifes when it was still a colony. Every culture that came to America, including West Africa, Britain and American Indians had midwifes and many traditions that were beneficial. This in part led midwifery to be localized and shared through the different communities. When medicine entered into the professional arena of the early part of the 1800’s it was still very difficult for the government to outlaw midwifery practice all together. Prodigious, on race, income, and education all played a part in whom the doctors would or would not care for. In the later 1800’s there was a power struggle between the educated and the uneducated. Between 1900 – 1920 two damning reports came out of the educated department of society, stating that obstetrics were poorly trained and to improve on this hospitals should do all deliveries and do away with midwifes. All obstetrical failures in the past 200 years can be traced back to this report. Had they only considered the midwifes as knowledgable, that skills had been passed down from generation to generation, worked together instead of against, things would have turned out a lot different.

k The Beginning

A few years after the report, medications were introduced, including the now famous twilight sleep. Perhaps some of the darkest moments in obstetrics was when doctors assumed that childbirth was painful and to be avoided at all cost and proceeded to medicate the patience with morphine and scopolamine, which is an amnesiac, that had the effects of wiping all memories of giving birth. At first it was welcomed by the community at large. It was a symbol of medical genius and progression. Though they would discover the side effects were not only negative but extremely harmful to both the mother and the baby. In 1915 Dr. Joseph DeLee, author of the most important obstetric textbook of that period, described childbirth as, A pathological process that damages both mothers and babies often and much. He said that if birth were properly viewed as a destructive pathology rather than as a normal function, the midwife would be impossible even of mention. In his first issue, American Journal of Obstetrics and Gynecology, DeLee proposed a sequence of interventions designed to save women from the evils of natural labor. All these interventions included the routine use of sedatives, ether, episiotomies, and forceps, and other harmful drugs not tested.

The focus changed from responding to problems as they arose to routine use of interventions to control the course of labor and delivery.

DeLee was a very influential obstetrician who served as head of obstetrics at Northwestern University, chairman of obstetrics and gynecology at the University of Chicago. He changed the focus of health care during labor and delivery from responding to problems as they arose to preventing problems through routine use of interventions to control the course of labor. This change led to medical interventions being applied not just to the relatively small number of women who had a diagnosed problem, but instead to every woman in labor.

A century later American obstetrics has not changed much. Many of these misguided ideas are still being refered to and used. It still follows the misguided demeaning view of women, midwifes, and maternal care.

sect ion 11 The History of Child Birth in the usa

The medical system in the usa is structured in order that the more care provided to a patient the more money is made so there is not a lot of incentive to challenge or change anything. A scholar who conducted an intensive study concluded that the 41 percent increase in infant mortality due to birth injuries between 1915 and 1929 was due to obstetrical interference in birth. In the late 1920â&#x20AC;&#x2122;s midwifery began to pop up again in North America Frontier Nursing Services founded by Mary Breckingridge, in order to serve the needs of a poor rural community. She had served as a Red Cross nurse in France during the Second world war. She and her team of nurse midwifes, though a small group, were influential in the medical system introducing familycentered maternity care. They offered comprehensive childbirth education, involved the fathers, let mom and baby stay in the same room, and helped momâ&#x20AC;&#x2122;s learn how to breast-feed. Most certified nurse-midwifes work in the obstetric departments of a hospitals. The desire to avoid routine use of medical interventions motivated midwifes to develop non-hospital birth-centers. A new form of midwifery, the lay-midwifery with the home-birth movement, developed during the 1960's and 1970's. As part of a grass-roots effort by women to reclaim power over their own bodies and births, a small number of mostly well-educated, middle-class, white women started choosing to have home-births with Lay midwifes. Such midwifes are now known as direct-entry midwifes. Direct-Entry means that the midwife entered her profession Directly not through nursing. Some direct-entry midwifes are associated with religious traditions such as the Amish, Mormons, and other Christian and Muslim groups. Direct entry midwifes attended four of every one thousand births in the usa in 2003 and almost five of every one thousand vaginal births non-cesarean. The vast majority of women in the usa give birth in hospitals, attended by obstetricians. end |

+38+49+800

k The Beginning

83 countries with better infant mortality rates than the usa

2011 39th place 2012 48th place

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Evidence Based Practice for Women During Birth

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Weeks 1 â&#x20AC;&#x201C; 14

The Finance of Heath-Care fact 99% of women in the USA choose to give birth in a hospital. fact Hospital fees can average between $8,300 to $10,700 for a vaginal delivery. fact c-section deliveries cost $14,800 to $18,900 depending if there are complications. This does not include prenatal care or delivery fees can add $4 â&#x20AC;&#x201C; $6,000. 127 Data is from 2004. See Thomson Health, The Health-care Costs of Having a Baby, June 2007, p.8

Birthing Women Need

Honesty & Respect &

Trustworthy Care

sect ion 12 The Finance of Heath-Care

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The Finance of Heath-Care start | Excerpt from Amnesty International 2010 Deadly Delivery Report Access to affordable health-care in the usa fails to provide for both women and babies. This leaves open a window of problems largely associated with women of color, women of poverty and immigrant women. These women are unable to access the health-care system and therefore have much higher rates of untreated and unmanaged heath conditions especially relating to maternal care. Federal anti-discrimination legislation requires companies that have more than 15 employees to treat pregnancy, birth and related conditions in the same way as other temporarily disabling conditions, and prohibits employers from charging women higher premiums than men. As a result, most company health plans have care related to pregnancy and childbirth at no additional cost to women. Even women who are employed can still be denied coverage if they did not have insurance covering them before they were pregnant. They have to contribute a sum of money every month. If she looses her job she looses the insurance. Only 18 states offer coverage for pregnancy related care if they are under federal legislation which usually excludes smaller companies. 32 states donâ&#x20AC;&#x2122;t offer any protection. For an individual to be able to find personal insurance not through an employer is even more difficult, restricted, and expensive. With higher premiums, maternity care is often left out. In the state of California, insurance coverage of approximately 805,000 people, 78 percent of those with individual insurance, excludes maternity care. The insurance companies often refuse to provide coverage for pregnant women based on the grounds of their pre-existing condition, namely pregnancy. A study of over 3,600 individual insurance policies found that only 13 percent of health insurance policies provide you comprehensive maternity coverage. Maternal Heath-Care is in Crisis. Insurance companies are charging high premiums, extra tag on amounts for maternal care. All sorts of things can raise the cost of the insurance, such as on women who have had a previous operation like a c-section, and deny that service for a period of time after the first one. Insurance companies did research on patients to find the ones that they could drop, and that including pregnancy.

sect ion 12 The Finance of Heath-Care

Nearly 13 million women between the ages of 15 and 44 â&#x20AC;&#x201D; where one in five women â&#x20AC;&#x201D; are not insured. Women whose earnings excluded them from coverage by Medicaid as well as undocumented immigrants are not eligible for public assistance to cover prenatal care in most states. However, they may not earn enough to pay for private insurance. Over 4 percent of women give birth without private insurance or government medical assistance. Amnesty International spoke to a number of women who had received no prenatal care at all because they could not afford it. Low cost clinics will often aid and cover women who can not get care due to lack of funds and lack of insurance. These clinics are often overcrowded and underfunded and are not often allowed to treat women who have high-risk complications. Amnesty International, was told about one woman who was low income that enrolled in a clinic program that provided free prenatal care. When she started bleeding heavily, she went to a hospital emergency room for treatment. When she returned to the clinic she was told that they could no longer treat her because she was now high-risk and needed a specialist. She incurred approximately $8,000 in debt to receive necessary prenatal care. end |

k The Beginning

Amnesty International linked Medicaid delays in approval for getting care to low income women not getting heath-care they need in a timely matter. This is due in part by bureaucratic procedures, and a lack of case workers to help process and access the applications. Carolyn Clancy, Director, Agency for Health-care Research and Quality, Amnesty International, 7 January 2009

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Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 – 14

Failure to Inform – usa's Maternity Crisis

The 2012 cdc National Vital Statistics Report states 34% of maternal deaths occurred within 24 hrs of the birth, an additional 55% of deaths occurred 1 – 42 days following birth. cdc National Vital Statistics Report 2012

It is important to

Inform & Provide

Options & Respect

sect ion 13 Failure to Inform â&#x20AC;&#x201C; usa's Maternity Crisis

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Failure to Inform – usa's Maternity Crisis start | Excerpt from Amnesty International — 2010 Deadly Delivery Report In the usa informed consent is an ethical obligation recognized by all medical associations and it is a legal requirement based in statutes and case law. While there is some variation of the legal standard by each state; all 50 states have informed consent requirements. Physicians must always disclose the health risks of treatment for a patient’s consent to be valid. However, these standards are not always applied. The usa has fewer options for women regarding its maternal care than any other industrialized nation regardless of the fact that we spend more money on our heath-care system than anyone in the world. ob/gyn Obstetricians are the primary care providers for maternal care in the usa; most of the rest of the world is opposite; providing family practitioners and midwifes fulfilling that role. With approximately 83 percent of women in the usa having low-risk pregnancies it seems silly to have all these women seeing an obstetrician whose primary job is to care for and prevent disease and complications caring for women who don’t need that type of care.

Options for alternative care in the USA are slowly being pushed out by insurance companies and laws that are not based on scientific evidence.

One factor contributing to the limited nature of options available is the failure to include community members and advocacy for groups in the decision making process regarding what constitutes appropriate, quality maternal care. A woman’s ability to actively participate in her care is hampered by a lack of information about care options and the failure to involve women in decision making regarding their own health care.

sect ion 13 Failure to Inform – usa's Maternity Crisis

That is why it is so important to not only inform but provide the option for women to have alternative means of care. The midwifery model of care is women-centered care and has been shown through both studies in the usa including the cdc and abroad that it is safer for both the mother and baby to have maternal care and birth outside of obstetrical care. There are a lot of barriers for women who want a women-centered birth. One barrier is that certified midwifes work mostly in the hospitals, directly in the medical system and not the home or birth-centers. In the usa, 24 states do not allow midwifes who have been through certification and exams to practice outside the hospital. The care is often not covered under insurance, regardless of the fact it can cost significantly less to have a midwife in the home. Compare a midwife who might charge $4,000 for an entire pregnancy which includes hour long visits and home visits before and after delivery. Whereas a hospital can change anywhere from two to ten times that amount. Enhancing women’s choices of maternal care options can play an important role in ensuring the right to health. In some cases physicians or hospital staff have treated midwifes and even their patients with hostility and disrespect that compromises the quality of care women receive. One midwife told Amnesty International about a woman from Iowa, who had been declared a perfect candidate for home-birth by a specialist a week before and went into labor at home. The midwife became concerned when labor did not progress and referred them to the hospital. At the hospital, staff tried to prevent the midwife from entering, but the husband insisted she accompany them. The woman’s pain was excruciating, the midwife there told Amnesty International. Upstairs we wait 45 minutes — but nobody comes to see us. She was sobbing profusely from the pain. She was very scared for herself and her baby. Finally, a staff member says, We can’t get a doctor to come in as long as you the midwife are in the room. The doctor told the them that the woman needed an emergency c-section because, he said, the woman’s history of bleeding during pregnancy indicating a condition called placenta previa – a potentially life-threatening condition where the placenta blocks the cervix.

k The Beginning

After completing the operation the doctor admitted the complications had been caused by a polyp, not by undiagnosed placenta previa. Even though the couple was upset at having been coerced into an unnecessary c-section. The family did not file a complaint because they said they feared retaliation or mistreatment should they seek care at that hospital in the future. Having a midwife can actually greatly increase maternal survival as the midwife checks the mother and the baby on day 1, day 3, day 6 and so on until 6 weeks in the home. There are some programs in the US that allow for home care through the hospital but that is in the minority..

Maternal Care does not stop once the baby is born. Many complications can happen even a year after giving birth for both mother and the baby. According to a study conducted by the cdc 34 percent of maternal deaths occurred within 24 hours of childbirth. 55 percent of these deaths occurred between one and 42 days following birth. Complications arising from medical interventions like a c-section leading to hemorrhaging, and pulmonary embolisms the two most common causes of maternal death. Most postpartum care consists of a one time visit to the office with a physician, sometimes not even with the doctor that delivered the baby, approximately 6 weeks after birth. This is highly inadequate in light of the research that shows the two most common causes of maternal death happen within two weeks of birth. end |

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Evidence Based Practice for Women During Birth

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Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Accountability & Lack of Supporting Data

Who takes the responsibility for the implementation of best practice in the feild of Maternity Care in the usa? The short answer Everybody & Nobody Carolyn Clancy, Director, Agency for Health-care Research & Quality, Amnesty International, 7 Jan. 2009

sect ion 14 Accountability & Lack of Supporting Data

k The Beginning

Accountability & Lack of Supporting Data start | Excerpt from Amnesty International â&#x20AC;&#x201D; Â 2010 Deadly Delivery Repor Who is accountable to the women and babies the usa system fails to provide health care and adequate services for? The answer should lie within the usa's Government, but sadly it is often not, because our health-care system is in all sorts of business, centralized or not, private or public it is often impossible for the government to create regulations and procedures based on quality of care and the patience best interests. It is their responsibility to provide health-care for everyone, without discrimination yet discrimination is present on all levels, income, race and gender just to name a few. The failure to meet either international or domestic targets for improving maternal health in the USA is linked to a fundamental breakdown in accountability, There is not one source of data collected. The system for collecting, and analyzing data is inadequate and is not being fixed. According to the cdc, the number of maternal deaths may be twice as high as current estimates. The lack of comprehensive data collection makes the full extent of maternal mortality and morbidity in the usa and is hampering efforts to analyze and address the problems and so improve maternal health overall. Maternal complications are the fourth leading cause of infant death in the usa, yet death certificates often leave out many important details, often they are an afterthought done by a person who was not privy to the information or even there at the death so the fact that a woman was pregnant or had a baby in the year prior to death is not documented properly. Public health experts and researchers told Amnesty International that studying complications and injuries can provide a more effective basis for a systemic review of maternal health, because they are more common than deaths. Maternal complications are the fourth leading cause of infant death in the usa, they are reducing maternal complications and improving womenâ&#x20AC;&#x2122;s health would also reduce infant deaths. However, little data is currently available on maternal complications or near misses and few maternal mortality review committees review or analyze these cases.

sect ion 14 Accountability & Lack of Supporting Data

There have been a few attempts at tracking complications and injuries related to maternal care such as the Patient Safety and Quality Improvement Act of 2005, and the support of ahrq, the National Quality Forum. They have created a list of 17 quality and safety measures. Though this will help provide much needed data to the system it is still inadequate to implement them and analyze them. Only 18 of the 21 states that actually have a maternal mortality review committee have legal protections for the disclosure of the information for public heath investigations. In those 18 states providers are still concerned that they are not legally protect against a law suit. This is bad for both the individual in their care and for the government who is obligated and trying to ensure health-care is available, accessible, and acceptable and of good quality without discrimination. end |

k The Beginning

In the usa there are 20 states whom have at least a Review Community for Maternal Morality, and of those 18 states fear the review system is not adequate. 30 states do not have any type of Maternal Morality Review community. Deadly Delivery â&#x20AC;&#x201D; The Maternal Health Care Crisis in the usa by Amnesty International

sect ion 14 Accountability & Lack of Supporting Data

m.a.n.a. State by State Midwifery Legal Status 2011 Status l, cpm l, cpm l, cpm l, e, r cpm p, cpm l, e

l, cpm

l, cpm p

• • • • • • • • • • • • •• •

l, cpm

l, e c, cpm

• •

State

Status

Alaska Arizona Arkansas

c, cpm l, cpm l, cpm c, cm

California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Main Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada

vl, cpm c l, cpm c, cpm l, cpm vl, cpm l, cpm, cm l, cpm

l, cpm l, cpm

State

• • • • • • • • • • • • • • • • • • •

New Hampshire New Jersey New Mexico New York Northern Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington d.c. West Virginia Wisconsin Wyoming

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20+80+A 8+92+A 3+97+A 9+91+A 14+86+A 17+83+A 2+98+A 9+91+A 1+99+A 2+98+A 4+96+A 20+80+A 3+97+A 50 States /

Legal Licensure or Certification

Illegal Prohibited by Statute, Judicial, Interpretation, or Stricture, of Practice

Not prohibited, Not regulated

Medicaid Reimbursement

Legal but Not legally regulated, and not prohibited

Full Licensing

Voluntary Licensure

Certification

Registration

Permit

NARM test for licensure

Certified Professional Midwife

Certified with American Midwifery Certification

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a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Exercise for Pregnancy

You know exercise is important; that also includes you, while your pregnant. So donâ&#x20AC;&#x2122;t labor under the illusion that you can eat anything and lounge around. Try using the New Life exercise cards provided within the box throughout the duration of your pregnancy.

Preparation for Birth Includes

Heathy & Exercise

Commitment & Love

k The Beginning

sect ion 15 Exercise for Pregnancy

k The Beginning

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a woman-centered birth

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Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

When is That Baby Due?

When it comes to determining your due date, are seldom what they seem. Today the methods of calculation are far from exact, common assumptions about the average length of pregnancy are wrong and calling it a due date is misleading.

Birth Is and Should Be

Natural, Safe, Amazing

Beatufiul & Wonderful

sect ion 16 When is that Baby Due?

k The Beginning

When is That Baby Due? start | When is that Baby Due? By Henci Goer http://parenting.ivillage.com When it comes to determining your due date, things, as the Gilbert and Sullivan ditty goes, are seldom what they seem. The methods of calculation are far from exact, common assumptions about the average length of pregnancy are wrong and calling it a due date is misleading. Understanding these uncertainties may help to curb your natural impatience to know exactly when labor will begin. Many obstetricians want to induce labor when you exceed your due date by a set number of days, in the belief that prolonged pregnancy increases risk. As with dating the pregnancy, the evidence for inducing labor after a certain time past the due date isn't nearly as clear-cut as you might think, but that's another subject. If induction were harmless, it wouldn't matter, but it's not. Among other adverse effects, inducing labor increases the odds of fetal distress during labor and cesarean section in first-time mothers, and mistiming the induction can result in a premature baby. How long does pregnancy really last? You might be surprised how the idea of a 40-week pregnancy came into being. In the early 1800's a German obstetrician simply declared that pregnancy lasts ten moon months counting from the start of the menstrual cycle prior to the pregnancy. It took nearly 200 years for researchers to investigate whether this was, in fact, true. It turns out that it wasn't. When researchers in the late 1980's followed a group of healthy, white women with regular menstrual cycles, they discovered that pregnancy in first-time mothers averaged eight days longer than this, or forty-one weeks plus one day. The average was three days longer than forty weeks in women with prior births. The researchers also refer to other studies suggesting other races may have average pregnancy lengths that are shorter than white women. As you can see, the due date was only a probability that labor would begin sometime around that day. It was not a certainty, much less a deadline. Until recently, obstetric practitioners defined a full-term pregnancy as extending anywhere from 37 to 42 weeks. Today, many obstetricians will say that any pregnancy lasting to the beginning of week 41 post term. This, you will note, is one day less than the average length of pregnancy in first-time mothers.

sect ion 16 When is that Baby Due?

How accurate is ultrasound at setting due dates? A study has shown that an ultrasound isn't any more accurate than a reliable menstrual history combined with a pelvic exam by an experienced obstetrician. Researchers confirmed this by looking at pregnancies with known conception dates and comparing due dates arrived at by ultrasound measurements with dates arrived at by menstrual history and pelvic exam. The fact that the old-fashioned method for dating a pregnancy does just as well as ultrasound is a vital point. While a sonogram may be useful in cases where there is uncertainty about when conception occurred, first-trimester sonograms are currently used as the ultimate standard. Your due date will often be changed if it differs from the one derived from the sonogram no matter how the date was previously determined or how sure you are of when you conceived. Even first-trimester sonograms have a range of plus or minus five days, or a ten-day window, around the calculated date. The range increases to plus or minus eight days in the second trimester and plus or minus ten days for third-trimester scans. For this reason, experts say the due date should not be altered based on results from an early scan unless the calculated date differs by two weeks or more from the date determined by physical signs and symptoms and menstrual history. What does this mean to you? The first lesson to be learned is have patience, unless there is a good reason not to wait for nature to take its course. When the fruit is ripe, it will fall from the tree. Inducing labor may be presented as a far more straightforward decision than it actually is. Think carefully about the risks and benefits of an induction recommended solely because you have not begun labor before some arbitrary cut-off date. Because it introduces risks, intervening in the natural process should only be undertaken to fix something that has gone awry. End |

k The Beginning

For those of you who donâ&#x20AC;&#x2122;t know, Evidence based care means that your healthcare is based on the most up-to-date medical evidence about what works best. Evidence-based care also means that you are informed accurately about risks and benefits of different options, so that you can make the best informed medical choices for your unique situation.

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Evidence Based Practice for Women During Birth

The

Beginning section

Weeks 1 â&#x20AC;&#x201C; 14

Note Book

Take notes and begin this journey...

Evidence Based Care should be

The most up-to date

Practices & Procedures

sect ion 00 Note Book

k The Beginning

Notes for Book 1

section 00 Note Book

k The Beginning

section 00 Note Book

k The Beginning

section 00 Note Book

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m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell