Monday, November 21, 2016

Year in Review: Elective Induction of Labor

Today I begin a review of the most talked about topics of 2016.  In the next few blogs, titled "Year in Review", I will share findings, thoughts and resources for you, the birth professional, as well as resources for your clients.  If there is a topic you would like to see in "Year in Review" please email me at

In May of 2016, attendees at the ACOG annual meeting participating in a stimulating debate on elective induction at 39 weeks.  Points were made that fetal macrosomia increases after 39 weeks which can increase the incidence of should dystocia and increase the risk of cesarean section.  Induction at 39 weeks could potentially reduce all of those risks, but admittedly, induction could be associated with a higher rate of cesarean.  Errol Norwitz, chair of the Department of OB/GYN and professor at Tufts University of School of Medicine, made the now famous comment, “My position is 39 weeks and out!” He additionally said in the Washington Post, “Nature is a terrible obstetrician.”

On the other side of this issue is, among others, Rebecca Dekker, who has her doctorate in nursing and is founder and writes for the blog, Evidence Based Birth.  Dekker is quick to shine light on the flaws in the research plus cautions about public complacency about inductions.  Inductions are not benign, simple or non-invasive.  Some of the medications used for induction, Pitocin or Cytotec, can create contractions that are too frequent, very painful, and can increase the risk of restricted blood flow and oxygen to the baby.

Still other questions need to be asked.

What part does a woman’s due dates play in the scenario?  Are we absolutely certain that dates are accurate? And based on those dates, elective inductions are made.  The answer here is there are no absolutes on the due date, which should actually be called Due Zones.  Neonates are still maturing in the uterus, the optimum place for growth and maturity.

Studies show that cesarean section risk rises when the Bishop Score is 7 or less.  Is the Bishop Score being taught by childbirth educators or doulas?

What happens with the American Board of Internal Medicine/Association of Women’s Health, Obstetric, and Neonatal Nurses “Choosing Wisely” Campaign?  Being certain that patients have a clear understanding (for informed decision making) of the process of induction “don’t promote induction or augmentation of labor and don’t induce or augment labor without a medical indication; spontaneous labor is safest for woman and infant, with benefits that improve safety and promote short- and long-term maternal and infant health.

The question still remains, in the situation where there is no indication of clinical risk, should the pregnancy continue until labor begins on its own, or should care providers take prophylactic measures to end the pregnancy before there are complications?  If the latter is the case, then full disclosure for clear and complete shared decision making must be completed.  Women must know the risks and the benefits of maintaining the pregnancy and of elective induction.  Scare tactics based on the discomfort that care providers may have about waiting for labor to begin on its own has no place in the shared decision making process. 

This is not a simple question to answer and one that must be given careful consideration.  In the Listening to Mothers Survey II, of the women in that sample (over 600) who experienced a medical (vs. self-initiated) induction, 25%  gave the reason that their care provider was “concerned that they were overdue,” while only 19% had a medical indication. Then 17% reported that their induction was due to the care provider having concerns about the size of the baby.

We must be cautious about early elective induction and the complications for both mother and baby.  Admitting preemies to the NICU due to “failure to wait” causes its own cavalcade of risks.  

For further review:
ACOG Committee Opinion 561 Non-medically Indicated Early-Term Deliveries, Reaffirmed 2015.

AWHONN Position Paper on Non-Medically Indicated Induction and Augmentation of Labor

Evidence on Inducing Labor for Going Past the Due Date by Rebecca Dekker (Evidence Based Birth)

Major Survey Findings of Listening to Mothers III: Pregnancy and Birth.

Monday, November 14, 2016

Certification as a Childbirth Educator or Doula – Yes or No?

There is much controversy around training and certification as a childbirth educator and doula.  Which organization shall I choose?  Is certification even necessary?  Will certification make a different to my clients?  How will certification benefit me?

All of these very legitimate questions need to be answered one by one by the individual.  In choosing an organization through which to become certified, it is important to thoroughly investigate the organizations being considered.  Ask the following questions:

  • How long has this organization been established?
  • Does the mission and vision of the organization fit with your personal philosophy?
  • Is it an organization, a 501c3 non-profit, or for profit company?
  • Does the organization have as its foundation evidence-based information?
  • What is the process of certification, including fee structure?
  • If this is a membership organization, what are the member benefits?

Once you have decided on an organization with which to align yourself, accessing the benefits of certification to you is vital.  Certification indicates to your clients and colleagues that you have cared enough to go the extra steps to read, learn, and take the exam for certification.  This puts you ahead of those not seeking certification – not every person is a natural teacher or labor support assistant and training and certification gives you that edge.  Along with certification comes recertification and the need to attain continuing education.  If a person is not certified, there is no compelling reason to learn new things.  They can become stagnate and dull, teaching outdated with materials and information.

In the US, there is no standardized training, certification or licensing for childbirth education as there is for nursing.  Individual hospitals or birth centers may have their own policies that dictate who teaches expectant families.  For example, a hospital may mandate that only certified childbirth educators teach the childbirth classes and only lactation consultants can teach breastfeeding classes.  On the other hand, some facilities do not require that their childbirth educators be certified; the only requirement is that they are nurses.  However, nursing schools are typically not teaching how to teach, therefore an increasing number of nurses (and non-nurses who wish to teach) seek out programs that can teach them how to teach the information for a variety of teen and adult learners. 

Some organizations or programs take those with little or no maternal/child health background and provide a rigorous path of external reading, observation of other educators, workshops, and other educational work.  Other organizations and programs require a certain level of expertise prior to entry into their paths of study, such as labor/delivery nursing experience, midwifery, doula training or similar experience.

Affiliation and/or certification by an organization often carries with it adherence to an established Scope of Practice.  A scope of practice for childbirth education or doula work can indicate boundaries or limitations set by that organization, often with evidence-based information to back up those boundaries or limitations. Again, there is no standardization.  So no, technically, one does not have to be trained or certified.  However, it is common for expectant parents to ask for background training and certification – it shows a commitment to the professionalism of the field. Additionally, nurses who have been teaching from a set childbirth education curriculum find training and certification exciting for themselves and they then share this excitement and enthusiasm with their students.  This increases “patient satisfaction” and increases popularity of the hospital or birth center programs.

Doulas may or may not choose to become certified due to initial outlay of cost.  However, being able to advertise that you are a certified doula with a certain organization does raise awareness of the level of expertise and quality of labor support.  While many certification programs for both doulas and childbirth educators may include in-person workshops (2-4 days in length), many organizations now are piloting online training workshops that can be done in the comfort of one’s own home.  This not only saves time, travel but also money on the peripheral expenses associated with training.  Along with online training may come an offer of mentoring, which can truly help bridge the educational gap between in-person workshops and online offerings.  These online training opportunities are also attractive to those living in remote areas, countries other than the US, and in areas not typically served by in-person workshops.  While online offerings may not be the preferred method of learning for some individuals, it can certainly increase the number of childbirth educators and doulas, and thus increase the information and support to expectant families around the globe.

Below is a table that can be used as a summary of what has been presented in this blog.  The ultimate decision is up to you.  Want to compare childbirth education certifications?  Click here.

No Certification
Specific, targeted learning
Cost for starting to teach
Yes, training
Adherence to Scope of Practice
Benefit of aligning with recognized organization
Recognition by other birth professionals
Recognition by clients
Membership $ for organization
Need for recertification
Need for regular continuing education (CE)
Support from organization
Yes, perhaps
Access to specific CE
Yes, perhaps

Monday, November 07, 2016

What is Informed Decision Making?

One of the main constructs on which I have based my entire career, is informed decision making or informed consent.  What that means to me as a nurse, childbirth educator and doula is that I will, to the best of my ability, give to my client(s) understandable, current, accurate evidence-based information on a variety of topics pertaining to their impending childbirth experience.  I make it my job to empower them to understand completely and have an appreciation of the facts, implications and possible future consequences of their decision(s). 

In order for a person to be ready for informed decision making, they must first have the evidence-based information, be able to ask questions freely in a non-judgmental and unbiased environment, be able to list the pros and cons, discuss these findings not only with their support team but also their health care provider, have
time for their decision to be pondered, and then implemented.

Based on the many acronyms for informed decision making from BRAND (Benefits, Risks, Alternatives, Nothing, Decide) to BRAIN (Benefits, Risks, Alternatives, Instinct, Now decide), clients can get their information and study that information.  Ideally, the nurses and health care providers are responsible for obtaining the decision or consent; the consent must be informed, voluntary and not obtained through misrepresentation. Along with the ability to make this informed decision is also the right to the information necessary to refuse care – the implications of the right to refuse must also be clearly understood by the client.  According to the Health Care Consent Act of 1996 (Ontario, Canada), “medical care is wrongful and “battery” unless the patient has given consent to it.”

Consent must also be free from bias in that health care professionals should be insightful as to the power of their persuasiveness in either word, voice inflection, facial expression or presentation.  As mentioned in the ACOG Committee Opinion 439 (original date August 2009, reaffirmed 2015), “care should be taken that the physician’s perspectives do not unduly influence a patient’s voluntary decision making”.

Good communication is key to the success of informed decision making.  Collaborative relationships between expectant clients, nurses, physicians, midwives, childbirth educators, doulas and lactation consultants are unique and specifically designed for a central focus – optimum birth outcomes. Ongoing communication must be clear, distinct and respectful, focusing on the patient-centered care and impact on the mother/baby dyad.  To ensure that these collaborative relationships are powerful and serve the expectant client, the Institute of Medicine defines quality of care that improves outcomes  with Six Aims:

1. Safe – avoiding injuries to patients from the care that is intended to help them.
2. Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and over use).
3. Patient- centered – providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.
4. Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care.
5. Efficient – avoiding waste, in particular waste of equipment, supplies, ideas and energy.
6. Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status.

For childbirth educators and doulas, nurses, lactation consultants, and midwives, our knowledge of the aspects of quality of care is imperative to drive the informed decision making.  Especially with doulas and childbirth educators who are often the “first responders” with whom expectant parents interact, we must stay focused on the latest information, what is and is not evidence based, and be able to respond to our clients’ needs for informational resources.  We cannot sit on our laurels and expect someone else to take up the mantel and provide our clients with information.  If our clients hear information multiple times from multiple sources, then so be it!  They will know that those sources are quality sources that can be trusted.

Study after study has proven that respectful care, and respect for decision making can improve birth outcomes and satisfaction.  And we as birth professional must continue to ask the hard questions about the iatrogenic rise in interventions, including cesarean section as compared to the rise of maternal/infant morbidity/mortality.  We must take care that there is not disconnect in the communication and care continuum.

For further review:

AWHONN: Women’s Health and Perinatal Nursing Care Quality Draft Measures Specifications
Health Care Consent Act 1996 

Tuesday, November 01, 2016

The Importance of ACOG's New Hydrotherapy Opinion: November 2016

Available now in pre-release online, ACOG's update on their April 2014 Opinion on Hydrotherapy contains some interesting and impactful aspects.  Here is a synopsis of the November 2016 Opinion Update.

ACOG states that hydrotherapy/water immersion is advisable for uncomplicated pregnancies, and labors that occur after 37 0/7 and 41 6/7 weeks.  They suggest that labors may be shorter when hydrotherapy is in use, and the incidence of epidural anesthesia is reduced.  This implies, as both evidence-based information and anecdotal information shows, that hydrotherapy reduces the perception of pain during labor.

While the opinion says that sufficient evidence does not exist to fully inform laboring women of the risks and benefits of hydrotherapy, the opinion states that the laboring woman should not only be advised of risks and benefits but also the hospital must establish strict protocols surrounding hydrotherapy.  Until sufficient data does exist, the opinion is that birth should be on "land" rather than in "water". 

Most importantly, the opinion states that "a woman may request immersion during the second stage of labor, including giving birth while submerged. This decision should represent an informed choice; a woman who requests to give birth while submerged in water should be informed that the maternal and perinatal benefits and risks of this choice have not been studied sufficiently to either support or discourage her request."

Interestingly, the references used range from the early 1990s to 2016.  In fact 21 of the 39 references would be considered unusable by the "within 3-5 year" rule of references used by many hospitals, physicians, nurses, childbirth educators and other birth professionals.  The opinion, however, does use the ACNM Position Statement on Hydrotherapy, the Royal College of Midwives Guidelines on Hydrotherapy and the NICE Guidelines on Intrapartum Care (includes hydrotherapy) as references.

Among the missing from the opinion is information from earlier in 2016 from the largest cohort study, with nearly 18,000 in the U.S. study.  The study from the Journal ofMidwifery and Women’s Health (full text available from this link) reported separately on outcomes for mother-baby dyads.  The research used in the study was from the Midwives Alliance of North America Stats Project with births during the years 2004-2009. Since the information did come from the MANA Project, the women in the project gave birth either at home or at a birth center – this may or may not make them representative of all U.S. childbearing women, as they received minimal medical intervention.  The key piece to this voluminous study is that water labor/water birth did not confer an increased risk of newborn morbidity/mortality, suggesting that  waterbirth “is a reasonably safe option for use in low-risk, low intervention births – especially when the risks associated with other forms of pharmacologic pain management are considered.”

To accurately discern your own opinion about water labor and water birth based on the evidence available world wide, I highly suggest the following resources:

"Birth Bath and Beyond: The Science and Safety of Water Immersion during Labor and Birth" by Barbara Harper in the Journal of Perinatal Education (2014)

Evidence Based Birth - this article is a history of waterbirth and a perspective on the previous ACOG Opinion of 2014.

Tuesday, September 27, 2016

The World Council on Birth

The World Council on Birth is one of the most prestigious organizations we've ever seen.  Shortly after it's inception, representatives from all of the leading maternity nursing, childbirth education, doula, lactation, midwifery and physician organizations flocked to the first annual meeting!

During that amazing first annual meeting, which lasted seven days, members of the Council discussed the alarming rise in cesarean section rates, maternal morbidity/mortality rates, and infant morbidity/mortality rates.
Evidence based information on every conceivable topic was presented on both a flash drive and print version to each Council member.  It was also posted on the WCB website.  During committee discussions, great headway was made on how to implement evidence-based information in medical school/nursing school teachings, hospitals and birth centers.

The high point of the annual meeting came when one Council member demanded that the observation that everything that is done during the birth process directly impacts breastfeeding implementation, success and duration.  The entire Council rose to its feet with a 25 minute standing ovation.  Then it was back to work in committees to implement yet another stellar concept.

Since that first annual meeting, 55% of the world's medical school/nursing school, hospitals and birth centers are actively implementing the evidence-based policies and procedures, with another 22% coming by the end of the year.  Implementation includes drastic changes in practices, training of all staff in evidence-based/physiologic birth practices and mother-friendly/baby-friendly care.  Over 400 hospitals in the US alone have begun hospital-based doula programs and another 600 are actively referring to doulas in the community.  The statistics for attendance at childbirth education classes is staggering also - we have seen a jump from 34% attendance to 77% attendance in just a few short months in the US.

We are just beginning to see the fruits of their labors!  Cesarean section rates, maternal morbidity/mortality rates, and infant morbidity/mortality rates are beginning a slow but steady decline in every country.  Postpartum PTSD and PMAD and just now also beginning to decline somewhat.  We are making progress!  We ARE moving forward.

(Disclaimer: the above information about the World Council on Birth is 100% satire.  Absolutely none of it is true or accurate.  It is all made up.  It is an exaggeration.  And how disappointing!)

Monday, September 19, 2016

What the Lancet has to say about TLTL and TMTS

Acronyms have become a part of our culture, especially with texting. LOL, ICYMI, and others are part of our new vernacular.  However, two new acronyms were introduced on September 15, 2016 by the Lancet: TLTL and TMTS.  Here's what authors Miller et al had to say:

In a recent article titled "Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide", authors Miller et al have identified that we are at an intersection in maternity care: too little, too late (TLTL) and too much, too soon (TMTS).  They describe TLTL care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity in many countries, not just the United States. Also described is the concept of TMTS:  the routine over-medicalization of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. It has been found that TMTS causes human harm and increases health costs, and many times, concentrates disrespect and abuse. 

Moving from "just" a maternity issue to a global public health issue, TLTL and TMTS has at the core a lack of evidence-based maternity care (EBMC).  EBMC includes care that is humane and dignified, and delivered with respect for a woman's fundamental rights.  In the Lancet's Midwifery Series, it has been shown that women not only value appropriate clinical interventions but also timely information and support so they can make the best possible informed decisions.  Patient satisfaction with care rises when this information and support leads to a feeling of dignity and control. Yet, evidence continues to demonstrate that women are too frequently not informed of risks nor have they been given informed consent for medical interventions. Leading international childbirth education and maternal/child health organizations have been say this for decades.

A prime example is the 2010 estimation that there were 3.5-5.7 million unnecessary cesareans done.  Cesarean section is an aspect of maternity care that is globally monitored and an example of an intervention that can be either TLTL or TMTS with disparity rates in nearly every country on earth.  While cesarean rates appear to be somewhat decreasing in the US, they are rising globally.

Significant to this conversation is the failure of the medical community to embrace and put into the practice evidence-based care.  Known as the "Know-do" gap, research shows that there is a sluggish effort for implementation of evidence-based care.  A dynamic effort must be made to target providers of maternity care for dissemination of this information, while also doing an audit of action, feedback and additional targeted educational interventions.  In short, the buy-in for reducing the "Know-do"gap and improving maternity care (plus improving maternal/infant morbidity/mortality rates) must be felt at all levels of management.  

The words "move toward more respectful maternity care" should basically scare the hell out of care providers today.  The implication that today's care is not respectful to a woman's physical, mental and emotional health goes against what many of us joined the profession to provide.  It can be shocking to know that traditional practices that are the "way we've always done it" are actually harmful for women.  Denial and anger are common responses to this epiphany.

As more and more research and statistics are revealed, the pressure on care providers will increase.  For hospital policies, procedures and practice guidelines to change there must be also social and economic pressure for change.  There needs to be intense pressure from the customer of maternity care for respectful care without fear of retribution.  There should also be pressure from insurance companies to refuse reimbursement for non-evidence based care.  Unfortunately, if we cannot appeal to the care providers' hearts, we will need to hit them in the wallet.

Providing evidence- based respectful care is not impossible.  There are providers, facilities and whole health care systems that have embraced implementation and currently practice this type of health care.  Sadly, the majority do not.

The authors state that excessive, unnecessary or inappropriate use of obstetric interventions in health facilities are a cause for concern.  I believe we've been concerned and complacent for too long.  Too many women have been the victim (yes, I said victim) of this type of inadequate care.  I say it is now time to sound the alarm.

Miller, S. et al. (2016)  Beyond too little too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.  The Lancet. Published online September 15, 2016

Monday, September 12, 2016

Discussing the New WHO Standards for Improving Quality of Maternal and Newborn Care in Health Facilities - Trying to Address the Flaws in the System

In a welcome response to the stagnate reduction in maternal/infant morbidity/mortality as well as a response to the quality of care that contributes to maternal/infant morbidity/mortality, the World Health Organization has created the new global document, "Standards for Improving Quality of Maternal and Newborn Care in Health Facilities".

This document centers around eight standards that the WHO feels should be implemented, monitored and improved based on the health care system in which it is adopted.  Not unlike the Healthy People 2010 and 2020
standards, the WHO standards define exactly what is needed to obtain high quality care during the childbirth experience.  Each standard is followed by a series Quality Statements that further define what researchers are looking for in the standard.  

While the use of the word "routine" is seen several times, it is the desire of the WHO Standards writers that evidence-based care become routine and not be the exception.  In far too many facilities world wide, evidence-based care is not practiced.  Traditional practices, perhaps years old, are the rule and not to be questioned.  This is a matter of culture and understanding.  In more industrialized nations, the use of evidence-based care has been slow to be embraced in part due to the political bureaucracy of the hospital system.  Creating, researching, reviewing, approving, and implementing new policies, procedures and practice guidelines takes time. Unfortunately, time is something that those in management positions rarely has and so the old adage, "if it ain't broke, don't fix it" becomes an unspoken mantra.  Again, unfortunately, many policies, procedures and practice guidelines do need to be updated or even recreated to ensure evidence-based care.  This is where there is a flaw in the system.

Below is a list of the Standards.

Standard 1. Every woman and newborn receives routine, evidence-based care and management of complications during labour, childbirth and the early postnatal period, according to WHO Guidelines. 

Standard 2. The health information system enables use of data to ensure early and appropriate action to improve the care of every woman and newborn.

Standard 3. Every woman and newborn with condition(s) that cannot be dealt with effectively with the available resources is appropriately referred.

Standard 4. Communication with women and their families is effective and responds to their needs and preferences.

Standard 5. Women and newborns receive care with respect and preservation of their dignity.

Standard 6. Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens the woman's capability.

Standard 7. For every woman and newborn, competent, motivated staff are consistently available to provide routine care and manage complications.

Standard 8. The health facility has an appropriate physical environment, with adequate water, sanitation and energy supplies, medicines, supplies and equipment for routine maternal and newborn care and management of complications.

These standards, as do the Healthy People 2020 Initiative, help to develop a proper framework, set of definitions and standards of care.  These standards have not been created by chance, but by a comprehensive set of research standards assessing the global issue of maternal/infant morbidity/mortality.  Resources for research of the standards included The Joint Commission (US), the National Institute for Health and Care Excellence (NICE) UK, the Council for Health Service Accreditation of Southern Africa, and the Australian Commission on Safety and Quality in Health Care (2012).

Each standard carried the same characteristics of the care being safe, effective, timely, efficient, equitable and people-centered.  This is of particular interest to childbirth educator and doulas who, as part of their role today, act as guardians of labor support and informed consent.  For expectant families to truly understand if these eight standards are being implemented by their hospital or facility, education becomes the key.  Standard 4 discusses at length the importance of effective communication - communication cannot be effective if both sides of the conversation are not speaking the same language.  By same language, I don't imply English or French.  I am talking about the knowledge of labor and birth, effective and evidence-based care, and listening to the mother's preference.  When preferences cannot be granted due to medical complications, appropriate care and information must be given that is respectful and preserves dignity.

Standard 6 is nearly a mandate for birth doula care.  What else can I say?  The research for the last 30+ years screams the benefits of doula care for the expectant/laboring/postpartum mother!  Why oh why are we embrace that which improves outcomes and patient satisfaction?  What is the medical community afraid of?  Yes, afraid?  Is it financial?  My feeling has always been that if a hospital had a doula program, they could market that in an incredible way and become the hero of the community based on maternal satisfaction alone.  And we all know who drives the medical referral bus in families - yes, mothers.  It is one of those magical moments that hospitals are missing.

To read more and get your FREE copy of the WHO Standards of Care, click here.