I'm continuing to review some 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 info@birthsource.com.

Birth Doula/Postpartum Doula Care

Doula care worldwide is increasing in popularity, where popularity is both defined as public knowledge of the word and its meaning, and also the access and use of doula care both in the birthing process and in postpartum.  After nearly 35 years of research, this is a welcomed statement to make.  Current research in journals, particularly nursing journals (AWHONN), demonstrate the definite benefits to the laboring family and care providing team of

birth doulas.  From reducing the cesarean section rate through non-pharmacologic pain relief methods and the integration of upright/gravity positive frequent position changes, doulas provide the 1-1 care that (especially in the US) maternity medical care so frequently talks about, richly needs and from which huge benefits can be derived.

Postpartum doula care has been attributed to extended breastfeeding, easing of postpartum mood and anxiety disorders and an overall reduction of stress brought about by new parenthood.  With immediate and extension of breastfeeding comes better health for the new society being born, and a healthier society for tomorrow.  Postpartum doulas care today for the health of the community of the future.  This may prove to have significant effects on future health care studies.

One overall drawback to doula care is the lack of standardization in training and certification.  There are currently a myriad of nonprofit organizations, startup companies and small businesses who provide doula training and certification.  It is the opinion of this author that a standard, professional training and certification module would greatly enhance the acceptance of doulas as members of the health care team (much like nursing) as well as increase credibility in the lay community.  Standardization would also help eliminate the person who enters the profession of doula care with their own agenda.  Regretfully, these hidden agendas are brought forth after training and certification are complete and when the doula begins practice in their community.  It is then that negative agendas appear and the entire doula community may be labeled according to one doula’s rogue agenda.  This can happen in any segment of the medical community, however, if the doula is not an employee of a hospital or birth center, or not a member of an organization with a grievance policy, there is precious little that can be done to “save face” after an act has been completed.  Knowing the lengths that some individuals would go to promote their own agendas, this author sometimes doubts that a threat of suspension or withdrawal of standard certification or even licensure would thwart a doula’s rogue agenda.  We don’t know until we try.

Community based/hospital paid/volunteer

There are currently several ways to access doula care.  Doulas may be independent small business owners and operate within the community in which they live.  Most of their business is referral by “word of mouth” or perhaps low cost marketing such as business cards or self-generated brochures or flyers.  Cost of community based doulas generally vary with services provided, community cost of living, and years of experience of the doula.  Community based doulas may or not be trained by legitimate organizations, and may or may not even be certified.  Community based doulas may or may not carry their own malpractice insurance.  The thinking is that since the doula performs no clinical skill, the chances of them being included in a law suit are minimal.  To be on the safe side and to protect their personal and professional assets, some community based doulas do carry malpractice insurance.  Clients pay the doula directly, either by cash, credit card or even barter.  The doula is solely responsible for their own taxes. (Discussion of the decision to be certified has been addressed in an earlier blog: http://childbirthtoday.blogspot.com/2016/11/certification-as-childbirth-educator-or.html  )

More and more hospitals are bringing in doulas into their staff.  Generally, hospital based doulas are trained and certified by legitimate organizations, overseen by a doula director or manager, and evaluated year.  They may be included in the malpractice insurance of the hospital and should there be a grievance against them either by a co-worker or client, the doula director or manager would be the one to handle the grievance issue.  Payment to the doula is made by the hospital and general is a flat fee for service.  This service may include 1-2 prenatal visits, the length of labor, and 1-2 postpartum visits.  Clients pay the hospital in advance and the hospital is responsible for all taxes and fees, as in any other business.

Occasionally, a hospital based doula program can provide volunteer doulas for those in a specific population (for example, if they are conducting a trial to reduce cesarean rates in a given population) or if they are grant funded for a specific population. Volunteers may be asked to serve as doulas for a number of births in exchange for their training and certification.  Since training and certification through a reputable organization can cost upwardly of $500-$1200, this can be a win-win for a hospital serving a low-income population while also giving a new career to a person who would otherwise not be able to afford such quality training and certification!  This can also be a huge benefit for the community, as more and more doulas are brought in to the community for support.

Nurse labor support skills

Much has been published in the nursing literature about nurses being the perfect labor support person.  Who better to support the laboring mother and her family than the nurse who also has intimate knowledge of this woman’s medical condition.  Nurses are by definition caring and loving individuals.  It just makes good common sense.  It makes good common sense until you realize all of the other mandatory tasks that a staff nurse in L & D has on her plate on any given day.  Not only is she given 1-3 actively laboring patients, but there may also be a myriad of other non-patient related tasks (such as crash cart audits).  Today, nurses are also required to actively chart electronically on each patient.  This may be an easy task for those who are tech savvy, and quite the challenge for who are not technologically oriented.  All of this makes for nurses who are stretched emotionally and physically.

However, for those facilities who wish to give their nurses the non-pharmacologic pain relief knowledge to support physiologic births that is not taught in nursing school, organizations such as ICEA have special, one-day workshops (complete with nursing CEs) to provide this knowledge.  ICEA’s Mother Friendly, Evidence-based Labor Support Skills Workshop for nurses is a prime example of meeting the nurses’ needs almost before the nurse knew she had the need.  In this eight hour workshop, nurses not only learn the non-pharmacologic skills but also the science and rationale behind these skills.  Nurses can go back to their units and immediately apply their new skills ~ increasing nurse satisfaction, patient satisfaction and improve labor/birth outcomes!

Doulas still are the best way to provide physical, informational, emotional and practical support to expectant families with positive, statistic changing results.  Research has shown that doulas can positively impact length of labor, perception of pain, and reduced the incidence of interventions such as cesarean section.  

In the wise words of the late Dr. John Kennell, 

“If a doula were a drug, it would be unethical not to use it.”

For Further Review

1. Aschenbrenner, A.P. et al. (2016) Nurses' Own Birth Experiences Influence Labor Support Attitudes and Behaviors.  Journal of Obstetrics, Gynecology and Neonatal Nursing.  Jul-Aug;45(4):491-501. doi: 10.1016/j.jogn.2016.02.014.
2. Fortier, J. H., & Godwin, M. (2015). Doula support compared with standard care: Meta-analysis of the effects on the rate of medical interventions during labour for low-risk women delivering at term. Canadian Family Physician, 61(6), e284–e292.
3. Kozhimannil, K. B. et al.  (2013). Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health, 103(4), e113–e121. http://doi.org/10.2105/AJPH.2012.301201
4. Kozhimannil, K.B. et al. (2016) Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery.  Birth.  Mar;43(1):20-7. doi: 10.1111/birt.12218.
5. Kozhimannil, K.B. et al.  (2014) Potential benefits of increased access to doula support during childbirth.  American Journal of Managed Care.  Aug 1;20(8):e340-52.
6. Kozhimannil, K.B. et al. (2016) Disrupting the Pathways of Social Determinants of Health: Doula Support During Pregnancy and Childbirth.  Journal of the American Board of Family Medicine.  Vol 29. No 3. 308-317. Doi: 10.3122/jabfm.2016.03.150300.
7. Roth, L. M. (2016) North American Nurses' and Doulas' Views of Each Other Journal of Obstetrics, Gynecology and Neonatal Nursing. Nov - Dec;45(6):790-800. doi: 10.1016/j.jogn.2016.06.011.
8. Zielinski, R.E. et al (2016) The Value of the Maternity Care Team in the Promotion of Physiologic Birth.  Journal of Obstetrics, Gynecology and Neonatal Nursing. Mar-Apr;45(2):276-84. doi: 10.1016/j.jogn.2015.12.009.

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 info@birthsource.com.

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.

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Nonmedically-Indicated-Early-Term-Deliveries

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

http://www.jognn.org/article/S0884-2175(15)31585-9/abstract?utm_source=awhonn.org

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

http://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date-post/

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894594/

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.

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

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:

ACOG Committee Opinion 439
http://www.acog.org/-/media/Committee-Opinions/Committee-on-Ethics/co439.pdf?dmc=1&ts=20150309T0843479479

AWHONN: Women’s Health and Perinatal Nursing Care Quality Draft Measures Specifications
https://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/Downloadables/perinatalqualitymeasures.pdf

Health Care Consent Act 1996 https://www.ontario.ca/laws/statute/96h02 

IOM Six Aims: Crossing the Quality Chasm
https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

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:

ACOG CommitteeOpinion #679 November 2016 Immersion in Water During Labor and Delivery

ACNM Position Statement on Hydrotherapy 

Royal College of Obstetrics and Gynecologists/Midwives joint statement.

"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.

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!)

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 http://dx.doi.org/10.1016/S0140-6736(16)31472-6