When I first started in birth work, I wondered why such obvious good questions were not researched. As I learned more I began to understand the problems of good research, and why certain types of studies would likely never be done (what woman wants to be randomized to epidural or not?) This week I am learning about another step researchers with questions must take — having a grant proposal reviewed.
The problem is, no matter how big a problem I think something is I still need to be able to convince a group of other scientists that my question is worth funding. This means I need to craft a compelling argument in just a few pages. I need to convince them the research is feasible, and that the answers will change practice and add to scientific knowledge.
And if that wasn’t enough pressure, I also need to convince them that my grant is more important than other grants they are reviewing because they cannot and will not fund them all.
What used to feel like conspiracy against natural birth now seems so obvious. While I am consider the utility of interventions that reduce the need for medication or shorten labor by half an hour invaluable, other grant readers are likely to consider them insignificant in the grand scheme of all the research that should be done — and then they would likely fund the research that has a bigger “impact.”
This is the side of research I had never really appreciated, but without it no work gets done. The next time I read a study about positioning in labor I will give due appreciation to the research team that took the time to craft a solid argument and convinced a funding committee that understanding comfort in labor was as important as understanding cancer.
Spring is conference season for me, and every year I have to make decisions about which conferences I will attend. How do I make those decisions? I rank them on their ability to meet my priorities.
When I first started working in the world of birth, conferences were about learning as much as possible. Attending them energized me (and every other newbie) and refreshed the excitement for working in the birth world. But that aspect of conferences quickly fades. I don’t learn very much at conferences anymore – I pretty much have the basics down, and speakers must turn in their outlines months in advance, which means I’ve usually already read any new research that is being talked about. This happens to everyone, and for many professionals it gives them a bad taste for conferences as a waste of time and money.
My priorities for conferences are a little different now. If I have an opportunity to present my research, that conference gets priority. If I have an opportunity to meet and talk with other researchers and leaders who could be part of a collaboration, that conference gets priority.
This year’s conference list begins with the International Confederation of Midwives — not only would I have to wait three years to attend again, but I have been accepted to present a poster. This makes this conference double priority because I can talk about my research as I network with leaders.
The second conference was a difficult decision, do I attend AWHONN (a group for MCH nurses) or Academy Health (a group for policy researchers)? I decided to go with AWHONN. The timing was a little better, and the connections I could make for research have a better chance of being focused on prevention effectiveness in reproductive health. Also, AWHONN has a mentored leadership position that I would love to participate in. My local meetings are always scheduled when I have class, so if I am going to get involved I have to step up at conference.
I am also attending a conference just for fun. Christian Midwives International is a group I’ve participated with for several years. Many of the members are friends, and I enjoy the opportunity to relax and catch up. It also gives me an opportunity to give back to the birth community. I don’t go to network and spread my research, instead I use the opportunity to help continue the education for midwives working ‘in the trenches.’
So, that is my spring conference schedule. Maybe I’ll see you at one.
Last week I challenged you to use spring break to plan out some educational opportunities for the upcoming year. If traditional courses don’t fit into your weekly schedule, you do have other options.
Check out edX, a totally free way to take classes for major universities. There are several classes wanna-be midwives could benefit from.
Food for Thought looks at the role of food in health.
Introduction to Global Health teaches you to identify and analyze variations between countries.
Health and Society looks at the social variables that affect health.
Behavioral Medicine teaches concepts to help clients make healthy changes.
Plus a whole section on statistics to help you become a better consumer of research.
Here’s to a very educational summer!
I am about half-way through the second semester, which brings me to spring break. For me it is merely a week to catch up, and I spent the first couple hours this morning cleaning and organizing emails, contact lists and calendars. I have three conferences coming up, so part of that time was ensuring all my documents were in order:
- I’m actually registered with a confirmation number in hand.
- Flight or rental car is actually booked.
- Hotel is reserved.
I am probably not the only person who “knows” what I’m going to do long before I do it and sometimes forgets a vital or piece or two until the early registration has ended or the hotel is full or the airline prices have jumped. But that’s a different story.
Today I wanted to remind you that spring cleaning is a great tool to use for your birth business. Here are some ideas for your spring cleaning:
- Organize contact lists, send emails to keep up important networking relationships
- Plan your conferences for the next year, organizations generally have them at the same time every year so plan ahead and save the money or book yourself some time off to attend
- Clean out and restock bookshelves, handouts, etc
- Fully clean your birth bag, including the fabric
- Update your website
- Update your contact information on internet directories and networks
- Make sure your finances are in order and complete your taxes
- Price out any big purchases (new Doppler, birth pool, take some classes?) and make a plan to save that money
- Look at educational opportunities and figure out which ones will serve you best in the coming year
- Update your marketing materials, and reassess marketing opportunities
I’m sure you can add many more to this list, it really is just meant to get your creativity flowing. Here’s to a very productive spring break!
I was reading one of the original publications on the three delays to care in childbirth emergencies this morning, and was struck with an unpleasant thought.
First, let me acquaint any readers who have not heard of them with the three delays. It is a framework for thinking about and dealing with the problems that lead to increased maternal mortality. It has generally been applied to women living in low resource settings.
- The first delay is the wait time between the problem occurring and the woman or those with her recognizing there is a problem. This generally has to do with lack of education and trained birth workers. In areas where poor outcomes are endemic due to multiple effects of poverty, women and their families may consider the signs of a problem to be normal because this happens to nearly everyone.
- The second delay is the wait time between identifying the problem and seeking help. This generally has to do with the costs of seeking care, the low value of women to a society (and her ability to decide for herself to seek care), and the perception of the health system’s ability to provide help.
- The third delay is the wait time between arriving at the place where help is available and receiving that help. This generally has to do with under funding health systems causing lack of staff, supplies and necessary resources to handle emergencies.
What stuck me today was that although this framework was designed for use in low resource settings, I can see reflections of some of the causes of delays in conversations with home birth in the US. I understand that in the US, the maternal mortality rate is not driven by women not having access to care in obstetric emergencies. Yet, I can’t help but wonder if some of the push back against home birth comes from the successful implementation of this framework into the international obstetric community.
I want to explain why this framework was adopted. Prenatal care was supposed to have solved maternal mortality by identifying women at risk and referring them to appropriate resources. While this might work for hypertension issues, that is only one small chunk of the maternal mortality pie-chart. Once the research started to show the failure of prenatal care to predict obstetric emergencies, the momentum changed to improving access to emergency care by making sure facilities with obstetrical services were well distributed, properly staffed, provided with adequate supplies, and able to be accessed when an emergency occurred.
In the United States, most of the country has the emergency services available (but there are geographic pockets with low population levels that are simply under served in all areas of health care). In the minds of decision makers, the existence of emergency obstetric care is evidence the third delay has been dealt with, and it is only the first two delays that could cause problems.
If you look back on the first two problems, these relate to poor decision making by unskilled labor attendants. In the developing world this was most often family members of the woman. In most of the United States, registration or licensing helps to ensure minimum competency of birth attendants for home birth. To some, this serves as evidence that the first two delays have also been dealt with.
So what was the unpleasant thought? When viewing birth from two different paradigms, it is easy for sides to see very different courses of action as appropriate. While homebirth supporters may feel they are expressing faith in the natural process, I can see how practitioners who view birth from a different paradigm could hear something very different in the comments I hear.
So a comment about how it took two days of labor, but the baby finally came out might be seen as evidence the midwife is not trained in the partograph to help identify obstructed labors.
A comment about how a woman had to birth unassisted because she didn’t want a cesarean might be seen as evidence of an inability to recognize risk.
These are just examples. I’m sure you could come up with additional ones. The point is, a paradigm can make a comment be received very differently than it was intended. It makes me wonder what the best way to bridge the various birth paradigms may be.
I have to admit, I wasn’t quite prepared for a new semester to start. It didn’t help that instructors didn’t have readings available until the day of class so I couldn’t be a week ahead (my comfort zone). What really had me not prepared was that I actually spent my break doing something for me. No editing papers for submission, no posters. No credentialing tests to get done. So I ran a marathon.
I use the term ran rather loosely, I walked about 25 miles of it. I intended to take walk breaks so it wasn’t a huge disappointment. I had intended to take a walk break every 8-9 minutes, so it was a little sad. I had made a classic newbie blunder – I over-trained. Not that I was trying to be really fast or beat some time. I just figured I could do a little extra and it would be OK.
My legs are now receiving the rest they so desperately needed, and the experience was not so bad that I won’t go near another marathon. In fact I am planning to run again. So what did I learn from this experience (aside from the importance of not over-training as defined by your running ability?) I learned that the running a marathon metaphor I had been taught to use when explaining why women should prepare for birth is not quite as good as I had always imagined.
The metaphor for those who have never heard it: A person couldn’t run a marathon without training. Childbirth is like running a marathon, you need to train to do it well. There are lots of variations of phrasing, but it basically boils down to: you have to get your body in good shape and have lots of endurance to give birth.
Yes, I did have to build endurance. But that didn’t mean I needed to think about running all the time, and it didn’t mean I needed to practice running every day. And honestly, there was no question about my ability to do a marathon. I had read the statistics on marathon finishers — it turns out that if you actually train you have a pretty low chance of not finishing. That little piece of information surprised me, and kept me motivated. Unlike childbirth, there were not things outside my control that could wreak havoc on my ability to finish. I might fall, or crash into another runner — but really the chances of something happening that could prevent me from finishing was pretty small.
And really, the building endurance was only part of the training. Seems there are people who are quite athletic, but don’t run long distances regularly, who are not able to finish a marathon when they first try because they assumed it was all about strength and endurance. These people end up vomiting, leaving the race due to blisters or chaffing, or overdo it in the beginning and just can’t make it to the end. I learned how often I needed to eat when running — too infrequent and I would be weak, too frequent and I would be nauseous. I learned which clothing causes chaffing, and which outfits keep my skin intact despite sweating in them for six hours. I learned my best strategy for hydration. I learned which shoes do the best at protecting my feet on long runs. All these things I needed to be able to finish I could learn because I was really running during the practice. This doesn’t happen when women practice positions and comfort measures for labor. A teacher might try to simulate pain with pinching or ice cubes, but until you are actually in labor (or running), you cannot be sure what does and does not work. This is probably one of the reasons women say they have an easier time with the second and subsequent labors – they know what to expect and what didn’t work.
I have been challenged to do a triathlon this summer. While my legs rest from running I’ve been working on the swimming and cycling portions. I’ll let you know if this turns out to be a better metaphor for labor.
Just found an interesting site for those who want to improve their ability to understand research articles. I haven’t dug too far into it yet, but seems promising:
Looking for an interesting self-study program during the holiday break? Here is one from the CDC on vaginitis. It is such a common issue for women, midwives need to understand the condition.
At the end of a random self-talk conversation this morning I remembered how awesome I thought it was when the midwives at the birth center taught me to hear the fetal heartbeat with a stethoscope. At the time is seemed so hard, and it took me a few tries. But the more I traveled, the more I realized this method is pretty common in low resource areas. But in the US where you are likely to learn to listen with a fetoscope or dopler, transferring those skills to a stethoscope will take a few adjustments.
Here are some things I had to learn to master listening with the stethoscope:
- It helps if you are already well practiced with a stethoscope. You need to know how to position it properly in your ears to block out the ambient noise.
- You need to already know how to find the baby and identify landmarks. You will have to position the stethoscope over the back near the head, and there is less room for error than with a doppler.
- You need to be willing to press the bell very firmly onto the mother. You will be pushing hard enough to ‘indent’, and you will leave a red ring (that lasts about 5 minutes) where the bell was pressed against the skin.
- You need to already know how to “hear” the heartbeat. The sounds are different than when you use a doppler, and they are more subtle than with a fetoscope. One friend equated it to the difference in listening for the blood pressure sounds between an 18 year old healthy young man and a 90 year old lady – the sounds are there, but they are subtle and you need to learn to hear them.
Hope this lists help you master this skill. If you are just learning how to use a stethoscope and/or to identify fetal parts, it might help to use the stethoscope after you have already found the heartbeat with a doppler. Figure out where you hear it the loudest, and begin your stehoscope search for the heartbeat there. It may also help to try it on women near term the first few times – it can be easier to identify parts and the fetus is squished right next to the abdominal wall.
For those who think their calling may be more on the political activism side of the spectrum, I wanted to take a minute and give you some resources you might not have considered. Most major organizations have advocacy priorities that are set by the national board. For example, if you read at the Royal College of Midwives, you will see a collection of research and briefings that share what the RCM thinks is most important right now.
Do you have a political leaning in your call? Check out the national organizations that work around birth – think organizations of nurses, midwives, doctors; and think about international organizations such as Lamaze and La Leche League. Check out the advocacy sections of their website and see if you can find a current need to help fill.