Infertility from Various Angles

Nov 11th, 2013 Research

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I’ve decided to dig deeper into infertility for one of my class papers.  It is paper number three in a series of short essays on the mechanisms that lead to different health outcomes.  The previous two focused on disparities in cesarean and how stress doesn’t affect breastfeeding. The essays are limited to three pages in APA format, which gives just about enough space to describe the situation before you need to start your concluding paragraph–no messing around with flowery words here. The limitations mean you focus on a very small piece of the puzzle.

For my infertility paper, I am focusing on the smallest piece — the microbial ecosystem that inhabits the genital tract.  While the known details are interesting, it is the unknowns that are fascinating.  For example, women with BV have a higher preterm birth rate and early pregnancy loss rate and are less likely to achieve conception with assistive reproductive technologies.  Unfortunately, we can’t really say why…yet. And as interesting as the mid-vaginal microbes are, there apparently exists a controversy over whether or not the uterus is a sterile environment.

Me, I’m very clearly on the non-sterile side of the debate.  The cervical os opens monthly, and we know it is possible for pathogenic bacteria such as chlamydia and gonorrhea to ascend all the way up to the tubes.  Why would we assume the good microbes would not also make the trip? This view is also supported by the evidence that babies who are born via cesarean after the bag of waters has broken appear to have the same microbial gut colonization as babies born vaginally — current evidence suggests only babies who do not have time in the uterus without the protection of the amniotic sac have a different gut colonization. Based on this, I’m proposing that better understanding of uterine microbial ecosystems can help explain some of the 10% of infertility cases that are currently labeled as “unknown reasons.”

Excuse me now,  I need to do a bit more research so I can make recommendations of possible collection techniques to obtain uterine microbe samples (without too much human DNA) for 16S rRNA sequencing and  can finish this paper.



The concept I tackled…”elective” induction

Nov 8th, 2013 Research

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I hadn’t realized it had been a month since I shared about concepts.  I completed the assignment, and hopefully did a good job communicating what I found. As expected it was different, but not difficult, and very eye opening.

I chose to look at the concept of “elective” as we use it to describe an elective induction.  I knew there were problems with the use of the word, and I wanted to learn how to highlight those problems.  As expected, my analysis found multiple meanings of the word, which leads me to today’s reminder:  always ask questions about everything you read.

The problem with multiple meanings is that we are talking about very different things–things that could even be the opposite of each other–and we make the assumption that we are talking about the same thing. What was the most disturbing to me is that for the assignment I was limited to peer-reviewed scientific literature; I was only looking at published research.  This wasn’t disagreement by pregnant women about what was a legitimate reason for an induction. This wasn’t disagreement among health care providers. This was disagreement among scientists trying to determine what the risks and benefits of the procedure may be.

What questions should you be asking when you read?  Basically, what was the methodology (the boring science part of the study).  So, if you wanted to know about how eating carrots affects pregnancy you need to ask yourself, “Who did they include, and who did they exclude as carrot eaters?” Did they only include women who are otherwise healthy, or did they only include women who are having a particular issue with pregnancy? You need to know how they measured “eating” carrots. Did a woman count as a carrot eater if she at a carrot once, or did she need to eat them every day, or did she need to eat a certain total amount of carrots?  You need to understand why this particular population was selected, and what that means about how they are defining a carrot eater or not a carrot eater. Were women chosen because they visited a dietitian during pregnancy, or recruited through a cooking class, or were they chosen because they happened to be the women using a particular clinic?  Where women are recruited might make a difference in what the “normal” diet is, and you need to be able to decide if that difference is meaningful.


Are you measuring a concept?

Oct 9th, 2013 Research

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Chances are you know what a concept is…something that represents something that isn’t physical.  Like “democracy” or “faith.” And chances are you could list a few concepts that relate to childbirth.  In case you are feeling lazy, I can list a few:

  • natural childbirth
  • continuous support
  • elective induction
  • woman-centered care

I’m sure you get the idea.

So, why is this important? Because when you read research about concepts, you need to be very careful about how those concepts are defined.  For example, is an induction for post-dates at 41 weeks an elective induction?  Is scheduling one-to-one nursing care the same as continuous support? Is it a natural childbirth if the woman chooses to use oxytocin, or if she has a vacuum assisted birth?

For researchers, the decisions about what “counts” and what “doesn’t count” when measuring these things matters because if your definition isn’t correct you could be measuring the wrong thing.  There is also potential for misunderstanding on the part of the reader, especially if the reader does not have access to the full article and can only see the abstract. If the authors make a statement such as “our results show home birth is safe” (or “not safe”), you need to be able to look at the inclusion and exclusion criteria to see how they defined a home birth.  Was it any birth that didn’t happen in the hospital? Was it only planned home births? Did it include women with risk factors that would ordinarily prevent them from choosing home birth? If you just assumed the researcher thought about home birth the same way you did, you could be making assumptions the actual research doesn’t support.

Some of the concepts in the birth world are big and hard to measure. Think for example of mobility in labor.  Do you count it as mobility if the woman has the freedom to move, but chooses to stay in bed? What if the only walking she does is to the bathroom? How much walking would a woman need to do for you to count her as “mobile” during labor? Or would she not have to walk at all, but simply change her position as much or as little as she wanted?  See, these are not always easy things to measure. In reality, you might want to measure different aspects of the same concept.  How much women do walk when a policy promoting mobility is put in place is a great question.  How does labor change when women spend at least 10 minutes of every hour walking is another great question.

So the next time you read a research paper or the abstract, ask yourself if what they are measuring is a concept. Then try to figure out how close you think they came to actually capturing the effect it has on labor, and what other ways the concept could be measured.


Social Causes for Cesarean?

Oct 2nd, 2013 Raising Awareness, Research

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One of the courses I am taking this semester is about determinants of health.  We look at things both within the individual, and within the environment, and how they interact to affect health. A very interesting topic, and very challenging to integrate the research on a topic into a three page essay. But integrate I must.

For the next paper, I’ve decided to look at race and ethnicity and its effects on cesarean.  I know enough epidemiology to know that when you adjust for risk factors African American and Latina American women are more likely to give birth via cesarean than their Caucasian American neighbors. It isn’t a small increase either – check out this study which is pretty representative of the epidemiology all over:

What the adjusted odds ratio means is that when we control for all the things that we know affect having a cesarean (like social or medical risks), we end up with this number.  In the case of African American women, that number is 1.54 – so an African American woman with no risk factors for cesarean is 54% more likely to give birth via cesarean than a Caucasian American woman with no risk factors in the next room.

Does this surprise you?

What about the result that African American women have a 2.19 adjusted odds ratio of having a cesarean for non reassuring fetal heart tracings. This means that if two women are in labor in rooms right next to each other (this was data from one hospital system), the African American woman has more than twice the risk of being told she has non-reassuring fetal heart tracings and that she needs a cesarean than the Caucasian American woman in the next room.  Does this seem biologically possible to you?

There are potential social factors that cannot be adjusted for – for example, are Caucasian American women and African American women likely to use different practitioners for their care – and therefore the choice of practitioner is affecting the rate of cesarean?

Another idea is the effect of racism on the actual health of the woman – do the effects of racism and the chronic stress of that racism reduce the capacity of an African American woman’s body to handle the additional stress of labor?

Or is it more obvious than that? Are our healers and care institutions still making decisions based on racism – deciding African American women are either too lazy, too unhealthy, too unfit, too complaining, too controlling, too loud, too sexual, too poor, too proud…. (you get the idea) to give birth naturally and so the decision to cesarean is made faster, easier, with less compelling data?

I don’t know what the answer is. I don’t think I’ll find it in the literature, but if I do I’ll let you know.  In the mean time, consider what your advocacy group for physiological childbirth looks like – and if the increased cesarean risk for racial minorities is something your advocacy group speaks against.



Electronic Learning Resources

Sep 30th, 2013 Best of the Web, Training

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I was cleaning out my inbox this morning and found some links to educational materials that can be helpful for midwives in training.

Cardinal Movements

How to Suture Correctly

Perineal Repair Study Module

Knot Tying

More Knot Tying







Running Skirts and Giving Birth

Sep 27th, 2013 Raising Awareness

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I shared my excitement about ordering some new running skirts for my birthday with a colleague at work. She’s a runner, and her less than enthusiastic response was, “I’ve never understood why people like those.” As I reflected on her response, and the less than enthusiastic responses many women receive when they share their desire for a natural birth, I noticed some parallels.

The first thing to point out is that my friend wasn’t judging me even though she was responding negatively. She really was perplexed – in her experience running skirts were about vanity. She’s only 26, naturally thin and been a runner since high school. Her “uniform” for running has always been shorts. There was no need for something to make you “look” better when you run – and really, can anything make you look better when you are running? In the same way, most people who react shocked when they find out you are planning a natural birth are not judging you, they are just surprised.

The second point is that her experience was limited to … her experience. The idea that someone would really want a running skirt was outside her experience – I was the first woman she met to share my desire even though she’d seen them in stores and on runners. So she had never had the opportunity to learn about the reasons women want them, and was left to determine the only reason must be vanity. The same holds true with birth. If a person has never known a woman who gave birth naturally, that person is limited to what they show in TV and movies – or the horror stories people share. The fact that natural childbirth is misunderstood by people who have no experience with it shouldn’t surprise us.

The third point is that she was open to hearing why I wanted them. I shared about the realities of a rounder body – and 39 year old legs – and feeling exposed when I only where spandex tight running shorts or tights. I shared about the bunching that shorts do when you have fleshy inner thighs, and how a skirt provides a bit of modesty without adding the uncomfortable bunching. This also holds true with sharing goals for birth. Sharing the things that are priorities to you, and how they shaped your decision lets the other person see what you see, and if someone asked a question you can feel pretty confident that a thoughtful and polite answer is welcome.

The forth point is that she realized there was a good reason to like running skirts. Her actual comment was, “That makes a lot of sense, no wonder they are so popular.” Our conversation about skirts ended there. She didn’t try to talk me into wearing shorts, and I didn’t give her information about where to get the best deals on running skirts. Neither of us tried to “convert” the other to our line of thinking. Wouldn’t it be lovely if conversations about natural birth were able to end this way?


Cleaning Advice

Sep 23rd, 2013 Working With Clients

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I was reflecting on the advice I often hear for pregnant women and housework.  There is nothing necessarily bad about doing housework while pregnant – no more than any other time – although pregnancy does cause some interesting challenges.  What I struggle with is that the advice is usually to have your partner pick up more of the workload.  I have a couple problems with the assumptions this advice makes.

1. That there is a partner (i.e. she isn’t single)…

2. Who is available (i.e. the partner isn’t deployed military, working long travel shifts or two jobs)….

3. And is able to pick up more of the household workload (i.e. not ill or disabled).

Granted, these concerns may not represent the majority of pregnant women, but women in these categories deserve real help in maintaining safety and health in their household as well – especially if hiring the job out isn’t an option.  So I did a bit of brainstorming and research to come up with the following tips for expectant mothers who cannot lessen their domestic workload.


Some chores are not necessarily difficult, but for a woman with allergies or asthma they can seem dangerous.  I think of a relative whose allergies are so bad, that dusting causes asthma exacerbation – something you definitely want to avoid while pregnant.  What can you do if you find your allergies are more sensitive (or bother you more) when pregnant?

Some potential solutions:

Use a “dusting” method that puts fewer allergens in the air, such as using a vacuum with a brush attachment or a microfiber cloth that traps the dust.  Prioritize the offending chores so they are done more frequently to prevent build-up of allergens – wipe down surfaces twice a week with a damp cloth, throw out foods more than once a week.  Break up the job into smaller parts – only dust one room a day, or mow the lawn on a different day than you do other yard chores.

Heavy Lifting:

I used to think a friend of mine was crazy that she moved her refrigerator every week to clean under it – then I had toddlers who spilled things and didn’t avoid the area around the refrigerator when they spilled. When we moved to the South even small drips on a floor could mean insects the next day. My point, different households have different timelines for how long the heavy-lifting chores can be put off.  For some women these types of tasks are harder during pregnancy because of the changed body-mechanics leading to back-aches. If you don’t want to wait until the end of the pregnancy to clean under your appliances or furniture – but you also don’t want to do anything that might risk a bad backache, you’ll need to find a way to get this work done.

Some potential solutions: 

Space heavy-lifting chores as far apart as possible.  Invite a friend or relative to help with the moving, in exchange for helping him/her. Experiment with different cleaning tools to see if you can get the “bad” parts without having to move the appliance.

Food Aversions:

Cleaning out the refrigerator can be a gross task, and even more gross if you start to feel nauseous at food smells.  But not cleaning out the refrigerator isn’t really a healthy option either.  What can you do?

Some potential solutions:

This is a job where more frequent cleaning makes it more tolerable.  Try getting into the habit of emptying left-overs on day two, and wiping down at least one shelf in the refrigerator each evening or morning (maybe while preparing a meal or while cleaning up). This will prevent it from becoming a big job, and will reduce the chances any particular food will be smelly enough to make you feel ill.

Cleaning Products:

I have trouble with the smells from cleaning products all the time – it is one of my migraine triggers.  Some women experience sensitivity to the smells while pregnant and others simply don’t want to risk any potential harm from being in contact with cleaning products.  What can you do?

Some potential solutions:

Try using alternative cleaning products.  These may be chemical free versions of cleaners or simple “home made” cleaners from vinegar and baking soda.  Try using a steam cleaner, which can give you a deep clean without any chemicals.  Experiment with different microfiber cloths to see if you do most of your cleaning with just water.  Bathroom and kitchen counters can be cleaned with hot soapy water.


For some women, the only thing that will make household chores more difficult in pregnancy is fatigue.  But fatigue is enough to make a woman frustrated that her home doesn’t meet her standards anymore.  Some women begin to feel comfortable with a new set of cleaning priorities to make chores more manageable.  If you are not one of those women, you will need to change your thinking about how to get cleaning done.

Some potential solutions:

Don’t try to do all your cleaning in one day, instead break up the chores into manageable chunks.  This may be by room (Monday I clean the living room, Tuesday the bathroom), or it may be by jobs (Monday I vacuum, Tuesday I clean toilets and counters).
Write out your cleaning plan so you can see when you plan to do things, and then check them off as you do them. Keeping track may help prevent anxiety if you miss a day, or need to change something one week.
Plan your chunks of cleaning to coincide with when you are going to use a room. This could be cleaning the toilet and sink as you are getting ready for the day, sweeping or mopping while dinner is cooking, dusting while you watch TV.

As much as possible, clean up as you go – keep a dish pan with hot soapy water ready to soak dishes while cooking, put your makeup away after applying it. These small habits will make cleaning chores less time-consuming.


So, that is my mornings worth of brainstorming for my pregnant friends who don’t have the option to have someone else clean their house. Do you have tricks that worked for you?



Theory and Practice

Sep 15th, 2013 Training

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The last few weeks I’ve had to do readings on nursing theory. You see, when you are going to become a professional researcher, you need to understand the framework of the discipline within which you intend to study. This gave me two thoughts to share with you.

First, the reality of practice is that a midwife is by nature an inter-disciplinary practitioner. You must understand physiology, development, medicine, sociology, psychology, pharmacology…need I go on?  It makes me wonder what role a discipline-specific theory plays in a multi-discipline practice.  I am not alone.  Midwifery’s sister discipline, nursing, has been struggling through this concept for the better part of 60 years.  If nursing uses knowlege from so many disciplines, what is unique about nursing?

The second is that theory drives your perception of real-life situations.  Whether you know it or not, you are subscribing to different “theories” of pregnancy, birth, and early parenting. These theories may not be spelled out with diagrams of conceptual frameworks or models, but they are verbally shared through the apprentice process, and they are shared through the books want-to-be midwives read as they prepare for childbirth, doula work or to become childbirth educators. I would challenge you to spend some time really considering the theories you are learning.  How do those theories drive your decision making during normal pregnancy and birth? How do they drive your perceptions of unusual and unhealthy variations?


Systematic Review

Sep 10th, 2013 Research

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At a conference I attended this weekend, one of the topics was the level of understanding needed to assess a study. The question went something like this: If a clinician doesn’t understand how research is conducted or if the statistical tests used are valid, can the clinician really assess the validity and usefulness to practice of any study?

It’s a good question. I’ve seen midwives and doulas cling to one piece of research over another not because the results were more robust, but because the authors conclusions were in line with what the midwife wanted to believe. But the results are only as good as the quality of the research methods.  I just read an article last night that concluded induction of labor at 41 weeks for postdates and expectant management result in the same rate of cesarean – but upon critical review of the article I noticed the subjects were divided into groups based on the preferred practice of the physician attending that woman. This tells me the paper is NOT about the overall differences of the two protocols because too much other pieces of practice style is built into the dividing of the two groups.

In a class I am working with a group of nurses were concerned they shouldn’t pursue their topic for an evidence based practice project because there was already a systematic review, and doesn’t that mean the question is already answered.  Actually, no.  A systematic review is a very specific overview of what information is available.  The results are going to be based on the inclusion and exclusion criteria – which means there are many pieces of research that may pertain to the topic that are not included in the review.  The review may add some validity to a line of thought about the question, but cannot be the final answer.  And a review cannot “keep up” with new research, it is a glimpse of the literature at a specific point in time. The publishing of a single systematic review (or writing of a guideline or protocol) should never prevent clinicians from regularly reviewing and revising practice – without reviewing practice regularly a clinician would miss new information that may change the understanding and types of care given.

With all these questions in mind, I want to share this learning module:

Cochrane Collaboration

It can help you understand how a systematic review is performed, so you can be a better consumer of research.


So you want to be a researcher?

Sep 8th, 2013 Jennifer's Training

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I am happy to say I have survived my first week of coursework. I am also happy to say that I am (so far) enjoying the coursework. I had fully expected the program to be rigorous – research can be difficult work.  I was not expecting the program to be so challenging to my understanding so quickly.

Challenging? Yes.  I had in my mind a concept of research from my MPH, and I understood the parts of a study and how to put it together.  But I am getting the impression that is the work of a technician really.  A researcher starts several steps back in the process because it takes more than seeing a clinical problem to identify good research questions. I don’t have a concept of what it is yet, I’m sorry.  But I know it goes beyond the basics of evidence based practice.

An example from my readings this week. One of the reasons we use theory is because it allows us to predict. As a clinician, this has been my level of theory work – and by itself this can be challenging.  My concept of cause and effect in wellness will determine how I work with a client. However, the authors from this week’s readings debate the concept of a theory that goes beyond predicting – ways of thought in which predictive theories become only a piece of the concept. I feel as if I can glimpse this idea, but not fully grasp it because I can only think of it in clinical terms –  as similar to a health system or similar to a religion.  In a religion you might have a theory about prayer that tells you when and how and how much and what you can expect to change due to prayer.  But in that religion, prayer is only one piece of the puzzle of how to grow spiritually, and in most religions is not sufficient without other practices.  Or in a health (wellness) system, I think of the use of yoga, a practice which has many variations that all agree yoga is one key to a healthy and balanced life.  But in each of those variations is built in the idea that yoga in itself plays only one part and the healthy individual also has other practices such as meditation and deep breathing, or nutritional prescriptions. A person can practice yoga outside the health belief system, and can add it to another health belief system – and the question then becomes how that changes the yoga practice and how it changes the health beliefs. But notice, I am still thinking in terms of the clinical.  At least I know I learned how to think like a midwife.

I feel like I’m not describing this very well, but that is unavoidable.  I’m only one week into the process and have a very limited understanding of this difference myself. But I am diving in and working hard to “free my mind” from the thought patterns of clinical work. As far as I can tell, my mantra for the next year should be “Question Everything.” Scary really, because I was a rather skeptical and critical person to begin with (probably what drew me to research), and I’m finding I am not even on the first step of learning to critically analyze like a researcher.


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