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The Nature of Pain

Aug 21st, 2013 Research

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I’m doing some reading about research on methods to manage labor pain today, and reviewing an old study:

Niven, C. and Gusbers, G. (1984). A Sudy of labour pain using the McGill Pain Questionnaire. Soc Sci Med, 19(12):1347-1351.

Before I had even gotten to the meat of the study, the authors had my attention with one simple and honest assessment of reality – understanding labor pain is difficult. How can a 5 point or 10 point scale of “pain” really capture the full experience of any woman in labor.

  • The pain a woman feels may change over time, even if she does nothing different.
  • The pain a woman feels may change as she changes positions, even if nothing physically changes with her contractions or labor.
  • The pain a woman feels may or may not continue between contractions.
  • The pain a woman feels may be less intense or troublesome than negative emotions or negative thoughts she feels during labor.
  • The pain a woman feels may or may not reflect how well she feels she is coping with that pain.

And yet, despite the problems with rating pain on a scale, it is the only “objective” measure many women get to share about their labor experience. Nurses may chart both the “pain” and how well the woman feels she is coping, but again, that misses so many aspects of what the pain experience is.

It makes sense women will tell each other labor rates an 11/10 for pain – if the scale isn’t able to measure the full experience, the actual measurement should be off the scale.

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Lobbying for Midwives

Aug 20th, 2013 Raising Awareness

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The American College of Nurse Midwives has declared August Midwifery Lobby Month.  That means they want all members and supporters to talk to legislators about policies that improve access to midwifery care. One of the national bills they encourage support for is MOMS for the 21st Century. Take a look at the information and let me know what you think.

I want to draw your attention to one item this bill would address – maternity care shortage areas. Why? Because this is my main research interest.  Currently, we don’t really know where these shortage areas are.  How do I know. I just finished my master’s thesis on the subject and honestly, the information doesn’t exist.

We don’t have an accurate count of what, if any, family practice physicians are still providing maternity care and which perform cesareans.

We don’t have an accurate count of which OB-GYNs are providing maternity care, and which are doing only gynecological work or specialized in areas without providing general maternity care.

We don’t have an accurate count of what midwives are providing maternity care – in fact in some states a direct entry midwife could be legally providing care, but there is no registration so there is no count.

As if the lack of numbers of providers were not enough, the estimates of how many providers are needed is really an estimate.  There has never been validation of the number based on maternity outcomes.

And when you add in the problem that that United States doesn’t actually have a health system, and that in some states 50% or more of births are paid for through Medicaid, having an accurate number of which practitioners are providing services for medicaid recipients becomes important in determining where care is adequate.

There is a lot of work to be done to improve maternity care in the US, and it isn’t all about changing practice protocols. My research is quite timely, but first I need to make it through two years of coursework.

 

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Why we need midwives in research

Aug 13th, 2013 Research

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This article came across my inbox this morning: Yerks Research Center receives five-year, $9.5 million grant to study oxytocin.

As you probably remember, I graduated from the public health and nurse midwifery programs at Emory in December, and am returning to Emory to begin work on a PhD in nursing in just two weeks.  I was as excited to see this research project as I was when I learned Lynn Sybley had received an $8.1 million dollar grant to improve maternal and newborn survival rates in rural Ethiopia. She’s a pretty impressive  midwife, wouldn’t you say?

As much as I am excited about the new Yerks oxytocin studies, my heart sinks just a bit because there is no midwife included in their research staff.  I suppose it is possible a midwife from another part of the university is on this project, but I’m not counting on it.

Why do I care if a midwife is on the project?  Because currently the only uses of synthetic oxytocin are reproductive. This means, if there is disruption in oxytocin production or reception associated with these problems, one must question the effect of the use of synthetic oxytocin during labor on these disruptions.

While any PhD can read about the uses, and any doctor will know, and any obstetrician will be familiar with its effects, a midwife brings a unique, holistic understanding of the uses of synthetic oxytocin. This is part of the reason multidisciplinary teams are so important – because each specialty brings a unique perspective to help ask the right questions and interpret the answers.

I understand the order of research, and that before links can be made between synthetic oxytocin use and problems with oxytocin metabolism, you need to find out if problems with oxytocin metabolism really do exist.  But I still wish a midwife were on this team to be part of the question generating before the research begins.

 

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Website Updated with Research

Aug 10th, 2013 Research

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This summer I embarked on a project to update the website.  This would be only the second real redesign since its humble beginnings in 2000. I had updates style before, and added more articles.  But really the website simply grew by lumps and outcroppings the way a small house slowly has rooms added on.  The result was a website that didn’t flow well for readers, with redundant information. The growth of the internet as a whole meant some sections which were previously important (such as recipes) were no longer needed.

Along with the update, I decided to put research references for the information right on each page. I had already moved to this style for some topics, but wanted navigating research to be easier for the readers. Sometimes this was easy, other times it mean hours of pouring over studies to gather as much information as possible, and then hours of rewrites to condense the information in as easy to read a format as possible.  This consumed my summer.

I am happy to say, it is finished!

Yes, there are still articles I decided to leave as is and add research later. For the most part these are the less debated topics. In the end I felt having the information available to readers was more important than giving research references for the month by month guide to pregnancy.

I hope you’ll spend some time on the updated site.  Check out what’s new and let me know what you like or what could be improved.

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Midwifery Regulation Matters

I’m updating the directory this week, a very boring task involving staring at a computer screen and writing code…….yawn.

But in the midst of these updates I do more research, look for more resources and find more information about midwifery in places I don’t live…like Canada.

Here in the US, midwifery is regulated at the state level.  This means laws can be very different depending on where you live.  This is not a problem unique to the United States.  Canada’s midwifery laws are province specific and create equal havoc for Canadian families. Check out this summary of current midwifery laws.

Not being Canadian, I don’t know the system well enough to know if this is direct entry midwifery or all midwives.  At least in the United States, nurse midwifery is legal in all states even if direct entry midwifery is not yet regulated or completely prohibited. So while states may have policies that make it more difficult (or nearly impossible) for a woman to have a midwife, at least there are some midwives.

Perhaps I’ll have the opportunity to look into some of the Canadian midwifery policies when I begin my PhD research this fall.

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Refreshing an internet directory

Jul 9th, 2013 Best of the Web

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I’m beginning the last segment of the website reconstruction – cleaning up the Natural Childbirth Directory.  This is a big task.  The directory has over 200 pages of information just about services available in the United States.  Every page has to be reformatted to the new look.  Every link has to be checked to ensure it still works.  And that is what I find interesting today.

Having a list of useful links on a website is like shooting an arrow at a moving target. The internet is a dynamic information source, changing daily.  A link that was helpful last week may be “broken” this week.  A website with some interesting articles a year ago may be gone today.

When I began the directory, I wanted to be able to send readers to great sources of information.  I wanted the unique articles that start discussions. I sought out web pages that complimented the information on Birthing Naturally, not pages that gave readers the exact same information. I wanted to be a link to resources families might not find otherwise – the hidden gems.

But the internet has changed. I think I first built the directory in 2005, and at that time it felt like a big deal to me to not send families to commercial sites they would find listed in any internet search (remember when search was basically looking through an edited list of websites?). I reasoned that if it took me a long time to find these resources, as plugged into the natural birth community as I was, it would be nearly impossible for families looking for information to find them.

I still think there may be hidden gems out there in the folds of the web, but I don’t spend time each week finding them.  Many of the articles I considered great reads don’t  exist anymore. But what is more interesting to me is that I don’t need to send families to an unknown webpage in the middle of a family’s personal website to provide research.  There are great websites that do a fabulous job of educating women, integrating research and statistics with advice and basic information.  Childbirth Connection, La Leche League, even the World Health Organization has pdfs that can be downloaded free to help women plan for birth – and usually in multiple languages.

So, just as in the other sections of the website, I find the needs of readers have changed and the directory must change to provide the best opportunities for the readers.

 

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Midwifery Evidence

Jul 8th, 2013 Paths

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I’ve been trying to be diligent at getting the website updates completed.  They must be completed before I begin classes again in the fall, or their importance will drop to the “don’t have time” category.  Ugh.

It’s been an interesting journey to update the website.

Some days I surprise myself with how thorough I had been.  I’ll make a list of things to “add” to the website, only to find in the midst of updating a section that I already added that five years ago!

Some days I’m surprised with how messy the navigation had gotten.  The website “grew” organically from questions being received and interactions with mothers.  Without an easy way to change the overall navigation scheme, pages were wrapped in an interestingly hard to navigate web. This time, I’m starting over with navigation because I’m updating the whole website.  I hope this makes it easier for new readers to find what they are looking for.

Some days I struggle with how to balance evidence and information. My biggest example is the pregnancy concerns section – where I share things women sometimes try to get rid of backaches, stretch marks or nausea. It is in this section I have the most difficult time finding “evidence” that things work or don’t work. This is partly due to the difficulty in randomizing women to study the effects of an intervention.  Do you randomize before they complain about something – before they get nausea? Because there may be differences in their diet that lead to nausea.  If it is overall diet problems, then depending on the problem in their diet they may have different solutions to the problem.  This gets really complicated really fast.  Most studies tend to be observational, which might point in good directions but might also hide what is really working.

This is a struggle for me because I believe women have the right to the best information possible. I believe that information includes whether or not an intervention works – even if the intervention is eating fresh papaya.  Why?  Because if this is not something the woman ordinarily does, she has to take extra time and money to obtain and prepare the papaya – and she may not like the flavor.  I have no right to decide for her if the extra time, money and eating something she doesn’t care for are worth the “relief” she gets, especially if I don’t know the papaya actually gives relief.

In preparing a talk on menopause, I came across an interesting study that looked at the effects of different types of treatments on hot flashes.  Most women used hormone replacement or soy supplements, a few women used other things and some women used nothing.  This was interesting because it didn’t matter what the woman used, if they followed her for  about two years she reported improvement in the hot flashes – did you get that, they get better on their own.  The only treatment that had any difference in the swiftness of improvement was the hormone replacement.  But here is where I really paid attention – like a good research team they went back and shared what they had learned with their volunteer subjects.  And they asked one more question – now that you know this, what will you do.  Overwhelmingly the women who used soy said they would continue because even though most women didn’t have any benefit, it worked for them.  But remember, the soy didn’t work any better than not doing anything – hot flashes improve on their own when given time.

There are many reasons the women in this study didn’t have improvement from soy, and other studies have found improvements – that isn’t the point.  The point is the women in the study attributed the success of their relief to the soy when there was no added benefit of the soy to just waiting for menopause to progress. The soy cost the women money, took extra time I’m sure.  But it wasn’t doing anything real for these women.  Yet they couldn’t let go of the idea it was the soy, not the normal progression of menopause, that was making the difference for them.  As an author on the internet and a midwife, I need to remember that what I say affects decisions women make.  I don’t want to be the cause of someone believing they have to spend extra time and money on a solution that doesn’t really do anything.

This is one of the reasons the hair on the back of my neck starts to stand when women make comments about how there are many types of evidence, or that some trick always works for them even if evidence doesn’t support it.  You cannot judge the value of a “trick” or treatment or intervention on it’s own.  Just because I ate papaya and my nausea seemed to improve does not mean it was the papaya.  It could have been something else I was doing — maybe getting more sleep or that I stopped eating something else. Or it could have been that I didn’t try the papaya until the time the nausea was going to be relieved on its own.

Considering a small sample without a control to be “evidence” is dangerous.  It is what kept doctors believing some unnecessary things like episiotomy where helpful rather than harmful. And even if the biggest harm that comes to a woman is that she feels she must eat a food she doesn’t like, it still is not worth it to me.

So here I struggle with wondering how to let women know about the things most likely to help their symptoms, and about the things they are going to read that may waste their time and money because we just don’t know if they are helpful at all. And as I struggle through this, I am intensely aware that my natural birth friends may see this concern for quality information not as growth in me, not as a healthy concern for the women and families I serve, not even as responsible midwifery, but instead it may be seen as evidence that I am not really a midwife or not really interested in natural birth anymore.

 

 

 

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Being Honest about Evidence Based Care

Jun 12th, 2013 Self-Care

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The next piece of hypocrisy for me to tackle is the idea that my style of care is more evidence based than someone else’s idea of evidence based.

I love the natural birth community for many things, evidence based care is not one of them. Much of what my community supports for birth is good, best quality care based on evidence. But often, with the next breath, I hear suggestions not based on evidence but on faith in natural health care.

Some of this is not necessarily bad.  The way we learn is to try new things – things not yet supported by evidence.  Then if the things work we get more evidence and can make quality decisions based on that evidence. This is how a knowledge base grows, and I’m sure there is some percentage of disagreement that marks a healthy, growing knowledge base.

But at the same time, I need to accept that going natural rouge is as bad and potentially unhealthy as going medical rouge. Most everyone I know in the natural birth community believes it is not OK for a physician to decide that even though evidence doesn’t support use of cesarean for a particular problem, in this case she thinks it is the best way to go.  Yet this same community accepts midwives recommending a particular herb, homeopathy or other complementary treatment, without anything more than the recommendation of another midwife.

I understand the concern that there is little research done on certain treatments, but I do not accept the idea that a midwife would begin using something without researching it.  The problem lies in the fact that without adequate controls, you can draw the wrong conclusion.  Think of all the physicians who used to believe an episiotomy was necessary, or that it was beneficial.  The are still places in the world where episiotomy is taught from midwife to midwife and the belief that it works and is important is passed from midwife to midwife. Yet we know from research the place for episiotomy in best practice is very small.

The same thing can happen with any treatment because without the control you cannot tell the difference between how often the problem is resolved without the treatment and how often it is resolved with the treatment. The reality is, a treatment that is no better at resolving a problem than doing nothing is a waste of a family’s time and money.

So, in an effort to ensure the information I share is evidence based, I will be spending this summer updating the website to include evidence.  Where evidence is lacking, I will be honest with my readers.

 

 

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Being Honest With Yourself

Jun 10th, 2013 Self-Care

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I’ve come to accept that I lie to myself, even though I could never successfully lie to anyone else.  I’ve also come to accept this is a pretty normal human condition.  It seems we lie to ourselves more often than anyone else.  I lie about how much food I eat and how healthy it is.  I lie about how much time I waste. I lie about my motivations for the things I recommend.

This week I want to spend  little time identifying some of the lies I’ve recognized in myself, in the hopes it helps you identify the lies you tell yourself.

Why?  Because even though I try so hard to believe these lies, other people see right through them.  And when I am obviously being dishonest, my integrity will be questioned.  It’s called hypocrisy, and it damages relationships and reputations.  If the women I work with think they can’t believe me, I lose the opportunity to share the truth about healthy pregnancy with them.

The most obvious place I am dishonest is in my diet and exercise.  I do try both – I try to exercise 5 or more days a week and I do try to maintain a healthy diet.  But the truth is despite trying to balance diet and exercise for my entire adult life, I was only at a healthy BMI for about 6 months.  The entire rest of my adult life I have been overweight, and for a sizable chunk I measured as obese. And even in the midst of those times I saw myself as a person who eats healthy and exercises.

I’m sure the women I work with wonder if I’m joking when I recommend good nutrition and exercise. If it was really so great, why don’t I do it. Because the truth is, if I was eating healthy and exercising my weight would be normal. My weight continues to measure as overweight because despite my dedication to healthy meals, I bake frequently enough that having one or two things from each baking episode keeps me overweight. My wight continues to measure as overweight because if I find myself with candy, I don’t stop eating it.  My weight continues to measure as overweight because my “scoop” of ice cream is really more like two servings even though I estimate it as one.

These are deep habits, often difficult to even see myself doing. I am working on them, but I still make enough food choices based on desires other than health to keep me overweight. I tried an experiment once.  When I talked about nutrition with women in childbirth classes I shared my struggles and asked the women to share theirs too. They shared, and it was much easier to help them meet nutritional goals when I understood what barriers were in their way. This works OK in a childbirth class, but I struggle to wonder if it is appropriate during a first prenatal.  I have tried half, asking women to share their biggest food struggles. I’ve tried approaching it as areas many women struggle with, including me.  It still isn’t the same as having the time to talk through it with a group of women.

My words will never speak louder than my body.  If I look as if diet and exercise don’t matter to me, the families I work with will get the message loud and clear. They might even get angry if I suggest they make changes I obviously am not willing to make myself.

 

 

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Competencies, Certification and Midwifery Basics

May 28th, 2013 Paths, Training

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I have just over 24 hours to my midwife certification exam.  In my midwifery path, certification by exam is a requirement for licensing.  But when I get that certification, I will be able to be licensed to practice in any state and it will make my international work a little easier.

Certification and licensing are frequent topics of discussion among my midwifery friends.  I have some on both sides of the licensing fence, and on both sides of the certification fence. Due to the crazy nature of this world, not all my friends who think licensing is good are licensed (some are in states without licensing opportunities).  Similarly, not all my friends who think licensing is not a good idea are not licensed (some states require licensing to work as a direct entry midwife).

So what about me, where do I land in the debate?

I personally have no problem with certification  for midwifery or any profession.  Education alone would be nicer (and cheaper), but certification does provide a protection for the midwife consumer and me as the midwifery school consumer.  Why? Because I believe knowing your graduates must pass an exam on the basic competencies of a midwife improves the didactic quality of the school.  I can’t imagine spending thousands of dollars on a program only to find out it didn’t really give me the information I needed to work independently as a midwife.

I know there are some who feel the certification exam is no proof you are a good midwife, and I agree.  Honestly, the only way to be a good midwife is to be a midwife for a few years.  I will still be a new midwife, with or without the exam. But the certification exam shows I have a minimum competence with the tools and materials I will be using . It shows I understand the basics of evidence based practice — even if the process of test writing means it will be two to three years behind.

As for licensing, I am a fan. Again, I don’t think licensing makes you a good midwife.  It is simply a way for the profession to be regulated — to ensure that all those who are practicing have met the minimum standards.  But from the public health side, it does some amazing things. First and foremost, it gets midwives counted.  Midwives, especially direct entry, tend to be invisible in research. As long as they are invisible, they will not be taken seriously and their practice will suffer from “evidence” problems. I want to change that.

I also have friends who are against licensing because they feel it restricts their practice. I disagree on two counts.

The first is that every state has a midwifery practice act, and if your practice doesn’t meet the definition your practice is already restricted. If your state’s laws don’t mention midwifery beyond nurse-midwifery it is too easy for your practice to be labeled as illegal.  Licensing prevents that.

The second is that I believe midwifery practice (as with any health care practice) should have restrictions. A midwife should be expected to provide evidence based care, even if that means some mothers will be told home birth is not a safe option for them. I believe this as much as I believe physicians should be expected to provide evidence based care, even if that means some mothers will give birth vaginally in the middle of the night on a weekend.  I don’t want midwives making their own estimations about which woman is or is not safe birthing at home any more than I want physicians making their own estimations about what is or is not an indication for cesarean. It is too easy to keep moving your own line in the sand.

The current problem is the lack of universally accepted evidence based guidelines – but this I see as a temporary problem.  If the system is broken, you fix the system. When you ignore the system completely you lose opportunities to make change (like the problem I have with my research where direct entry midwives cannot really be counted and therefore their impact cannot be estimated).

Change is a slow process, and some of my friends have been waiting too many years (some whole lifetimes) for change. Some have been so burned by past “change” that they have learned to distrust the system. Some gave up fighting years ago, and now just want to do their midwifery without interference from governments or certification organizations.  I know this. The sad truth is  I don’t personally see a way to move midwifery forward — to extend the rights and protections for direct entry midwives — without causing their practices to be interfered with.

For me, the importance of licensing goes beyond my direct entry friends here in the US.  For me, it is also an international thing.  Midwives everywhere should have access to good quality training, good and useful tools to do their work, and be paid by the health system for the work they do. For this to happen, midwives need to be a real part of a countries health system rather than an invisible “problem” the health system sometimes ignores and sometimes attacks. Midwives need to be taken seriously. Licensing is one step to being taken seriously.

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