People like to say that statistics lie. Actually, the statistics tell the truth, people just are not always educated to understand what they mean. This happens alot in the birth world with the cesarean rate.
The CDC releases statistics about birth in the United States each year. In 2010, the CDC reported that 32.8% of all births in the United States were by cesarean surgery. This data has lead some childbirth professionals to assume a woman giving birth in the US has about a 33% chance of ending up with a cesarean. But this isn’t necessarily true. Why?
Because that number includes two different groups of women with two different rates of cesarean surgery.Childbirth Connection has a graph that may help visual learners get this concept, and statistics nerds may prefer this 2005 report from the CDC.
One group of women in that number is women who either never gave birth or only gave birth vaginally. The other group of women in the number is women who previously gave birth via cesarean. Women with a previous cesarean may give birth vaginally, or via cesarean. Currently the VBAC rate in the United States is pretty low, which means the cesarean rate for women who previously gave birth via cesarean is pretty high.
As you look at the graphic on the Childbirth Connection page, notice how in 1989, the cesarean rate was about 23%. Using this graphic we see that about 18% of women who had a cesarean previously gave birth vaginally, which means about 82% of those women gave birth via cesarean. In the same year about 16% of women who had never had a cesarean before gave birth via cesarean. Although the overall rate was 23%, a woman who had never had a cesarean before only had a 16% chance of having a cesarean.
Fast forward to 2004 on the Childbirth Connection graphic and you see the rate of cesarean increased to about 29%. Rate of VBAC declined to about 9%, meaning about 91% of women with a prior cesarean gave birth via cesarean. Primary cesarean rate also increased, but to about 19%. So although the overall rate of cesarean was 29%, only 19% of women without a prior cesarean gave birth via cesarean.
The graphic stops at 2005 because of implementation of a new birth certificate system which prevents accurate counting, but we can estimate as long as we accept the numbers we have are only estimates. In 2010, 33 states were using a birth certificate that allows us to count primary cesareans. So we have a count, but it will miss about 25% of the births in the country (because they happened in one of the 17 other states).
From the data we have, we can estimate that in 2010, 23.6% of women without a prior cesarean gave birth by cesarean while about 91% of women who previously gave birth via cesarean did so again. This means, that although the overall rate of cesarean in 2010 was 32.8%, a woman giving birth for the first time had a 23.6% chance of having a cesarean. Instead of 1 in 3, her chances are more like 1 in 4.5. On the flip side, 9 in 10 women with previous cesarean are likely to give birth via cesarean.
I heard it again today, “They won’t let me….” Whenever I hear someone talking about “they” or “them,” my ears begin to perk up because I know there is more to the story than I am being told. Here are the things that go through my mind.
1. Does this woman understand what she was told and why? I don’t ask that to be smug, but out of real concern about miscommunication. It can be easy to believe everything you hear, even if what you heard was not what was said. It is also easy to believe things you hear from individuals who are not in a position to be decision makers. If a friend tells you the hospital doesn’t do water birth, you are much less likely to ask about the option on a tour. If you don’t ask, you won’t find out that they only have two water birth rooms so if you are interested in a water birth you need to tell someone on admission.
2. Is this woman making assumptions due to misinformation? If you were to believe everything you read, every doctor, nurse and midwife is out to make sure you have a terrible birth experience that hinders your breastfeeding and bonding. The good news is that most health care providers are NOT like the stories you hear. In fact, each health care provider is a unique individual, just like every mother. Individuals have strengths and weaknesses, good days and bad days, get tired and will even have opinions. Sometimes the opinions of other individuals will be different from yours. But you cannot know this unless you ask. Making sweeping generalizations about everyone within a profession is stereotyping. Not only is it unfair, accepting your assumptions based on stereotypes means you are less likely to ask the questions you need to ask to prepare for the kind of birth you want.
3. Is this woman feeling judged about choices she made and just trying to get out of the conversation? For those with a passion for helping mothers have natural births, it can sometimes be difficult to understand why a woman wouldn’t choose a natural birth – and this can come across as judgmental in conversation. Some women politely smile and nod as you continue explaining the perils of epidural, some will get angry and tell you it is none of your business, and some will blame the decision on someone else so you will leave them alone.
How do I handle these situations? First, I never assume the mother and I are “on the same side.” I don’t make assumptions about who she is or what she wanted from birth or how she feels about not having an option. I don’t argue against the medical establishment, medical techniques or individual caregivers. Instead, I listen. I let her talk, sharing what she feels is important. If she needs to know I am listening and not judging I might ask if she can “Tell me more about that?” Instead of deciding for myself how she is feeling, I ask her, “how do you feel about that decision?” Then, I listen. Because she might be angry the option is gone, but she might be relieved.
This week I have been sharing some of the harder lessons I had to learn to become a midwife. The value of humility is perhaps the hardest one I faced.
I thought I did approach birth with humility. I believed I understood the process and knew that the best course of action was to let the labor take it’s course. Yet, at the same time I failed to see how I approached birth with arrogance.
- When I would hear labor stories, I would decide for myself what doctors, midwives, doulas and mothers had done wrong despite not being present for the labor.
- I had answers for every problem a woman might face because natural birth was always possible.
- I assumed what I knew about birth was not only all there really was to know about birth, but also the most important things to know about birth.
I now approach birth with a different type of humility.
- I accept that there are things about the human body I do not know or understand. I accept the ability of others to know and understand those things even if I currently do not.
- I accept that problems can arise in labor without anyone being at fault. Babies and placentas can have problems despite the best health of the mother and care of the midwife.
- I accept that the hands and knees position and a doula cannot possibly be the answer to every problem.
- I accept that there are multiple ways to respond to a problem and most of them will give a good outcome most of the time.
If you don’t have a way to access full research articles, you need to get one. Check with your local libraries and state college system to find out what programs they offer for the local community.
Why is this so important when you can read the abstract free on Pub Med? Because an abstract is only a teaser of what is included in the study – think of it as the advertising content created to help researchers find the articles that are most likely to pertain to their topic. The abstract will list some results and conclusions, but due to space limitations they won’t really be explained.
The full article will also have a good amount of information that is necessary for understanding the generalizability of a study. It will have complete information about who the subjects were and how they were recruited for the study. It will give the limitations and delimitations – which means the things that limited what the researchers could study and the limits the researchers set for themselves. Think of the difference in recording length of labor in a group of women if recruitment is done at hospital admission, or if recruitment is done at the first birth center visit. How might these populations differ?
The full article explains the methods used, which is key to understanding how to interpret the results. Think of the possible differences in findings between a study that asks women to rate the pain they feel in labor at two hour intervals during the process and a study that asks women to rate the pain the felt in labor when they gave birth 1- 5 years earlier. Which method will you assume has better quality data?
Abstracts generally have a one sentence conclusion, but the full article will give you a better discussion of the way the current paper adds to past research and the next steps research should take. Think of a paper that finds an association between obesity and cesarean surgery – if you only read the abstract you might believe the researchers think obese women are more likely to need a cesarean. But if you read the discussion you could quickly find what the researchers were able to control for, and what additional factors (perhaps higher rates of failed elective inductions) are potentially causing the association.
The full paper can also lead you to additional research on the topic to help you form a good base of knowledge – because one of the most useful parts of a paper for a person who wants to fully understand an subject is the references. Any paper will only list a small proportion of the research reviewed by the authors before completing their study, but the ones listed are most likely the most relevant. The references are not going to be listed in the abstract.
Bottom Line: Find a way to get the full paper. Don’t make assumptions based on the abstract.
Yesterday I shared how my training has caused me to relearn how I think about the term “intervention.” Today I want to share another word that needed to be reframed in my mind – “normal.”
When I first began in the natural childbirth movement, when I heard the word normal I always interpreted it to mean “OK” or “Safe” or “Ideal.” I’m not sure if I had thought of the word that way before my first training, or if I somehow picked up on that meaning through my readings. It was, perhaps, a combination of both. I was too young and inexperienced to ever see something bad or dangerous as normal, and the training encouraged me to continue this line of thought.
The most specific example I can recall would be my thinking about newborns. Perhaps you’ve also had the same mindset about some of these. ”Physiologic Jaundice is so common, it’s just normal for babies to be jaundiced. I don’t know why doctors get so hung up about it.” or “It is normal for the newborn to have really low vitamin K levels at birth. They increase by the 7th or 8th day, this is no big deal.” or “They get so hung up on blood glucose levels. It’s normal for glucose levels to be low when you need to eat. Just give the baby the breast and she’ll be fine.”
Today, I look at the things I used to say and wonder how I could be so confident in my statements when I didn’t have a full understanding of all the issues. I also wonder how I always assumed “normal” meant good or safe.
You see, a Type 1 diabetic is going to have high blood sugar levels if they don’t take their insulin – this is the normal functioning of their body because a diabetic does not make insulin so the glucose cannot be metabolized. Yes, this is the normal functioning of the diabetic body, but it is not safe.
“But wait!” you say, “The ‘normal’ newborn is not sick, their body is functioning as it should be.” That is true. But neither is the ‘normal’ newborn body functioning like a one or two week old, an older child, nor an adult. Their body is in a state of transition, and it is this existence in a state of transition that makes these “normals” something worth watching a little more closely.
Before a baby is born, most of the work of the liver is done by the placenta. When the baby is born and separated from the placenta, the liver is just a little behind. It isn’t producing as many of the things needed to help blood coagulate when necessary. It’s ability to form glucose and store glucose are very immature, as are its production of hormones to regulate carbohydrates. It’s ability to conjugate bilirubin is limited, as is its ability to break down any medications.
Closely linked to the function of the liver is the function of the kidneys. Their job of regulating fluids and electrolytes is also done by the placenta before birth. At birth, blood flow to the kidneys does increase, but the filtration abilities are limited – salt stays in while glucose and amino acids leak out. The newborn isn’t very good yet at concentrating or diluting urine to regulate body fluids.
The newborn does a poor job of maintaining body temperature.
At the same time the digestive system is starting to gear up for use. Mucus is being eliminated and the necessary bacteria for vitamin K production are beginning to grow.
What does all this mean? This means the majority of newborns are going to go through these early transitions without a problem. But the newborn is in an delicate position – anything that causes additional stress can overload this immature system quickly. This is one of the reasons the highest rates of death in children under five occur in the first year; and the highest rates of death in the first year are among those less than one week old.
As a midwife, I am trained to watch for these things in all my newborns – not with tests but with my eyes and ears. If something is off, I am trained to investigate quickly to help keep the system in the proper balance during transition. Some of the most common problems look the same or lead to each other in those first hours. For example, if a baby is too cold, the body burns glucose quickly to try to warm the baby which can lead to hypoglycemia. Or a baby who doesn’t feed well may begin to have problems with hypoglycemia, and may also have higher bilirubin levels if they are not stimulating good bowel movements.
While I still accept that this transitional time is normal for a newborn, I no longer pass these first few hours or days off as no big deal. While the baby is transitioning to extra-uterine life, I watch a little closer because this is one time when early detection of a problem makes a big difference in overall health.
Intervention is a tricky little word that seems to divide midwives. Most midwives agree that midwives in general use less “intervention” then physicians. But that seems to be where the agreement ends. What makes some midwives feel a woman can be successful at an intervention free birth in a hospital, while others believe even women giving birth with a home birth midwife receive regular interventions?
The problem arises when using different meanings for the term intervention. Some midwives use the term to mean surgical or pharmaceutical techniques (cesarean, pitocin, epidural). Some midwives use the term to mean anything done to alter the natural course of labor (castor oil, cytotec, tocolysis). I remember being taught that intervention was a all the things a woman didn’t want to have happen when I was training as a childbirth educator. So, what does this term really mean?
To understand what counts as an “intervention” for health, I rely on my understanding of prevention. Why prevention? Because as a nurse this is how I order my thinking about the interventions I use to help a woman achieve the healthiest birth possible. Honestly, every contact I have with a woman is an intervention.
There are three levels of prevention, each with it’s own set of interventions based on whatever risks the woman may be facing.
The highest level of prevention is tertiary. This is when a serious problem has been identified, perhaps a woman has had an eclamptic seizure or the fetal heart tones reveal a prolonged bradycardia. In this case, intervention is focused on stopping whatever is causing harm and minimizing the effects of the problem to help the woman and her child achieve the highest level of health possible. So, with an eclamptic seizure the interventions include safely moving the woman to a recovery position, injecting the appropriate doses of medication to prevent additional seizures, close monitoring of the woman and baby to identify any residual problems.
The middle level of prevention is secondary. This is defined as early identification and treatment of problems to prevent escalation. In this case, interventions include screening to identify woman and babies at risk as well as all the things done to help minimize any risks identified. An example would be identifying a mother’s blood type. If the mother is Rh- blood and the father is Rh+, Rhogam can be used to help minimize the risks for the next baby. Taking a history during a prenatal appointment and screening tests are interventions for secondary prevention because they help identify health issues for the mother or baby. Taking blood pressure, monitoring the fetal heart tones by any method and monitoring the progress of labor are all interventions for secondary prevention.
The first level of prevention is primary. These are the things that are done to prevent a problem from starting in the first place. This includes most education I would give a woman, such as educating a woman about her nutritional needs so she can improve her diet as necessary. Another example could be offering an influenza vaccination. During labor, ensuring a woman stays adequately hydrated is a primary intervention because it helps prevent problems.
To help you get these concepts, here are a few more examples:
During labor, I recommend a woman change positions regularly as a primary intervention because I know it will help labor progress normally. If, during labor, the mother begins to have a backache, I may recommend certain positions as secondary prevention because I know she may have a baby in a posterior position and these positions will help relieve some of her pain and help the baby move.
During pregnancy (and as she is planning her pregnancy) I recommend a woman maintain optimal intake of folic acid (perhaps through a prenatal vitamin supplement) to help prevent neural tube defects – and this is primary prevention. If, during pregnancy, screening reveals a woman is anemic I may recommend an iron supplement as secondary prevention to help rebuild her iron stores and avoid the problems anemia can cause during the post-partum.
Is everything really an intervention?
Yes, everything I do as a midwife is an intervention on one of these three levels. This is because everything I do has a specific purpose – to help a woman make any necessary changes to have the healthiest pregnancy and birth possible. Providing education so she can make lifestyle changes is an intervention. Screening to give her information about the state of her health is an intervention. Responding quickly if there is a problem in labor is an intervention. This is true whether I do this work in her home, at a birth center or at a hospital. This is true whether I provide the education as a midwife, nurse, doula, or childbirth educator.
I hope you see “intervention” is not a word to be afraid of, and in the purest terms, an “intervention-free” birth is only possible for women who choose to give birth alone. Even women who hope to achieve a natural birth do not generally mean they want to avoid the interventions of the midwife listening to the baby’s heart tones or recommending things they can do to be the most comfortable. A birth does not need to be intervention-free to be natural.
Safe Motherhood. It seems like such a simple request. Around the world women and babies still die during pregnancy and childbirth – despite medical advances that could save many of them.
Five years ago, when I began my journey to fight maternal and neonatal mortality, I thought the problem was simple. Today, I see that the health of mothers is affected by more things than the availability of a skilled birth attendant. Like an onion, layers of cultural, socioeconomic and political problems continue to cause problems for women. While we are finding some solutions, we are not there yet.
Layer One: Family
It may be hard to imagine if you are reading this, but there are places in the world where a woman does not have the right to make decisions about her own health. The decision of whether or not she seeks care during pregnancy or birth may lie with her husband, her father, the family as a whole or even the community at large. The decision is based on the cost of care, the perceived need for care and the value of the woman to the society.
Layer Two: Poverty
Being poor in a developed country disadvantages a mother, but being poor in a developing country leaves many women with no options. If the closest health care is hours away, she may feel herself lucky to attend one antenatal clinic, and may simply accept that if something is not right in labor she will have no way to seek help in a timely manner. This is the risk many women take to achieve motherhood.
Layer Three: Cultural Norms
When accessing health care is expensive, accessing health care is the exception rather than the rule. This leads to cultural norms where normal healthy women give birth at home without assistance or with minimal family or community assistance. For many women in the world, this is a sister, mother or another mother from the community who has no training.
This becomes even more difficult in places where women have very little or no value. For example, if her only value is as a worker in the field she may not have the ability to take a day off to attend a local clinic without being considered lazy. Or if a woman is valued most for her ability to bear children, she may not be considered valuable enough for health care until she has proven herself by successfully giving birth the first time.
So women are caught in a cultural trap where the desire for high quality care is weighed against the belief that seeking even basic antenatal care means something is wrong with her.
Layer Four: Social Status
It seems the wealthy and educated look down on the poor and uneducated throughout the globe. This is so ingrained in cultures that we don’t even see it in our own as people laugh at jokes making fun of “country folks” and insult those who have different political ideas from our own because we cannot see why they might feel differently.
In the birth world, I see this through the poor treatment of mother’s within existing medical systems. Doctors and nurses are always educated. The poor women they work with will almost always have less education than them. In societies where status matters (which is basically all of them) there is a feeling that it is OK to treat poor women differently because the poor women deserve to be treated badly.
- You have to yell at them because otherwise they are so proud they won’t do what you say.
- You cannot be nice to them or they will be weak and not labor well.
- She needs to learn how to be tough because she needs to be a good mother.
- She doesn’t know anything and she won’t do what she is supposed to unless I tell her.
Layer Four: Community Resources
Even if her family desires care for her, if the community has no way to provide that care the woman may still have no options. Rural women living in communities without transport to the closest health post may lack antenatal care only because there is no realistic way to get the mother there and back safely. How should the family manage the upcoming birth – send the mother to an area with care before labor begins (paying for her stay of unknown length), or try to create a system that allows for her to access needed care when labor begins (risking not making it to a health post with emergency care in time if it is needed)?
I still wish safe motherhood for all the women of our world, but I no longer think the solutions to these problems are simple. If the solutions were simple, we would have the problems solved already. The truth is, families face difficult decisions when it comes to motherhood. My goal is to help them have more options.
I meet a lot of wannabe midwives, and a lot of midwives. The wannabe midwife I meet most frequently is the one who is angry with the “birth system” and plans to become a midwife to fight that system. Usually, the plan is to become a homebirth midwife to provide for births, “the way they should be.” I like to ask wannabe midwives two questions before I agree that is their path. Why? Because usually they do not realize all the ways to bring change to the system.
Question #1: What is it about the “birth system” that bothers you?
While your first response may be, “everything,” think deeper. Are you concerned about the treatment of women? Are you frustrated with the current protocols? Do you feel research is lacking? Is is restrictive legislation that irks you? It is important to understand what part of the system you feel is broken, and which part you want to fix because the fix for each part is different.
Question #2: How can you have the biggest impact on that part of the “birth system?”
I find wannabe midwives default to the goal of homebirth midwife because it feels like the best way to change what is happening in births. Some wannabe midwives feel it is the ultimate rebellion against a system they dislike. But rebellion can take many forms, and can happen within the system as well as outside the system. Let me share with you a few of my birth heroes who are not midwives to show you what I mean.
Joy Lawn is a pediatrician who was dis-satisfied with the lack of information about neonatal deaths around the world. She fought back with epidemiology by devising systems to estimate the number of deaths and to identify the causes so the public health community could begin to tackle the problem and measure their success.
Barbara Harper is a nurse who uses her skills to help hospitals around the world create safe and gentle birth protocols by collecting and sharing research. She teaches midwives, nurses and physicians the importance of gentle birth and ways they can achieve a gentle birth in their hospital.
Penny Simkin is a physical therapist who uses her understanding of the mechanisms of the physical body to help birth workers improve outcomes through positioning and non-medical interventions when possible. She participates in research to build the knowledge base. Her writings are required reading for many doula and childbirth education programs.
Citizens for Midwifery is a group of parents that advocate for good legislation for midwifery practice. Their work includes collecting and distributing research to local and national legislators while also educating and recruiting other parents to join the work.
EuGene Declercq uses his research skills and knowledge of political science to challenge current beliefs about the American maternity system. His papers point out hidden problems and highlight the importance of midwifery.
I addition to these “big” names, there are many unknown men and women changing the face of birth in the United States and around the world.
I think of the nurses who put in extra hours to participate in quality improvement and protocol committees at their hospitals to succeed in implementing policies prohibiting inductions before 39 weeks.
I think of the peer breastfeeding counselors with WIC programs who are improving breastfeeding success among low income women.
There are many more unknown individuals who need more help to achieve change.
I think of brave souls in insurance companies who are willing to champion the use of doulas, birth centers and homebirth midwives to ensure these services are covered by their programs.
I think of administrators at small hospitals who feel they need to close their birth services due to financial instability, forcing women to travel greater distances when they need care.
There is a great need for change in birth, in the United States and around the world. Where you fit within this change may be practicing as a homebirth midwife, but it might not. We definitely need good midwives. But remember that when you practice as a midwife, you limit the time available to do non-midwifery work and may limit the impact you can have in these other ways. Think of your passions, your skills and what is available around you to determine how to maximize your impact.
I am currently preparing to take the midwifery certification exam. Today I was reviewing intrapartum and was struck with the strange realization that I was on the “other” side of the fence.
When I first trained as a childbirth educator, I had it drilled into me that time limits in labor were arbitrary. Because they were arbitrary, they were useless. Story after story in the natural birth web sphere seemed to prove this philosophy. Doula’s and childbirth educators shared tips on how to know if the time limit you were given was real, or just or convenience. Friedman was blamed for the problem with his 1 cm per hour average, and his theories were thrown out as invalid.
As I reviewed today, I came to the data on Friedman. I realized I’ve grown to respect his philosophy, even if I want better data to make final labor cut-offs. While I was trained to see the Friedman curve as the way hospitals and doctors get patients to do what they really want, I have come to understand the usefulness of a tool to help me ensure labor is progressing. But I didn’t get there immediately, I had some learning to do first. Part of that learning was the importance of the Partogram in global public health efforts. The other part was that I didn’t have the full story on Friedman.
For example, Friedman’s active stage didn’t start until at least 3-4 cm, and it ended at 8-9 cm. which means the 11.7 hours as the upper end of normal active phase for nullipara’s wasn’t the whole picture – in other words, he wasn’t saying 12 hours for labor. The latent phase wasn’t prolonged for nulliparas until it reached 20 hours. 8-10 cm was called the deceleration phase, which wasn’t “prolonged” in a nullipara until 3 hours. Second stage began at 10 cm. So if you do all that math, contractions can start at midnight, and I can reach 10 cm at midnight the next day (24 hours later) and Friedman wouldn’t necessarily call my labor disordered. Second stage had it’s own timing and its own method of assessing progress with fetal descent – a baby that had no descent in one hour needed attention.
The second thing I had to learn was that Friedman was interested in identifying women who were having problems with labor – which I think is a pretty good thing to want to know how to do. While no one wants to say labor has to fit a particular schedule, labor not really progressing well can be an alert mechanism to look more closely at what is happening. Friedman defined several ways a labor may not be progressing well, it may be protracted, or arrested. Each of these had their own timing cut-offs. And the biggest thing they didn’t teach me as a childbirth educator, “falling off the curve” is not an instant intervention as far as Friedman is concerned. There is a four hour wait time before intervening. On the partogram the woman “falls off the curve” at the alert line, then intervention begins at the “action” line.
What is even more interesting to me now is that I realize the response to the “slow” labor is not something arbitrarily chosen. As a midwife, the slower labor alerts me that the patient may have a problem and I assess the situation. Depending on my assessment (is she having regular contractions? are the contractions strong? what position is the baby? ) I will make decisions about most appropriate course of action. Now that I am on this side of midwifery school, I understand why physicians and midwives do not always make the same suggestion. And that even though it looked like it to me before, the management (at least in the cases I’ve been with) is not arbitrary.
So overall, I think I like Friedman’s idea to identify and evaluate women who are far enough away from an average to warrant a high suspicion Now if we could just get some great data on what these averages and upper limits are in natural, epidural and induced or augmented labors.
I’m preparing for two upcoming conferences where I will be presenting. The first is a conference for Christian midwives where I will be providing a clinical update on menopause. The second is a conference for nurse midwives where I will present a poster of my original research. As I finalize my work for these two events, I can’t help but notice the similarities between educating my clients, and educating my peers.
You see, the natural instinct is to basically vomit out all the information you have. Everything you’ve ever read or heard is weighted equally without any regard to who the audience is. This tends to be very long and boring for the listener (trust me, I’ve sat through many really bad student presentations over the last four years).
If you want to really do the best job of sharing information, you need to do a lot of work to determine what needs to be shared, and when. What do I mean?
For example, in the clinical update on menopause I could go deep into the endocrine changes and types of testing available. But since this is a group of midwives who are not infertility specialists, this information is only relevant enough for them to understand that if a client says they had a particular test they know how to find out what that test is. What is relevant is the information women will want from the midwives, and the ways the midwives can help them get that information. For example, we’ll be spending a lot of time talking about menstrual cycles and how they can be used to track progress through the menopause transition. his information help women determine how much longer they probably have to achieve a pregnancy, when they can expect symptoms to subside, and when they can expect that final period.
Next time you are working with your clients, think about what information they really are looking for to make decisions. Make a list of the key things to share and don’t bring up the rest unless they ask. It will save time on your visit and make the clients more likely to listen to everything you have to share with them.