International Day of The Midwife – May 5, 2011

Fellow South Carolininans:

May 5, 2011, is the International Day of the Midwife. I write to make you aware of the dismal state of health of women and babies locally and globally. I write to you for the women and babies who cannot.

More than 340,000 women around the world die each year as a results of PREVENTABLE pregnancy and childbirth complications. That’s enough to fill the Cowboy’s Football Stadium more than 3 times over. Universal access to adequate health services, equipment, and an additional 4 Cowboy’s stadiums full of midwives are needed!

Seventy-five percent of maternal deaths occur during childbirth and the post-partum period. 99% of maternal deaths occur in developing countries – the bottom six countries account for over 60% of those deaths: India, Nigeria, Pakistan, Afganistan, Ethiopia, and Democratic Republic of Congo. The major causes of death are:
• bleeding
• infection
• unsafe abortion
• preeclampsia (high blood pressure in pregnancy)
• obstructed labor (the baby will not fit through the mother’s pelvis and there is no ability to perform a surgical delivery or cesarean)

A Somali woman has a 1 in 14 chance of dying from her pregnancy; in Europe, 1 in 4,200. The USA, while certainly higher in ranking than sub-Saharan African, has a maternal mortality rate of 13.3 per 100,000, and CLIMBING. Rates are very much higher among African American women. The US was unable to meet the Healthy People 2010 goal of 3.3 deaths per 100,0000 live births.

Only 23 countries on track to achieve a 75% decrease in maternal mortality rates by 2015. The World Health Organization, UN agencies, and other global partners have identified that midwives are the key to achieving reductions in maternal and newborn deaths and disabilities globally.

In the US, the Joint Commission, which accredits health organizations, found that two of the four preventable pregnancy-related causes of deaths were associated with cesarean section (current US cesarean rates are 32%). Other preventable causes were related to uncontrolled high blood pressure and fluid build-up in the lungs of women with preeclampsia.

The Coalition to Improve Maternity Services (CIMS) found that compared to maternity care provided by physicians for low-risk women, women cared for by professional midwives:
• have a lower incidence of hypertension and preeclampsia
• fewer hospital admissions for complications during pregnancy
• fewer cesareans and more VBACs (vaginal birth after cesarean).

The National Institutes of Health (NIH) Consensus VBAC: New Insights, confirmed that the risks of maternal mortality are increased with repeat cesarean section compared to vaginal birth after a prior cesarean. The WHO states that cesarean section rates should fall between 10-15%. Below that, mothers and babies suffer severe injury or die. Above that, outcomes also worsen for both mothers and babies. Increasing maternal death rates in the US are at least partially to blame on the increasingnumber of surgical deliveries.

While American women and babies fare far better than their third world counterparts, they don’t compare as favorably to industrialized nations utilizing midwifery care. “By expanding access to and reimbursement for midwifery care, home birth, and birth centers for low-risk women, health outcomes for mothers and babies are improved and the risks associated with routine costly hospital interventions and cesarean section rate can be reduced”, according to CIMS’s Nicette Jukelevics.

Currently, about 6% of South Carolina babies are born into the hands of hospital-based nurse midwives, 1% are born at home with other types of midwives. In Sumter, about 15% of babies are born with the help for a nurse-midwife. We are ahead of the curve!

But you don’t have to take my word for any of this! I challenge each of you to see for yourself the devastating effects poor quality or complete lack of health care has on outcomes for women and babies. Our society is fortunate to have the medical advances available, but we can do better for mothers and babies. My Motto: A Midwife for Every Woman!

Coalition For Improving Maternity Services (CIMS)

Baby Friendly Hospital Initiative

Global Survey On Maternal and Perinatal Health

International Confederation of Midwives: Strengthening Midwifery Globablly

www.mymidwife.org

Evidence-Based Maternity Care: What It Is and What It Can Achieve

The Placenta: More Than Just the “Ugly Twin”

I used to work with a doctor who would refer to the placenta as “the ugly twin”. I’ve seen providers rather unceremoniously drag the placenta out of mom and dump into a bag, never once actually inspecting it. As a midwife, I was taught to carefully examine the placenta, and further, to show it to the parents while explaining its marvelous functions.

The placenta is often called the tree of life in midwifery circles. This is because when it is lying flat, the fetal side where the umbilical cord inserts and fans outward looks an awful lot like a tree. I show parents the baby’s side with the tree, and the cord, and how the bag of waters is now in shreds. That bag of waters, two plastic wrap thin layers, held that baby in warm water for 40 odd weeks, all that kicking and rolling, and twisting – the bag held strong. Now mere moments after birth, I can easily tear it apart with the gentle pressure of my fingers.

We look at the maternal side of the placenta – the side that was attached to mom. I make sure all of the pieces, called cotyledons, are there. Any missing pieces left inside can cause mom to bleed or get an infection. If the placenta is “old” it will show areas of calcification – hard white spots that are no longer functioning. If mom is a smoker, or has a chronic medical condition that effects her blood vessels like high blood pressure or diabetes, her placental side will be likewise effected. Sometimes for no reason at all, I will see a very calcified placenta and I will be very happy that our baby is out because the placenta isn’t working so well.

I show them the cord, how the vessels inside twist and twirl and how the cord is coated with jelly to protect it from being crimped. Since I generally let the cord stop pulsating before I cut it, we watch was a big, thick cord drains itself of the baby’s blood and becomes thin and empty.

I realize that not everyone is as fascinated with the placenta as I; however, some scientists are, and rightly so. Now it seems there is a whole lot more to the placenta than just the “house the baby was in” as I say. Scientists already knew the placenta could make its own hormones, but a fascinating new research study has shown that the placenta can make a neurotransmitter called serotonin. Serotonin is linked to numerous mood disorders. Of course, there is more research to be done. Perhaps the secrets to the origins of autism and schizophrenia lie within the depths of the placenta. For more on this fascinating new research click the link to the NPR story and podcast.

Labor Pain: No Laughing Matter

In nearly every industrialized country women in hospitals, birthing centers, and homebirths have access to “the gas” as it is commonly known. Specifically, I am referring to a 50-50 mixture of nitrous oxide and oxygen, or laughing gas. Most of us are familiar with laughing gas when we visit the dentist. Some ERs and ambulances also make use of gas to decrease anxiety and provide some pain relief.

Laughing gas works by decreasing the anxiety or emotions associated with the pain. It has been described as still being able to feel the pain, but not really caring about it. Why don’t USA mothers have access to such wonderful pain relief? Many dynamics contributed to the current lack of choices in labor.
As mothers moved from home to hospital to birth, they did so because they were promised pain relief for labor. The first option women ever really had in hospitals was the use of ether gas. This was wonderful for labor pain as the mother was literally unconscious, but not so good for remembering the birth and being awake when the baby was actually born. Of course, the baby was born asleep too, and has to be resuscitated.

Somewhat more sophisticated than ether, was “twilight sleep” a mixture of several medications including narcotics and amnesiacs. Women went to the hospital in labor, got a shot, and never felt or remembered a thing. In reality the women were not asleep at all – they were in leather restraints or straight jackets as they thrashed and screamed through labor and then were delivered by forceps. The amnesiac drug administered ensured the woman remembered nothing of her birth. She just woke up and her beautiful baby was handed to her. Fathers simple could not be present during such deliveries –no explanation needed there.

Coinciding with the women’s movement of the sixties and seventies, women realized the power of consumerism, the power of their numbers, and demanded again a change in labor routines. First, they wanted NOTHING for pain – they wanted the choice of an unmedicated birth and they wanted a support team present. Daddies in the delivery room became more common, but usually only if the woman was “good” meaning she didn’t scream and yell!
As birth moved towards a more friendly consumer environment, women decided that unmedicated wasn’t the way to go at all. Now they wanted to be awake for the birth but not feel anything; thus, the introduction of the labor epidural. The number of epidurals has steadily increased yearly since its introduction in the late 70’s and early 80’s.

But epidurals have left many women unsatisfied. Sometimes the epidurals don’t work, or don’t work as well as the woman would like. Sometimes she arrives too late in the labor process to receive an epidural. Some medical conditions exclude use of an epidural. Sometimes the epidural causes a fever and she and her baby have to be treated for the fever with antibiotics when they are probably not really sick. Epidurals can slow labor and contribute to occiput posterior positions of the fetus necessitating cesarean or vacuum delivery. The epidural is expensive, requires anesthesiologists or anesthetists to start and monitor. And most importantly, the epidural is DONE to the woman – she is not in control of that epidural. Most hospitals have very few options for women other than an epidural.

Notice on this short trip down labor pain lane that all of these choices are CONSUMER DRIVEN CHOICES. Women, laboring mothers, pregnant mammas, daddies-to-be have a voice and a choice. If something is to be changed get loud about it, write letters, stage pickets, ask questions, demand answers, you WILL get what you want in labor. Look at the things you’ve changed already simply by consumer demand!

Currently, most hospitals have NOTHING to offer a woman for pain relief should she decline an epidural, or one is not available, or she is unable to receive one, or it doesn’t work!! A simple, very inexpensive, very safe alternative does exist – laughing gas. This is a woman-controlled form of labor analgesia. Much higher levels of this gas would be needed for anesthesia (to be put to sleep). But only small amounts mixed with oxygen are needed for analgesia or pain relieving effect. The beauty of the “gas” as it is known in Britain is that the woman holds the mask and administers it to herself. A nurse or family member does not hold it onto her face with a strap or. When the pain subsides or she becomes sleepy, she simply drops the mask.

The medication is NOT absorbed throughout her entire body, but is actually excreted through the lungs. This means by breathing fresh air, she gets rid of the gas in her body within about 5 minutes of time. For this very reason, the gas can be used during the second stage of labor, or the pushing stage. Health care providers are leery of giving moms narcotics during the second stage because they are likely to be ineffective due to the extremely strong contractions and the medication takes many hours to be processed and excreted through her body. Narcotics can slow or stop a baby’s respirations after birth. A woman arriving late in labor may not have a chance to get any pain relief –too late for an epidural or narcotics, and the nitrous oxide mixture isn’t available.

Ladies, mothers, families – why is such a simple, effective, inexpensive form of patient controlled pain relief not widely available in the USA? Many women of course have not heard of it. But now you have. There are only a handful of hospitals in America using nitrous oxide and NONE of these is in South Carolina.
To summarize, nitrous oxide – oxygen mixture is a very safe form of pain relief for women in labor. It is inexpensive, certainly when compared to narcotics and epidurals. It does not restrict movement of the mother – she may still get up to the bathroom, shower, or use the birthing tub. She does NOT require continuous monitoring as she would with narcotics or epidural. The gas does not slow her contractions as they are with narcotics or epidural. She may stop and start the flow of gas at any time, including the second stage of labor.

The gas is not meant to replace epidural anesthesia for those women desiring that. It may be helpful for her as she prepares for or waits for the epidural. It may be used during repair of lacerations or removal of the placenta manually or when compression is needed to stop a hemorrhage – something unexpected when there is no time for anything else.
So, mommas and daddies, if nitrous sounds like something your hospital needs, please let them know that LOUDLY and CLEARLY. There are several links at the end of this article you may access to read more about this form of analgesia.

American College of Nurse Midwives Position Statement on Nitrous Oxide

Laughing Gas Makes a Comeback

UCSF – Nitrous Oxide Use in Labor for
over 20 Years!

The American Anesthesiology Society review of Nitrous Oxide for Labor