February 19, 2003
Volume 5, Issue 4
Midwifery Today E-News
“Prenatal Care”
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Quote of the Week

According to the medical model, life is a problem because it is full of risk and in almost constant danger, an assumption easily accepted if one's professional career is spent surrounded by pathology, suffering, and death.

- Marsden Wagner, MD

The Art of Midwifery

When a laboring woman urinates while she is pushing, I think, "Thank goodness, that will get the bladder out of the way to make more room for the head." I have the same thought when I see stool. Then I know that mom is pushing effectively and that the baby's head is moving lower and closer to being out. Getting rid of any stool makes that much more room for baby, and it is that much less stool that mom has to pass later when the perineum is sore.

- Lori, Midwifery Today Forums

All Birth Practitioners: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

News Flashes

Epidural analgesia (EDA) has been reported to prolong labor. A study examined the concentration of plasma oxytocin and the progress of labor in women with and without EDA. Thirty-four full-term women in spontaneous labor were included, 17 with epidural and 17 controls, matched for cervical dilation and parity. Oxytocin was measured by radioimmunoassay before analgesia, 60 min later and after placental discharge. No oxytocin augmentation was given during the first hour. EDA during labor was associated with a fall in plasma oxytocin. There was no difference in plasma oxytocin levels between the groups at inclusion. One hour later, oxytocin concentrations had decreased in the epidural and increased in the control group. The change in oxytocin levels between the first and second sample differed significantly between the groups. No difference in cervix dilatation between the groups 1 h after inclusion was noted, but women with EDA had a longer labor compared with those without, especially those with epidural and oxytocin augmentation during the later phase of the first stage of labor.

- Acta Obstet Gynecol Scand 81 (11):1033- (2001)

Prenatal Care

A study titled "Racial Differences in Prenatal Care Use in the United States: Are the Disparities Decreasing?" and published in the December 2002 American Journal of Public Health, used all U.S. birth records from 1981 to 1998 to explore trends in early and adequate prenatal care use for African American and white women. For the 18-year study period, the percentage of pregnant African American women who received adequate prenatal care as measured by the month care began and the number of prenatal visits in the first trimester rose from 26.9% to 44%, an improvement of 64%. Among white women, the percentage receiving adequate prenatal care rose from 33.6% to 50.2%, a 50% increase. Overall, the racial gap in adequate care use has narrowed steadily since the 1980s, but the study revealed that the gap is actually widening among white and African American mothers 17 years of age and younger.

The study also found that

  • the percentage of women who began care in the first trimester increased from 61.1% in 1981 to 72.8% in 1998 for African Americans, a rise of 19%, while the percentage of white women who began first trimester care rose from 80.1 in 1981 to 84.8% in 1998, an increase of 6%
  • the percentage of births among mothers 17 and under with less than 12 years of education has decreased in both racial groups, while the percentage of births among unmarried women of both races has increased during the time span of the study.

- US Dept of Health & Human Services, Health Resources and Services Administration

A study by Giblin, Poland, and Ager (Journal of Community Health 15 (6), 357-368 [1990]) found a clear association between the level of tangible/behavioral, emotional, and informational support of expectant fathers and prenatal care use and health behaviors exhibited by the expectant mother. The study shows that women were more likely to participate in prenatal care and quit risky behaviors if the expectant fathers provided them with all three of those types of support. Thus, the informational support of the expectant fathers is as essential as emotional and behavioral support. Informational support is exhibited by the roles of information provider and information seeker.

Also, research conducted by Westney, Cole, and Munford (Journal of Adolescent Health Care, 9, 214-218 [1988]) suggests that the expectant mother is more strongly influenced by input from her partner than from any other significant person, including other relatives and healthcare professionals. This research suggests that expectant fathers were most influential in getting the expectant mother to comply with medical protocol and exercise good health behaviors.

A recent report, "WHO antenatal care randomized trial for the evaluation of routine antenatal care," (The Lancet, May 2001) concludes that for women without previous or current complications, a reduced number of prenatal visits, including goal-directed, effective activities, does not increase risk for themselves and their babies and may reduce the cost of pregnancy-related health care. This multicenter, randomized, controlled trial compared the standard model of antenatal care with a new model that has fewer clinic visits and emphasizes actions known to be effective in improving maternal or neonatal outcomes. There were two elements to the trial: not just fewer prenatal visits but also a set of specific, scientifically evaluated activities.

Fifty-three clinics were randomly allocated to the new model or to standard care. Women in new model care clinics were evaluated according to obstetric history, present pregnancy, and general medical condition to receive basic prenatal care, or more intensive care if appropriate. Twenty-three percent of women received the intensive model of care, and all women were included in the final analysis.

The new model consists of a set of specific activities implemented on a four-visit schedule. In fact, the women had an average of five visits, and in the control clinics the average was eight. Activities were familiar prenatal care activities in three general areas: screening, therapeutic interventions, and education ... The primary outcomes studied were low birth weight, preeclampsia/eclampsia, severe postpartum anemia, and severe treated urinary tract infection.

All primary outcomes were essentially the same in both models, except for preeclampsia, for which the authors report "the rates were clinically similar, but an increase in risk of up to 56% cannot be ruled out." Rates of eclampsia were essentially identical.

Women expressed concern about the reduced number of prenatal visits but were more satisfied with the length and content of the individual visits. Providers' responses were mixed. Costs were reported to be possibly lower. More referrals were engendered by the new model of care.

Perhaps the biggest concern is that government and third-party payers may use the study as a reason to reduce the access of vulnerable populations to prenatal care, a course that midwives should resist. In countries where economics does not permit access to prenatal care for the poor, the new model might be used to expand prenatal care in a beneficial manner while making the best use of available funds. The worst outcome would be a situation in which a frightened teen mom calls, anxious to be seen, only to be told, "Your medical card will cover only four visits. You can come in but you will be billed for it yourself." This kind of outcome would seriously decrease the quality of maternity care and increase complications.

- Marion Toepke McLean

Excerpted from "How Many Prenatal Visits?"Midwifery Today Issue 59.

To read the entire article, purchase Midwifery Today Issue 59. To order, click here.

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Other Products and Services of Interest

Prenatal Care for Emotional Well-Being

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Forum Talk

What do you think about having a birth plan when one is planning to have an assisted homebirth? And where can I find some examples?

To share your thoughts and experience about this topic, go to Midwifery Today's Forums. PLEASE DO NOT SEND YOUR RESPONSES BY E-MAIL!

Question of the Week

Q: A client having her first baby has a vaginal septum (one cervix and uterus). Does anyone have home- or hospital-birth experiences with this? I know what Williams says, but I want to hear from midwives. We are trying to assess the risk of homebirth in relation to bleeding and the possible need for sutures to the septum. —Keta Johnson

Send your responses to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.

Question of the Week Responses

Q: I am a doula and have a client with pelvic floor dysfunction (PFD) and interstitial cystitis (IC). She would like to have a natural birth. She has been told to get an epidural to "quiet the bladder and pelvic nerves." Does anyone have experience with PFD or IC? Any information would be greatly appreciated. —Rachel Porter

A: I had a woman who had IC through six pregnancies with no problems. However, she did realize that for her it was caused by an allergy to man-made products. So for example, she only sits on untreated wood or she covers a chair with a heavy large paper bag. She did a few other changes and wasn't bothered with the pain as she was in the beginning. —Carol

A: I am a doula and the mom of two daughters. I have had IC and pelvic floor dysfunction for 13 years. IC sufferers have painful bladder symptoms, but that shouldn't interfere with their ability to have a vaginal birth. I had an epidural with my first baby (vaginal delivery). It was strange not to feel anything from my bladder for the first time in seven years! I had an unmedicated birth with my second baby, and pushed her out in 20 minutes. The fact that I had pelvic floor dysfunction didn't affect my ability to push my baby out with either birth. As for the pain of labor, your client will probably be so focused on the contractions that she will not be thinking about her bladder, although she will likely feel the need to urinate more than the average client.

One negative side effect of getting an epidural is the possible need for a catheter. Catheterization is extremely painful for IC sufferers and that pain can last for days. Whether or not she has an epidural, the passage of the baby through the vagina will likely forcefully relax her pelvic floor muscles, which will be a good thing because, with IC, her pelvic muscles are probably very tight. This may decrease her pain. Encourage her to breastfeed, too. Many women find their symptoms ease during pregnancy and that continues throughout lactation.

- Julie

A: I recently met a woman who specialized in pelvic floor therapy. She had a physical therapy background. Several women at a recent doula networking event raved about the healing they experienced from this intensive physical therapy. Perhaps your local P.T. network would know of a pelvic floor therapist in your area.

-Nancy, St. Louis, MO

EDITOR'S NOTE: Responses to any Question of the Week may be sent to E-News at any time. Please indicate the topic of discussion in the subject line or in the message.

Midwifery Today Magazine Question of the Quarter

Theme for Issue 66: Birth Environment

Question of the Quarter: What do you do to create a positive birth environment? In your experience, what have you seen that disturbed or facilitated the birth environment?

Please submit your response by March 1, 2003 to the editor.

All responses subject to editing for space and style.

Write an Article, Receive a Free Subscription!

Here's your chance to get a free one-year subscription to Midwifery Today Magazine. Write a full-length article ( 750 words or more) about protecting the birth environment and what that means to you. Submit it by Feb. 26, 2003 for the next issue. If your article gets accepted for publication in the magazine, you get a free one-year subscription! We are especially interested in hearing from those of you who work in hospital settings. Tell us how you protect the birth environment in the hospitals, against all the inherent obstacles. Send submissions here.

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Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out!

Foundation for the Advancement of Midwifery

The Foundation for the Advancement of Midwifery is the only nonprofit, tax exempt organization devoted to raising funds and granting money to persons and organizations working to further the midwifery model of care. We support and fund programs relating to maternity care research, public education, increasing access to midwifery care, and strengthening other organizations with similar goals.

Our first priority is to fund the completion of the CPM 2000 Statistics Project, which we believe will provide critical support for the expansion of midwifery in all our discussions with policy makers, consumers and other healthcare practitioners. Beyond that, we will evaluate other programs for funding as long as they fall within one of our four programmatic areas: research, access, education and capacity-building (strengthening other organizations). For example, we envision underwriting a huge public relations campaign—probably in conjunction with other organizations—to counter pervasive negative misinformation about birth. We are confident that, with the generosity of individuals and organizations committed to change in our healthcare system, we can raise the large sums of money necessary to finance activities of that kind.

How can you help us? The most immediate and obvious way is by making contributions to the foundation. All contributions are tax deductible, and you will find all of our contact information at our website: www.mana.org/foundation. We can use help with writing grant applications, inputting data, responding to inquiries or otherwise participating in any of our committees. Please e-mail us at Foundation@MANA.org if you are interested.

We can also use your input into our ongoing needs assessment process, which helps us confirm that the community we serve identifies the same needs as we have. You can fill out our questionnaires on line at our website or print out copies and mail them to us. Please feel free to contact us if you'd like more information or have ideas to share. You can reach us through the e-mail address above or by calling our toll free number: (877) 594-9996. —Board of Directors, The Foundation for the Advancement of Midwifery


Do you have information about breastfeeding during pregnancy? My milk production has already decreased (I am able to objectively judge since I pump a few times a week), and I want to be able to continue nursing without supplements for a while longer. We were planning to wait till he was closer to 6 mos. before starting solids, and I don't use formula. The midwife's office recommended hot compresses three times a day and told me to drink plenty. Do you have any other ideas, or do you know of info on the Internet? -Anon.

Do you have advice for women who have been emotionally, physically and/or sexually abused about how to cope with their emotions and fears when they find they are pregnant with a boy? I hear many women say they have had these feelings and fears but no resources to help them cope through this difficult time. -TLC

Over the years, I have heard the same advice repeated that appears in the "News Flashes: Painful Procedures" [Issue 5:03]. There is another side to this: Breastfeeding is meant to calm and secure the baby. It is not just a handy soothing technique; it is also something that builds trust between mama and baby. To perform an invasive technique on the baby during this sacred time is to teach the baby that even breastfeeding can't be counted on to be safe.

- Anon.

An alternate suggestion is to hold the baby, skin to skin if possible, during the procedure, then breastfeed after. Let's teach our babies that breastfeeding is a time for trust and safety, not that life can creep up on you anytime, anywhere.

- Charlotte Millington

I am a Bradley instructor looking for information that explains the role nutrition plays in hormone production during pregnancy. Specifically, I am trying to establish if there is a link between excellent nutrition and the release of natural prostaglandins near term to soften the cervix. I am already aware of the effect of natural prostaglandins via semen, but am looking specifically for nutritional information. Seems prostaglandin gel use is on the rise in my area.

- Nancy Capo, AAHCC

My midwifery partner, Jenny Wilcox, CPM, of many years wrote the following:

"Midwifery is a privilege and an honor. It endows the midwife with a special power, and with this unique power comes the obligation of competency. Because we are given knowledge through experience, we become the guardians of birth. We must accept our power humbly and our responsibility to the safe passage of birth seriously. We touch within our hands the hearts of humanity. We are the guided overseers and are called to serve. Let us uphold the depth of midwifery and contribute to the betterment of humankind. May humility fill our hearts as we touch and are graciously touched in return. May we look so that we SEE and may we listen so that we HEAR - and may we be worthy of our endowment!"

-Dana Rudloff, CPM

EDITOR'S NOTE: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.

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