Research to Remember
A University of New Mexico study of a Zuni-Ramah Native American population found a 7.3% cesarean section delivery rate despite a high incidence of obstetrical risk factors among the group. In 1996, VBAC had been attempted 93% of the time compared with a 42% rate nationwide. The study revealed other significantly lower c-section delivery rates, including 11.5% vs. 35.4% for diabetes in pregnancy and 14.8% vs. 37.4% for preeclampsia. The c-section rate for indications including dystocia, breech, fetal distress, elective repeat cesarean and others was also significantly lower than among the general U.S. population. No increase in adverse outcomes was found. The researchers attribute the low cesarean rate to the "predominant involvement of family physicians and nurse-midwives…who have a significantly lower cesarean delivery rate and intervention rate; decreased use of cesarean for labor dystocia; almost universal acceptance of trial of labor after cesarean; an average birth weight of 118 grams less than the U.S. average; and a pronatalist cultural attitude toward childbirth and increased social support within the Zuni-Ramah community based on the reluctance of women to use obstetrical interventions."
— Annals of Family Medicine, May/June 2003
Most women with new HIV infections do not knowingly engage in high-risk behavior. The Centers for Disease Control (CDC) estimates that 75% of women are infected by heterosexual contact and 25% by drug use. Most contract HIV through unsafe sex with their male partners—many of whom, unbeknownst to the women, also have sex with men or are injection-drugs users. In a recent CDC study, 34% of African American HIV-positive men reported having had sex with both men and women, but only a very small proportion of HIV-positive African American women reported knowing that their partners also have sex with men. [African Americans comprise half of 40,000 new cases yearly. Sixty-four percent of newly infected women are black, 18% are Hispanic and 18% are white and other races.]
Many complex factors put a woman at risk of becoming infected with HIV. The power inequities and economic disadvantages of gender and race are huge contributors. The stigma against men who also have sex with men (and still define themselves as heterosexual) and the stigma against multiple partners and drug use lead to secrecy that results in women unknowingly putting themselves at risk. Additional factors are sexual violence and nonconsensual sex.
Two more issues that midwives can address directly with women and girls are the lack of knowledge about HIV risks and safer sex and the difficulties of accessing and negotiating condom use. As midwives we must bring the skills of meticulous, personalized care to issues around HIV/AIDS. "What do you do to protect yourself (and your baby) from HIV?" is the question we must ask women whether they are pregnant, desiring pregnancy, wanting contraception, coming for an annual physical and Pap smear, or seeking help for vaginal discharge or other gynecological problem.
"Are you or your partner at risk of being HIV infected?" is one of the questions we seek answers for in taking detailed sexual histories. "What can I offer this woman to help her keep herself (and her baby) safe from HIV?" is the question I ask myself.
But no one approach works with every woman. The woman who answers, "Who, me?" to the question, "What do you do to protect yourself from HIV?" needs a different approach than the one who looks worried in response to the same question. Another approach is needed for a woman who says she and her partner are usually consistent condom users, but the condom broke last night or they had both been drinking and somehow the condom never got out of the package. Just like each labor is an individual journey that we take with birthing women, listening and talking to a woman to help her find ways to keep herself (and her baby) safe from HIV may be an equally intimate, personalized process. It may evolve over several contacts. In my work setting, I also send women to very competent, sensitive HIV counselors. Not all midwives have that kind of support service available.
Taking a good sexual- and substance-abuse history is not easy to do—for midwives or the women we care for. We cannot make assumptions about a woman's sexual behaviors or the circumstances under which she has sex. We must ask sensitive, intimate questions and be able to talk about sex openly and frankly. We must learn not to act shocked if a woman discloses behaviors about which we have personal judgments. One of the hardest things for me to hear is teens telling me about the risks they take and their misconceptions about what is safe.
Many good sexual history and STD/HIV risk assessment tools are available. I introduce the assessment with a statement that goes something like this: "I am going to ask you some very personal questions about sex. I do this with everyone. I want to be sure you are protecting yourself against infections women can get through sex, including HIV. If you have an infection I want you to get the right care. I want you and your baby to be safe and healthy. Your answers will be kept confidential."
If a woman seems uncomfortable, I acknowledge that sometimes this is hard to talk about. If I sense that answering my questions is just too hard for a woman for cultural, religious, psychological, or other reasons, I may frame my teaching with phrases such as "Some women…," "This is safe, this is risky," "This is how you can protect yourself (and your baby)." My goal is that every woman I see leaves knowing how to protect herself (and her baby) against HIV and other sexually transmitted diseases.
A profession of monogamy cannot always be trusted. Midwives cannot assume that a pregnant client is not at risk, even if her account of her partner's and her own sexual history seems to indicate she is. Education is still essential.
Likewise, women must take appropriate precautions, even with sexual partners who appear not to be at risk of infection. Relationships are complicated, sex is complicated. These very complex issues require creative approaches. It is ideal if a couple discusses and agrees on protection before starting to have sex.
The most important behavior to facilitate condom use is producing a condom easily at the right moment during sex, whether its use has been discussed previously or not. A psychiatrist from Baltimore who works with teens says there is a four-second window of opportunity to get the condom on, or it is too late. Women must know about the notch on the condom package to get it open quickly and smoothly. These are complex skills to develop—as hard as developing trust and safety between partners in a relationship. We midwives need to seek new and creative ways to openly and comfortably talk with women about this "hard stuff"—ways that fit our personal styles of relating and that can meet women wherever they are coming from.
Excerpted from "What More Can We Do about HIV?" by Nancy Miller, CNM, MSN, Midwifery Today Issue 70
The Partners Project conducted a program in Los Angeles to build an integrated approach to disease and pregnancy prevention within the context of a Hispanic community. It conducted all intervention sessions at a community-based clinic that provides affordable, comprehensive and culturally appropriate health care services to the Hispanic community of East Los Angeles. It aimed to provide support that was culturally appropriate and specific to the needs and characteristics of that Hispanic community. Although traditionally Hispanic men not only are involved in decision-making about sexual issues, but also see their role as an important responsibility, the intervention was designed to engage both partners and included skill-building activities to improve communication between partners in terms of sexual needs, desires and safe-sex strategies. Skill-training components had previously been shown to be more effective in behavior change than purely informational interventions, so that strategy was implemented.
Sessions covered first, perceived vulnerability to unintended pregnancy, HIV and other STDs, transmission and prevention of HIV and other STDs, and strategies for safer sex; second, condom use skills and other strategies for safe sex; and third, preventing unwanted pregnancy.
Outcomes of the program were increased use of condoms and effective contraceptive use. Program leaders observed that bringing couples together for education about HIV and other STD prevention and contraception and focusing on the relationship context may have been enough to change their previous behaviors in these areas. Becker and Robinson [International Journal of Gynecology and Obstetrics, 1998, 61(3):275–281] had previously shown that programs targeted at couples are more effective than those directed at only one partner.
Program leaders were guarded in their assessment of the positive outcomes and suggested various reasons, including that the culturally appropriate recruitment techniques and sites may in themselves have raised awareness of and desire for better HIV/STD and pregnancy prevention strategies; baseline interviews alone may have increased awareness before the training even began; the process of bringing couples together for education may have compelled them to change their behaviors. Caveats include the fact that the participants were a relatively homogenous group; the interventions may have different effects when adapted to other cultural or age groups; the participants may have been in relatively stable partnerships; and as in many studies about sexual behavior, self reporting may not have been accurate.
For a detailed description of the Partners Project and its outcomes: http://www.agi-usa.org/pubs/journals/3616204.html
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What is advanced or essential midwifery knowledge may depend on who your authority is. Know to be humble, realizing we are a part of a miracle, but not allowing ourselves to believe by action or thought that we are the miracle maker. Know our place, much like the birthing woman: here, but not here. We may guide our clients to be the final decision makers, being artfully appropriate and bringing a gentle balance. Know how to facilitate empowerment by guidance and example. We need to exemplify faith, freedom, discretion, credibility and integrity, being careful with our own spirituality. Who we are is imparted. Strive for excellence; it shows. Know we teach by living example, not just words. And most of all, know to love, unconditionally, without judgment.
You can know the answers, get straight As in all your midwifery classes, know the right clinical maneuvers, details of a woman's history, community protocol, and on and on. Bu what is this to anyone without the warmth and love you give or the spirit you carry, helping women experience within themselves the transformation this rite of passage can give? It's such a holy time, unique unto itself!
— Carol Gautschi, Midwifery Today Issue 69
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