I have come to understand over 30 years of practice that risk assessment scores actually predict very little. If "over 5" is high risk and the components of a woman's score are: 1 for expecting a first baby, 1 for being low-income, 1 for having a parent with diabetes, 1 for smoking and 1 for having drunk a glass of beer before the positive pregnancy test, is this woman really high-risk? Does she need care by a physician to prevent problems from developing? Or does she need the loving, supportive care of a midwife more than at any other time in her life?
Let's say she starts out with a risk assessment score of 2: 1 for expecting a first baby and 1 for being low-income. At her 36-week assessment she gets another 2 for gaining only 19 pounds and another point for having an abnormal Pap. Now she's 5 and high-risk. Really? Does this woman need a physician to complete her care safely?
In tracking my own practice for over 20 years, I have found that the vast majority of women with risk scores over 5, which makes them high-risk in the system I use, have normal pregnancies and normal births with healthy babies.
We need to rethink risk assessment. How can it be that there are only two categories? Pregnancy is not a state of being either low-risk or high-risk. Why should we continue to use a system in which the majority of women who score in the high-risk category seldom develop a complication and many who score low-risk develop life-threatening conditions?
I suggest considering "risk potential." We don't even have to rewrite the systems, just our way of viewing and using the numbers and our response to them. A woman with a risk assessment of 2 has a different risk potential than a woman who has a risk assessment of 7. Neither woman may develop any of the conditions for which she received her score. In fact, the woman who received the score of 2 because it was her first baby and she was low-income may develop fulminating pregnancy-induced hypertension and spend a week in ICU, while the woman scoring 7 because she's had a previous cesarean and plans a VBAC (we'll pretend that's still an option for the moment) AND is low-income and weighs 210 pounds may have the most wonderful waterbirth ever recorded.
Every practicing midwife knows that those two extremes are not the slightest bit rare. So why do we keep using a system that truly tells us so little? In some physician/midwifery practices, the midwives are only "allowed" to see the low-risk clients, under this scoring system.
Here's another radical notion. The higher the risk, the more likely it is that the woman will benefit from midwifery care. A woman who scores high in her risk potential is usually scared. That's a midwifery specialty. Why should the women who would most benefit from the midwifery model of care be denied that opportunity by practice protocols that demand transfer of care to a physician if the risk assessment score places the woman in the either/or high-risk category?
Midwives are the experts of normal birth and all its many variations. We tend to also be the experts in caring. Every woman deserves the care of a midwife, if that is the care she chooses.
— Katherine Jensen, excerpted from "Reconsidering Risk," Midwifery Today Issue 74
MIDWIFERY TODAY ISSUE 74 can be purchased.
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Research to Remember
According to new research, both women who are overweight or obese when they become pregnant, as well as those who are overweight and lose weight prior to a pregnancy, are more likely to have babies that are oversized than women of normal weight. This is of concern because abnormally large babies are more likely to have birth trauma, and their mothers are more likely to undergo c-sections.
Women who were able to get down to a normal weight before their second pregnancy decreased the risk of having an overly large baby. That risk, however, still did not decrease to the level of women who had been thin consistently. The researchers speculated that this may be because a woman's metabolism is affected by weight gain.
— Am J Ob Gyn 196(6): 530.e1–530.e8, June 2007
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Web Site Update
Read these articles on our Web site about the challenging issue of female genital mutilation (FGM):
Korutun's Birth—by Kris Holloway-Bidwell
This article is an excerpt from the book Monique and the Mango Rains, which was reviewed in a previous issue of Midwifery Today. It tells the story of a difficult birth in Mali, Africa, following which two birth attendants have a personal discussion about female genital mutilation.
Unveiling Ritual Mutilation—by Jennifer Louisa Williams and Krystn Cohen-Dodge
"One day the phone rang at my house. 'Do you know anything about female circumcision?' asked Lisa, a midwife friend. No, I thought, but I had a feeling I was about to learn."
More information about female genital mutilation (FGM) can be found at the World Health Organization Web site: http://www.who.int/mediacentre/factsheets/fs241/en/
The Birth Market
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Norway Conference 2007
This international conference, "The Heart and Science of Midwifery," will be held in Oslo, Norway, September 12–16, 2007. Advertisers are invited to take advantage of several advertising opportunities, including program display ads, registration packet inserts, and exhibiting. This conference will offer the opportunity for participants to learn from the skilled and talented Norwegian midwives, as well as from presenters from all over the world. There will be a decidedly "international" focus to this conference. [ Learn More ]
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Question of the Week
Q: I need some help for a friend of mine, Sara, who is due with her second baby any day now. She very much wants a homebirth and has a birthing pool set up. Her first birth was in a birthing center and was without any problems. Her second baby has been transverse and breech for a while and her midwife easily turned the baby head down twice in the last two weeks, but the baby goes back to breech position. The midwife thought there must be some reason why the baby keeps turning head up, so she and my friend decided to get a sonogram. The sonogram showed the baby in a footling breech position with the cord wrapped twice around the neck. The doctor said the cord is short. The midwife herself was a footling breech birth and she is willing to go ahead with the homebirth if my friend is sure that she wants to do so. Sara's husband does not want to risk a homebirth, so she is feeling some tension and distance as she doesn't feel that he is supporting her.
Sara is willing to try natural techniques like acupunture, homeopathic pulsatilla, playing music at the cervix, swimming and getting in inverted positions. She visited the doctor who was at her first birth and he tried moving the baby a bit and checking its heart beat to see how tight the cord was wrapped. He said the heart showed no signs of distress, so moving the baby can be tried. This doctor is the head of the birthing center that is in the Roosevelt Hospital in Manhattan and he hasn't "delivered" a breech baby in five years.
I keep reminding Sara that the baby can turn head down at any moment, even during labor. Any thoughts or advice for her?
SEND YOUR RESPONSE to firstname.lastname@example.org with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.
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Question of the Week Responses
Q: I am the mother of a seven-month-old girl. I live on the Big Island of Hawaii and a cold/cough has been going around for quite some time now; nothing seems to be helping my daughter/family. Strangely, Dad and Grandpa have the cough as well, but I don't. A friend suggested a Chinese Herbal remedy (Plum Flower Brand—Quiet Cough Teapills/ Ning Sou Wan). I can't find any information about this particular remedy so was wondering if any readers have any experience with it.
Any information would be greatly appreciated.
— Kanu Priya Bernal
A: Ning Sou Wan "Quiet Cough" Teapills is a formula that has many herbs from the "transform phlegm and stop coughing" category of Chinese herbal medicine. These herbs clear heat, drain dampness and transform phlegm. This is a good formula for a productive, wet cough with some heat signs such as yellow sputum, fever, a red tongue or wheezing.
Mulberry root bark reduces lung heat and helps with coughs and wheezing. Almond Kernel relieves coughing, wheezing and moistens the intestine. Peppermint clears heat from the head and eyes and benefits the throat. Raw Licorice and rice sprouts help the body to digest the other herbs. Other herbs circulate Lung qi, benefit the throat, nourish yin and clear heat.
— Maureen Manning, L.Ac.
Q: A doula recently told me that a large percentage of clients for whom she had worked in hospital births had decided to have a homebirth upon becoming pregnant with their next child. They were motivated by the belief that what went wrong in the first birth was related to being in the hospital. Have other doulas had similar experiences?
A: I have not experienced what the quoted doula has. I certainly have had clients who have had hospital births and switched on subsequent births to a homebirth, but I would say that these women have definitely not been in the majority, but rather have been a very small percentage. What I do find, when I look at my logs, is that I have had more women who birthed only with their partners and a doctor or certified nurse-midwife (CNM) present on their first birth, who then chose a doula for the second birth regardless of where that birth took place. I also find that more clients switched from an obstetrician to a nurse-midwife or family practice doctor on their subsequent births, again regardless of where they chose to birth. In my state, only doctors and CNMs can legally attend births.
Opening up a different portion of this discussion, I find that when a woman chooses a homebirth attended by a homebirth midwife, doulas are rarely hired by the birthing woman. This may be because of the amount of time the homebirth midwife spends with her birthing clients, thus obviating the doula's role in the client's birth; or it may be due to bias on the part of the midwife who sees the doula as unnecessary or obtrusive; or it could be that the midwife works with her own particular doula or has an assistant who is part of the "package" when the pregnant woman hires the midwife. I find that most homebirth midwives, however, welcome another heart and another set of hands to help the family during the labor and certainly in the immediate postpartum hours.
— Susan Mooney
A: I am not a doula, I am a postpartum RN, with dreams of becoming a midwife myself, so I never questioned delivering my child with one. I had an amazing midwife deliver my first child in a small hospital, run similar to a birthing center. The debate about homebirth was difficult, in part because I loved and trusted my midwife who only delivers at the hospital and in part because I was scared of delivering at home. I know the statistics. I wanted to be one of those people who trusted in my body and the birthing process enough to trust in a homebirth. As it turned out, my son was a compound delivery and after four hours 40 minutes of pushing he was assisted by a vacuum. I don't think he would have been a successful homebirth: most likely I would have ended up with a c-section if I had been at home with a hospital transfer. I feel I had the perfect team to support me during my labor and delivery and feel so fortunate that I had a vaginal birth and a perfect healthy baby. All that being said, I have no doubt that my future children will be delivered at home. I want my son to be present (if he chooses to), I want the comfort of my home and I want to be away from "well-meaning nurses" (even though I am one).
— Eden Robertson
Responses to any Question of the Week may be sent to E-News at any time. Write to email@example.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
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Think about It
The Forbes Web site recently included an article entitled "Soaring C-section Rate Troubles Doctors," which is a refreshing departure from the usual take on this issue.
It includes quotes from Marsden Wagner and discusses the economic pressures contributing to this trend, the increased risks of cesarean, and an observation by another obstetrician that the overuse of this surgery runs counter to the sacred rule in medicine of "First Do No Harm." At the end, readers are directed to ICAN for further information.
This article is available at: http://www.forbes.com/health/feeds/hscout/2007/07/13/hscout602211.html
— From the Citizens for Midwifery's (CfM) Grassroots Network e-mail list
I am a mother, farmer, herbalist and student midwife/doula (taking a break right now) who would like to get back into the birth community when the time is right.
I just wanted to say that I was more than a little disconcerted to see the medicalized version of a response and an abundance of articles on studies and numbers [rather than more midwife-friendly responses] appear on the short version of E-News [Issue 9:14, July 4].
I realize the environment has changed and many women area again seeking interventions in birthing that they perceive will make them feel safer and better cared for. As a potential community practitioner who is familiar with the natural rhythms of birth and good supportive nutrition and holistic care, I feel strongly that the message that alternatives to testing and medication are available needs to be out there in front along with whatever good medical information is presented so that women have choices. That is part of informed consent.
The question of the week on the persistent cough was answered by a CNM who recommended testing and vaccination. It was not presented as "current medical practice recommends" but instead as a directive that should be followed. Yes, a whooping cough outbreak has occurred over the last few years. My youngest was hospitalized with severe breathing problems at about age 18 months and was diagnosed, along with many other young children, with a form of pertussis about 3-1/2 years ago.
As far as I know, no vaccines protect against viral illnesses, and the best thing to do is to strengthen the body and work with a practitioner when needed.
I am glad I went on to read the response from the sister in Hawaii who told about the winds and homeopathy and other remedies. I wish her reply had been posted on the short version.
I am glad for the number of CNMs and I have had my babies with CNMs. Nevertheless, a stillness and original uncluttered beauty that is the power of birth is being missed when we have too much information.
Please post other views along with the medical opinions on the short version as well. The days are already too busy and I am not encouraged to think that midwifery is being converted to medicalization.
— Birgit Johanson
Jaffrey, New Hampshire
Editor's Response: The mailed version of Midwifery Today E-News is shortened so it takes up less bandwidth upon mailing. The editorial department is not involved in choosing what gets cut; there is no intention to slant the mailed version in any direction. Readers are always notified when material has been cut and are encouraged to read the full version online.
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