I hope everyone had a wonderful Christmas! The time has gone by so fast this year! With homeschooling, and my schooling we are constantly running, studying or doing a project! Today, December 31st, is my 45th birthday! I don't feel like I am 45! I used to think that people who were my age were very "old". I know now that you are only as old as you feel, and I don't feel old at all!
Happy New Year everyone, and welcome to 2010!
Thursday, December 31, 2009
Tuesday, December 29, 2009
Maternal Mortality and Morbidity Research Paper 2009
Each year the World Health Organization publishes childbirth statistics. One of these statistical findings compares the number of births to the number of maternal and infant deaths in each country. For the last decade the United States has been evaluated as having one of the worst ratings of maternal and neonatal deaths as well as healthy birth outcomes in the world. This paper will examine the factors contributing to this rate, and ideas for lowering it. Many national and international public health agencies are involved in examining this problem, and have contributed both positively and negatively to its remedy.
According to David Steward, who is the Executive Director of the National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPSAC): “It is important to clarify that safety is measured by death (mortality), or illness (morbidity) during the labor and birth process, and shortly thereafter.” The United States has consistently high maternal and perinatal mortality and morbidity rates, compared to other industrialized countries. According to the World Health Organization a maternal death is defined as: “The death of a woman while pregnant, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes." In 1990 the U.S. was ranked 23rd by the Population Reference Bureau which publishes the mortality and morbidity statistics. In 2007 the U.S. was ranked 41st. This means that in 2007 there were 40 other countries where it is safer for women to give birth than in the United States (The report was issued by the World Health Organization, the United Nations Population Fund, the U.N. Children's Fund, the U.N. Population Division and The World Bank, Oct. 12, 2007; Retrieved 11-30-09).
In the United States, according to Barbara Harper, R.N., “Gentle Birth Choices”; the infant mortality rate was 8.9 deaths per 1,000 live births in 1991. This has now gotten much worse. According WHO, in the U.S. the infant mortality rate in 2007 was 11 deaths in every 100,000 births. In 1991 the infant mortality rate was 8.9 deaths per 1,000 live births. The worst state was Delaware at 11.8, with the District of Columbia even worse at 21.0. The best state was Vermont, with only 5.8. Vermont also has one of the highest rates of home birth in the country, as well as a larger portion of midwife-attended births than most states.
The international standing of the United States did not really begin to fall until the mid-1950’s. This correlates with the founding of the American College of Obstetricians and Gynecologists (ACOG) in 1951. ACOG is a trade union representing the financial and professional interests of obstetricians who have sought to secure a monopoly in pregnancy and childbirth services. Prior to ACOG, the U.S. always ranked 10th place or better internationally. Since the mid-1950’s the U.S. has consistently ranked below the 12th place and has not been above the 16th place since 1975. The relative standing of the U.S. continues to decline, even to the present.
The social, natural and significance of birth ensures that this biological and intensely personal process carries a heavy cultural overlay. In all cultures birth is a rite of passage (Van Gennep 1908) that embodies a culture’s deepest beliefs, which are transmitted and reaffirmed during the birth process. Birth practices point to the core values of the culture, telling the observer a great deal about the way that culture views the world and women’s place in it (Kitzinger 1978). Where women’s status is high, a rich set of nurturant traditions tends to develop around birth. Where it is low, the opposite occurs.
In the United States there is a patriarchal society in which women’s health care status is low, and is less supported by active legislation. The extreme emphasis on technology in the U.S. is mirrored in its birth practices (Martin 1987; Davis-Floyd 1992). The prestige of this Western high-tech approach has induced many developing countries to stamp out viable indigenous midwifery systems and import the Western model; even though their hospitals are often underfunded, understaffed, and replete with expensive machines that few know how to use or repair (Jordan 1993; Sargent 1989).
To counteract this unfortunate trend, the World Health Organization and UNICEF have begun to promote traditional midwifery in developing countries through programs for “upgrading” skills. However, because the medically-trained personnel in these programs value only the Western medical approach, they generally fail to take advantage of the knowledge and skills developed by community midwives within the context of their own cultural traditions.
In the United States, such attitudes resulted in the near complete elimination of midwifery by the 1960’s. Since then demands of many women for natural childbirth, coupled with scientific research into the dangers of interventionist techno-hospital birth (Goer 1995) and the benefits of planned, midwife-attended births at home (Davis-Floyd 1992, 1996), or in freestanding birth centers (Rooks, et al. 1989), have generated a midwifery renaissance.
In the four countries in which infant perinatal mortality statistics are lowest in the world: Japan, Holland, Sweden and Denmark – over 70% of births are attended by midwives (Wagner 1994; Fiedler 1996). In countries where women are allowed, or rather allow themselves to give birth more naturally and with fewer interventions, the outcome for both mothers and babies is remarkably good. Complications normally associated with pregnancy and childbirth in Western technological society are usually quite uncommon in tribal societies.
An anthropologist who observed the Arikara of North Dakota during the 1930’s noted that there were no tubal or abdominal pregnancies; no placenta previa (premature separation of the placenta blocking the cervix); no eclampsia (convulsions), and no premature birth. Phlebitis (inflammation of a vein) only occurred after tribal women became exposed to more “progressive” cultures.
Women in less technologically advanced countries give birth quickly, and easily as in Korea, during the 1960’s when it was described that in a rise field a working woman walked to the edge of the field, squatted down, caught her baby, strapped it on her back and was picking rice minutes later. Several people saw the birth from a distance, but no one helped or interfered in any way. She did it quietly, by herself (page 4, unassisted Childbirth by Laura Kaplan Shanley).
In the “Paleolithic Prescription,” S. Boyd Eaton writes about a typical birth in a !Kung San village in Africa’s Kalahari Desert: “A woman feels the initial stages of labor and makes no comment, leaves the village quietly when birth seems imminent – taking along, if necessary, a young child – walk a few hundred yards, finds an area in the shade, clears it, arranges a bed of soft leaves, and gives birth, while squatting or lying on her side – on her own. Showing no fear and not screaming out, they believe enhances the ease and safety of delivery (Eaton, Shostak, and Konner 1988:240 in Unassistted Childbirth).
Judith Goldsmith relays similar stories of birth in the “Childbirth Wisdom” from the World’s Oldest Societies (1990). Goldsmith compiled the accounts of scientists, anthropologists and historians who had observed tribal births over the past 400 years. She makes many references to the fact that tribal women often delivered their own babies.
Midwife Penny Armstrong writes about birth in an Amish community in her book “Wise Birth.” She writes: “I was struck by the casual, comfortable movements of the women laboring in their kitchen and giving birth among the quilts. I was undone by the infrequency of the need for me to display my midwifery skills. Birth appeared to be another animal out in the country. Labors were short and pain appeared to be less severe. Cuts and tears were fewer; hemorrhage controllable. Babies didn’t need suctioning devices or tubes pressed down their throats. They gurgled when they were born and began to breathe. Their mothers took them to their breasts and nursed without much complication. The births not only had power, but grace and simplicity” (Armstrong & Feldman 1990:34). Physiologically there is no difference between tribal women, the Amish and the more technologically exposed Western woman. If we are to understand the vast differences in birth outcomes, we must examine the method of delivery in the United States and compare them to the world.
According to Grantly Dick-Read in the book “Childbirth Without Fear,” the more civilized the people, the more painful labor appears to become. Childbirth should ideally reinforce a woman’s sense of power and autonomy. Instead it has become a painful, dangerous ordeal that often reinforces the belief that the woman is helpless, and dependant on others and not herself for her birth. Most women in western culture have been led to believe that they are incapable of delivering their own babies.
More research is being done that confirms the fact that intervening in the act of childbirth causes serious problems for both the mother and the baby. The presence of numerous doctors, nurses and hospital equipment make it very difficult for a laboring mother to relax and slip into the type of consciousness necessary for a baby to be born easily. The actual physical intervention of the doctor generally makes it impossible.
Some U.S. physicians claim that the increase in percentage of cesareans performed in this country (from 5% of all births in 1970 to 31% of all births in 2008), has lead to a lower infant mortality rate. When the new national rate is published for 2009, the hypothesis is that we will find about one mother in three is giving birth by cesarean section, a record level for the U.S. Studies have estimated that approximately 50% of all cesarean sections done in this country today are unnecessary.
Most European countries are now striving and successfully lowering their infant mortality rates, and they are much lower than ours. The percentage of European cesareans remains constant at 5% of all births, which explains the lower infant mortality rate.
Numerous studies have been conducted over the past 20 years that show that home birth is a safe alternative to hospital birth. The best-known study was conducted in 1977 by Lewis Mehl, M.D. (as reported by Davis-Floyd 1992:179). Mehl did a comparative study of 1,046 planned home births and 1,046 planned hospital births. After the births were analyzed for length of labor, complications, outcomes for the infants, and procedures utilized, he found that home birth was actually safer than hospital birth for both the mother and the baby. It was found that the hospital births have 5 times higher incidence of maternal high blood pressure, 3-1/2 times more meconium staining (indicative of fetal distress), 8 times more shoulder dystocia (due in part to the insistence on the supine position for delivery), and three times the rate of postpartum hemorrhage (primarily due to early clamping of the cord and attempts made to remove a placenta manually before it was ready to come out). Three times as many hospital babies required resuscitation (primarily due to medication), and four times as many became infected. Thirty times as many hospital babies suffered birth injuries (due to forceps and vacuum extraction). The injuries consisted of severe cephalhematoma (a collection of blood beneath the scalp), fractured skull, fractured clavicle, facial nerve paralysis, brachial nerve injury, eye injury, etc. Less than 5% of homebirth mothers received analgesia or anesthesia, compared to more than 75% of women in hospitals. Cesarean sections were three times more frequent in the hospital group than in the planned home group. Women in the hospital had nine times as many episiotomies and nine times as many severe tears. Both the maternal and neonatal death rates were the same for both groups.
Other studies have had similar results, and some even show the rate for maternal and neonatal deaths to be great in hospitals. English research statistician Marjorie Tew conducted a study during the 1970’s and 1980’s comparing home birth and births taking place in freestanding birth centers to hospital birth. The 16,328 births she evaluated were classified into risk categories of very low, low moderate, high and very high. In every category the neonatal mortality rate was lower out of the hospital. At the very low and low levels of risk, two to three times as many babies died in the hospital. As the moderate level, 8 times as many; and at the high level, 3 times as many babies died in the hospital. Tew concluded that care by obstetricians is not only incapable, save in exceptional cases, of reducing predicted risk, but actually provokes and adds to the dangers. The emotional security of a familiar setting, the home, makes a greater contribution to safety than does the equipment in hospital to facilitate obstetric interventions in cases of emergency (Tew 1990:267).
In one study done between 1986 and 1990 in Newcastle upon Tyne, a town in England, it was found that more babies died in hospital deliveries than home deliveries. In 1986 the perinatal mortality rate in Dutch hospitals was 13.9 per thousand, compared to 2.2 per thousand for home births. Robbie Davis-Floyd (1992) writes that studies done in Arizona, Canada, and Tennesee demonstrate the relative safety and viability of home birth. A study of 3,257 out-of-hospital births shows a perinatal mortality rate of 2.2 per 1,000, and a neonatal mortality rate of 1.1 per 1,000 (Sullivan and Weitz, Yale University Press, 1988).
A study of Washington State licensed midwives compared licensed midwife-attended birth outcomes to low-risk births attended by physicians in the hospital, certified nurse-midwife attended hospital births, and certified nurse-midwife attended homebirths. Overall, births attended by licensed midwives out-of-hospital had a significantly lower risk for low birthweight than those attended in hospital by certified nurse-midwives, but no significant differences were found between licensed midwives and any of the comparison groups on any other outcomes measured. The results of this study indicate that in Washington state the practice of licensed non-nurse midwives may be as safe as that of physicians in hospital and certified nurse-midwives in and out of hospital (Birth, 1994).
A study of 1,001 direct-entry midwife-attended home births in Toronto revealed that 3.5% cesarean section rate and a neonatal death rate of 2/1,000. One of the 2 babies who died was born at the hospital nine hours after care was transferred to a physician. This study noted – “The rates of transfer for emergencies for mother and baby were notably low. Maternal morbidity and neonatal morbidity were also low” (Birth, 1991).
A study of granny lay-midwives practicing in North Carolina’s areas of socioeconomic deprivation found that they were achieving an infant mortality rate of 1/3 that of hospital births, and 1/7 that of physicians doing births in private clinics (Journal of the American Medical Association, 1980, Vol. 244).
Data from the Utah Department of Health for planned home birth show neonatal mortality rates of 3.8 per 1,000 from 1989 to 1990, 0 per 1,000 in 1994 (Technical Report No. 201, Utah Department of Health Office of Public Health Data, 1998).
A six year study done by the Texas Department of Health for the years 1983-1989, revealed that the infant mortality rate for non-nurse midwives attending homebirths was 1.9 per 1,000, compared with the doctor’s rate of 5.7 per 1,000 (Janet Tipton, Editor; “Is Homebirth for You?”)
Planned homebirths with midwives have shown to have similar rates of intrapartum and neonatal mortality rates to those of low-risk hospital births, or better. Because medical intervention rates for planned homebirths were lower than for planned low-risk hospital births, every study published and executed in the U.S. showed that the midwifery model of care was as safe, or much safer than the medical model of in-hospital maternity care.
Despite these findings, many clinicians in the United States and their organizations continue to believe in the dangers of planned out-of-hospital birth. They reject the overwhelming evidence that out-of-hospital birth for low-risk women is safe.
To improve and lower the rate of maternal and neonatal deaths in the United States, we must encourage doctors to work together with midwives, and share the primary care of low-risk pregnant and birthing women. Good scientific research has shown that when unnecessary interventions increase, women’s satisfaction with their birth experience decreases. When doctors are given all of the responsibility for primary care of normal, low-risk healthy birthing women birth often becomes a surgical procedure with a high rate of unnecessary intervention. Alternatively, there is considerable evidence-based research demonstrating that there are major advantages to out of hospital births for low-risk women.
The final solution in reduction of maternal and infant mortality is to evolve a new social and political form structure for the medical profession and for the alternative care of pregnant and birthing women. Maternity care needs make a move towards change which empowers women to be proactive in their care, and open to consider alternative methods of childbirth separate from the Western model of care.
Within this paper we have addressed many ideas for reducing the maternal mortality and morbidity rate in the United States. There are many benefits to reducing maternal deaths and improving choice in health care. First and foremost addressing this issue affirms the value of women in our society, and leads to empowerment and more long-term health opportunities for women. In strengthening the capacity of our health care system monetary expenditures will be reduced, increasing the industry’s financial ability to provide improved human resources, supplies and equipment; as well as solidifying a healthy infrastructure in health care. Providing basic maternal and newborn health services outside of the hospital saves about $3 per capita per year in a low-income setting, and about $6 in a middle-income setting. The total cost of saving a mother’s or an infant’s life when complications arise is about $230 per woman served in a low-income setting, or if surgery and hospitalization are required.
Two public health agencies actively involved in reducing maternal morbidity and mortality rates worldwide are the WHO (World Health Organization) and UNICEF. These two public health organizations reccomend one comprehensive, and four basic essential obstetric care facilities for every 500,000 in population. When taking into consideration the importance of providing adequate supplies, equipment and infrastructure, as well as efficient and effective systems of communication, referral and transport, options beyond the traditional medical hospitals are a positive option for populations residing in remote and rural areas, as well as travelling homebirth midwives.. Birthing homes, private providers and maternity waiting centers improve access to these populations.
WHO and UNICEF have determined that there are four effective ways to reduce maternal and infant mortality. I have taken these explanations directly off their website without editing:
1. “Encourage delayed marriage and first birth for adolescents. Girls ages 15-19 are twice as likely to die from childbirth as women in their 20’s. Those below the age of 15 are five times as likely. Secondary school education should be ensured by setting a minimum legal age of marriage of at least 18. First births can be delayed by postponing the onset of sexual activity and by using effective methods of fertility regulation. Efforts should focus on changing individual and societal motivations for early childbearing. Education and employment opportunities play a critical role in providing alternatives to early motherhood.”
2. “Address unwanted and poorly timed pregnancies and the health risks associated with them. Access to voluntary, safe, affordable, and appropriate family planning information and services is critical to reducing unwanted pregnancies and to reducing the risks of maternal mortality. Include an appropriate array of high quality, consumer-oriented family planning information, counseling, and services in benefits/service packages offered by public and private providers, and extend these services to hard-to-reach groups (youths, poor rural and urban people) through outreach and social marketing programs. For women who resort to abortion to end an unwanted pregnancy, it is important that abortion services are safe when allowed by law and also that post-abortion services are provided, including guidance on contraceptive methods to avoid future unwanted pregnancies. Compared with women who give birth at 9- to 14-month intervals, women who have their babies at 27- to 32-month birth intervals are 2.5 times more likely to survive childbirth. Ensuring birth intervals of at least 24 months is best for maternal survival and health.”
3. “Improve coverage and quality of prenatal and postpartum care. The World Health Organization has developed clear practice guides on maternal and newborn care that can reduce the health risks of and provide quality services during pregnancy, delivery and the postpartum/postnatal period. Prenatal care which includes prevention and/or timely treatment for anemia, malaria, HIV, high blood pressure and other complications is very cost-effective.”
4. “Build strong political commitment and enabling policies to ensure equal rights for women, and promote cross-sectoral linkages. These include reducing poverty; improving women’s education and nutritional status; improving water and sanitation, roads and infrastructure, and transportation; empowering women; and addressing traditional harmful practices such as female genital mutilation. The design of interventions needs to take account of forces outside the formal health system that are associated with maternal mortality risks. Domestic violence also contributes to poor maternal health outcomes. Providers need to be trained to recognize the signs of violence, to use appropriate approaches for treatment and counseling, and to involve communities. Promoting community involvement and participation increases awareness of pregnancy complications and support for seeking care.”
Another public health organization that is striving to reduce maternal outcomes is the “Global Safe Motherhood Initiative.” The mission as stated on their website states that the project was launched at an international conference in Nairobi, Kenya in 1987. Its goal was: “To draw attention to the dimensions and consequences of poor maternal health in developing countries and to mobilize action to address the high rates of death and disability caused by complications and pregnancy and childbirth.” The goal set during the conference, and later on adopted by several United Nations conferences, was to reduce maternal mortality worldwide by half by the year 2000. The goals set forth by this organization require a global commitment, which is difficult to enforce due to the many different cultures and societal beliefs throughout the world. Most of this organizations accomplishments are made through grass-roots efforts by smaller populations in each country. Having this goal is honorable, but it may take much longer for them to reach it, as it is already 2009, and the maternal mortality rates in the industrialized countries have gotten worse, and not better.
According to the National Center for Health Statistics, Minnesota’s standing on maternal mortality in the United States is 5th in the nation (http://hrc.nwlc.org/Status-Indicators/Key-Conditions/Maternal-Mortality-Rate.aspx). Only four other states have a better rating on the safety of birth. Minnesota’s birth community is growing by leaps and bounds. Birth support in Minnesota comes in many forms. Minnesota’s positive ranking nationally is influenced by the availability of health care, access to health care, as well as its diversity in health care providers. Minnesota has worked as a cooperating community in changing the birth culture within the state, and encouraging the adoption of law and practice to include births attended by doctors and obstetricians as well as Certified Nurse Midwives in a hospital setting or birthing center, and Certified Professional Midwives (some licensed and some not) in a homebirth setting. Minnesota also has the highest rate of doula attended births in the nation (Minnesota Childbirth Collective). As a result of these options and their availability, birth outcomes in Minnesota over the last five years have greatly improved. But the process to adopt legislation is still in progress. Out of hospital births are difficult to reimburse through insurance. Currently there is legislation being considered for doulas to be reimbursed by Medicare, but the state legislators are taking their time in adopting this law. The American Medical Association is now doing its best to make alternative midwifery care illegal, as it is obvious that they are feeling threatened by the positive birth outcomes in alternative birthing care outside the hospital. However, the changes that Minnesota has installed to this date are a prime example of how birth outcomes improve with persistence in pursuit of change, and variability and availability of care.
Bibliography
1. Armstrong, Penny & Feltman. “Wise Birth.” (1990:34).
2. Bernstein & Bryant, Texas Lay Midwifery Program, Six Year Report, 1983-1989. Appendix VIIIf. Austin TX: Texas Department of Health.
3. Blackwell Dictionary of Anthropology: Thomas Barfield, ed. Oxford: “On Childbirth.” Blackwell Publishers, 1996.
4. Davis-Floyd, Robbie E., “Birth As An American Rite of Passage,” 1992.
5. Goer, Henci. “Obstetric Myths Versus Research Realities: A Guide to the Medical Literature.” 1995.
6. Goer, Henci. “The Thinking Woman’s Guide to a Better Birth.” 1999.
7. The Global Safe Motherhood Initiative website. Retrieved December 7, 2009. http://www2.doh.gov.ph/safemotherhood/alpha_safemotherhood_initiative.htm
8. Goldsmith, Judith. “Childbirth Wisdom From the World’s Oldest Societies.” 1990.
9. Grantley Dick-Read. “Childbirth Without Fear: The Original Approach to Natural Childbirth.” Fifth Edition, 1984.
10. Harper, Barbara, R.N. “Gentle Birth Choices.” Rochester, Vermont. Healing Arts Press, 1994:52.
11. Jordan, Brigitte. “Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States.” 4th Edition. Revised and expanded. Prospect Heights, IL; Waveland Press, Inc., 1993:48.
12. Kitzinger, Sheila. “The Complete Book of Pregnancy & Childbirth: Week by Week, Month by Month: The Most Comprehensive and Authoritative Guide for Expectant Parents.” 4th Edition.
13. Kitzinger, Sheila. “The Midwife Challenge.” 1989.
14. Klaus, Marshall H., M.D.; Kennell, John H., M.D; Klaus, Phyllis H., M. Ed., C.S.W. “Mothering the Mother: How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth.” 1993.
15. Macfarlane, A.; McCandlish R.; Campbell R. “Choosing Between Home and Hospital Delivery: There is no Evidence That Hospital is the Safest Place to Give Birth.” British Medical Journal 2000, Mar. 18:320(7237):798.
16. National Center for Health Statistics. "Compressed Mortality File 1999-2004," CDC WONDER On-line Database, compiled from Compressed Mortality File 1999-2004 Series 20 No. 2J, 2007, available at http://wonder.cdc.gov/cmf-icd10.html, analyzed by Quality Resource Systems, Inc. Data for live births from 1999 through 2002 also come from the CDC Wonder on-line site. National Center for Health Statistics, Division of Vital Statistics, "Natality public-use data 1995-2002," on CDC WONDER On-line Database, November 2005, available at http://wonder.cdc.gov/natality.html, analyzed by Quality Resource Systems, Inc. The 2003 live birth data come from Joyce A. Martin and others., "Births: Final data for 2003," National Vital Statistics Reports 54 (2005). The 2004 live birth data come from Joyce A. Martin and others, "Births: Final data for 2004," National Vital Statistics Reports 55 (2006). http://hrc.nwlc.org/Status-Indicators/Key-Conditions/Maternal-Mortality-Rate.aspx
17. Population Reference Bureau. http://www.scdhec.gov/CO/PHSIS/Biostatistics/an_pubs/vms_2007.pdf
18. “Pro-Homebirth Editorial. British Medical Journal, Homebirth; BMJ No. 7068, Volume 313, Editorial Saturday 23, November 1996.
19. Shanley, Laura Kaplan. “Unassisted Childbirth.” Published by Bergin & Garvey, Westport, Connecticut, London, 1994; Chapters 1 & 2.
20. Steward, David. “International Mortality Rates-US in 22nd Place.” NAPSAC News, Fall-Winter, 1993, pages 36, 38.
21. Steward, David, Ph.D. (Editor). “The Five Standards of Safe Childbearing.” Marble Hill, MO NAPSAC Reproductions, 1997.
22. Tipton, Janet (Editor). “Is Homebirth For You? Six Myths About Childbirth Exposed.” Sandy, TX: Friends of Homebirth, 1990.
23. Wagner, M. “A Critique of: Bastian H. Keirse M., Lancaster P.; Perinatal Death Associated With Planned Home Birth in Austrailia: Population-Based Study.” British Medical Journal, Vol. 317, 8. August 1998.24. On-line article recovered December 6, 2009: “Why Address Maternal Mortality?” Public Health at a Glance: May 2009. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,contentMDK:20944136~menuPK:2656916~pagePK:64229817~piPK:64229743~theSitePK:672263,00.html
According to David Steward, who is the Executive Director of the National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPSAC): “It is important to clarify that safety is measured by death (mortality), or illness (morbidity) during the labor and birth process, and shortly thereafter.” The United States has consistently high maternal and perinatal mortality and morbidity rates, compared to other industrialized countries. According to the World Health Organization a maternal death is defined as: “The death of a woman while pregnant, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes." In 1990 the U.S. was ranked 23rd by the Population Reference Bureau which publishes the mortality and morbidity statistics. In 2007 the U.S. was ranked 41st. This means that in 2007 there were 40 other countries where it is safer for women to give birth than in the United States (The report was issued by the World Health Organization, the United Nations Population Fund, the U.N. Children's Fund, the U.N. Population Division and The World Bank, Oct. 12, 2007; Retrieved 11-30-09).
In the United States, according to Barbara Harper, R.N., “Gentle Birth Choices”; the infant mortality rate was 8.9 deaths per 1,000 live births in 1991. This has now gotten much worse. According WHO, in the U.S. the infant mortality rate in 2007 was 11 deaths in every 100,000 births. In 1991 the infant mortality rate was 8.9 deaths per 1,000 live births. The worst state was Delaware at 11.8, with the District of Columbia even worse at 21.0. The best state was Vermont, with only 5.8. Vermont also has one of the highest rates of home birth in the country, as well as a larger portion of midwife-attended births than most states.
The international standing of the United States did not really begin to fall until the mid-1950’s. This correlates with the founding of the American College of Obstetricians and Gynecologists (ACOG) in 1951. ACOG is a trade union representing the financial and professional interests of obstetricians who have sought to secure a monopoly in pregnancy and childbirth services. Prior to ACOG, the U.S. always ranked 10th place or better internationally. Since the mid-1950’s the U.S. has consistently ranked below the 12th place and has not been above the 16th place since 1975. The relative standing of the U.S. continues to decline, even to the present.
The social, natural and significance of birth ensures that this biological and intensely personal process carries a heavy cultural overlay. In all cultures birth is a rite of passage (Van Gennep 1908) that embodies a culture’s deepest beliefs, which are transmitted and reaffirmed during the birth process. Birth practices point to the core values of the culture, telling the observer a great deal about the way that culture views the world and women’s place in it (Kitzinger 1978). Where women’s status is high, a rich set of nurturant traditions tends to develop around birth. Where it is low, the opposite occurs.
In the United States there is a patriarchal society in which women’s health care status is low, and is less supported by active legislation. The extreme emphasis on technology in the U.S. is mirrored in its birth practices (Martin 1987; Davis-Floyd 1992). The prestige of this Western high-tech approach has induced many developing countries to stamp out viable indigenous midwifery systems and import the Western model; even though their hospitals are often underfunded, understaffed, and replete with expensive machines that few know how to use or repair (Jordan 1993; Sargent 1989).
To counteract this unfortunate trend, the World Health Organization and UNICEF have begun to promote traditional midwifery in developing countries through programs for “upgrading” skills. However, because the medically-trained personnel in these programs value only the Western medical approach, they generally fail to take advantage of the knowledge and skills developed by community midwives within the context of their own cultural traditions.
In the United States, such attitudes resulted in the near complete elimination of midwifery by the 1960’s. Since then demands of many women for natural childbirth, coupled with scientific research into the dangers of interventionist techno-hospital birth (Goer 1995) and the benefits of planned, midwife-attended births at home (Davis-Floyd 1992, 1996), or in freestanding birth centers (Rooks, et al. 1989), have generated a midwifery renaissance.
In the four countries in which infant perinatal mortality statistics are lowest in the world: Japan, Holland, Sweden and Denmark – over 70% of births are attended by midwives (Wagner 1994; Fiedler 1996). In countries where women are allowed, or rather allow themselves to give birth more naturally and with fewer interventions, the outcome for both mothers and babies is remarkably good. Complications normally associated with pregnancy and childbirth in Western technological society are usually quite uncommon in tribal societies.
An anthropologist who observed the Arikara of North Dakota during the 1930’s noted that there were no tubal or abdominal pregnancies; no placenta previa (premature separation of the placenta blocking the cervix); no eclampsia (convulsions), and no premature birth. Phlebitis (inflammation of a vein) only occurred after tribal women became exposed to more “progressive” cultures.
Women in less technologically advanced countries give birth quickly, and easily as in Korea, during the 1960’s when it was described that in a rise field a working woman walked to the edge of the field, squatted down, caught her baby, strapped it on her back and was picking rice minutes later. Several people saw the birth from a distance, but no one helped or interfered in any way. She did it quietly, by herself (page 4, unassisted Childbirth by Laura Kaplan Shanley).
In the “Paleolithic Prescription,” S. Boyd Eaton writes about a typical birth in a !Kung San village in Africa’s Kalahari Desert: “A woman feels the initial stages of labor and makes no comment, leaves the village quietly when birth seems imminent – taking along, if necessary, a young child – walk a few hundred yards, finds an area in the shade, clears it, arranges a bed of soft leaves, and gives birth, while squatting or lying on her side – on her own. Showing no fear and not screaming out, they believe enhances the ease and safety of delivery (Eaton, Shostak, and Konner 1988:240 in Unassistted Childbirth).
Judith Goldsmith relays similar stories of birth in the “Childbirth Wisdom” from the World’s Oldest Societies (1990). Goldsmith compiled the accounts of scientists, anthropologists and historians who had observed tribal births over the past 400 years. She makes many references to the fact that tribal women often delivered their own babies.
Midwife Penny Armstrong writes about birth in an Amish community in her book “Wise Birth.” She writes: “I was struck by the casual, comfortable movements of the women laboring in their kitchen and giving birth among the quilts. I was undone by the infrequency of the need for me to display my midwifery skills. Birth appeared to be another animal out in the country. Labors were short and pain appeared to be less severe. Cuts and tears were fewer; hemorrhage controllable. Babies didn’t need suctioning devices or tubes pressed down their throats. They gurgled when they were born and began to breathe. Their mothers took them to their breasts and nursed without much complication. The births not only had power, but grace and simplicity” (Armstrong & Feldman 1990:34). Physiologically there is no difference between tribal women, the Amish and the more technologically exposed Western woman. If we are to understand the vast differences in birth outcomes, we must examine the method of delivery in the United States and compare them to the world.
According to Grantly Dick-Read in the book “Childbirth Without Fear,” the more civilized the people, the more painful labor appears to become. Childbirth should ideally reinforce a woman’s sense of power and autonomy. Instead it has become a painful, dangerous ordeal that often reinforces the belief that the woman is helpless, and dependant on others and not herself for her birth. Most women in western culture have been led to believe that they are incapable of delivering their own babies.
More research is being done that confirms the fact that intervening in the act of childbirth causes serious problems for both the mother and the baby. The presence of numerous doctors, nurses and hospital equipment make it very difficult for a laboring mother to relax and slip into the type of consciousness necessary for a baby to be born easily. The actual physical intervention of the doctor generally makes it impossible.
Some U.S. physicians claim that the increase in percentage of cesareans performed in this country (from 5% of all births in 1970 to 31% of all births in 2008), has lead to a lower infant mortality rate. When the new national rate is published for 2009, the hypothesis is that we will find about one mother in three is giving birth by cesarean section, a record level for the U.S. Studies have estimated that approximately 50% of all cesarean sections done in this country today are unnecessary.
Most European countries are now striving and successfully lowering their infant mortality rates, and they are much lower than ours. The percentage of European cesareans remains constant at 5% of all births, which explains the lower infant mortality rate.
Numerous studies have been conducted over the past 20 years that show that home birth is a safe alternative to hospital birth. The best-known study was conducted in 1977 by Lewis Mehl, M.D. (as reported by Davis-Floyd 1992:179). Mehl did a comparative study of 1,046 planned home births and 1,046 planned hospital births. After the births were analyzed for length of labor, complications, outcomes for the infants, and procedures utilized, he found that home birth was actually safer than hospital birth for both the mother and the baby. It was found that the hospital births have 5 times higher incidence of maternal high blood pressure, 3-1/2 times more meconium staining (indicative of fetal distress), 8 times more shoulder dystocia (due in part to the insistence on the supine position for delivery), and three times the rate of postpartum hemorrhage (primarily due to early clamping of the cord and attempts made to remove a placenta manually before it was ready to come out). Three times as many hospital babies required resuscitation (primarily due to medication), and four times as many became infected. Thirty times as many hospital babies suffered birth injuries (due to forceps and vacuum extraction). The injuries consisted of severe cephalhematoma (a collection of blood beneath the scalp), fractured skull, fractured clavicle, facial nerve paralysis, brachial nerve injury, eye injury, etc. Less than 5% of homebirth mothers received analgesia or anesthesia, compared to more than 75% of women in hospitals. Cesarean sections were three times more frequent in the hospital group than in the planned home group. Women in the hospital had nine times as many episiotomies and nine times as many severe tears. Both the maternal and neonatal death rates were the same for both groups.
Other studies have had similar results, and some even show the rate for maternal and neonatal deaths to be great in hospitals. English research statistician Marjorie Tew conducted a study during the 1970’s and 1980’s comparing home birth and births taking place in freestanding birth centers to hospital birth. The 16,328 births she evaluated were classified into risk categories of very low, low moderate, high and very high. In every category the neonatal mortality rate was lower out of the hospital. At the very low and low levels of risk, two to three times as many babies died in the hospital. As the moderate level, 8 times as many; and at the high level, 3 times as many babies died in the hospital. Tew concluded that care by obstetricians is not only incapable, save in exceptional cases, of reducing predicted risk, but actually provokes and adds to the dangers. The emotional security of a familiar setting, the home, makes a greater contribution to safety than does the equipment in hospital to facilitate obstetric interventions in cases of emergency (Tew 1990:267).
In one study done between 1986 and 1990 in Newcastle upon Tyne, a town in England, it was found that more babies died in hospital deliveries than home deliveries. In 1986 the perinatal mortality rate in Dutch hospitals was 13.9 per thousand, compared to 2.2 per thousand for home births. Robbie Davis-Floyd (1992) writes that studies done in Arizona, Canada, and Tennesee demonstrate the relative safety and viability of home birth. A study of 3,257 out-of-hospital births shows a perinatal mortality rate of 2.2 per 1,000, and a neonatal mortality rate of 1.1 per 1,000 (Sullivan and Weitz, Yale University Press, 1988).
A study of Washington State licensed midwives compared licensed midwife-attended birth outcomes to low-risk births attended by physicians in the hospital, certified nurse-midwife attended hospital births, and certified nurse-midwife attended homebirths. Overall, births attended by licensed midwives out-of-hospital had a significantly lower risk for low birthweight than those attended in hospital by certified nurse-midwives, but no significant differences were found between licensed midwives and any of the comparison groups on any other outcomes measured. The results of this study indicate that in Washington state the practice of licensed non-nurse midwives may be as safe as that of physicians in hospital and certified nurse-midwives in and out of hospital (Birth, 1994).
A study of 1,001 direct-entry midwife-attended home births in Toronto revealed that 3.5% cesarean section rate and a neonatal death rate of 2/1,000. One of the 2 babies who died was born at the hospital nine hours after care was transferred to a physician. This study noted – “The rates of transfer for emergencies for mother and baby were notably low. Maternal morbidity and neonatal morbidity were also low” (Birth, 1991).
A study of granny lay-midwives practicing in North Carolina’s areas of socioeconomic deprivation found that they were achieving an infant mortality rate of 1/3 that of hospital births, and 1/7 that of physicians doing births in private clinics (Journal of the American Medical Association, 1980, Vol. 244).
Data from the Utah Department of Health for planned home birth show neonatal mortality rates of 3.8 per 1,000 from 1989 to 1990, 0 per 1,000 in 1994 (Technical Report No. 201, Utah Department of Health Office of Public Health Data, 1998).
A six year study done by the Texas Department of Health for the years 1983-1989, revealed that the infant mortality rate for non-nurse midwives attending homebirths was 1.9 per 1,000, compared with the doctor’s rate of 5.7 per 1,000 (Janet Tipton, Editor; “Is Homebirth for You?”)
Planned homebirths with midwives have shown to have similar rates of intrapartum and neonatal mortality rates to those of low-risk hospital births, or better. Because medical intervention rates for planned homebirths were lower than for planned low-risk hospital births, every study published and executed in the U.S. showed that the midwifery model of care was as safe, or much safer than the medical model of in-hospital maternity care.
Despite these findings, many clinicians in the United States and their organizations continue to believe in the dangers of planned out-of-hospital birth. They reject the overwhelming evidence that out-of-hospital birth for low-risk women is safe.
To improve and lower the rate of maternal and neonatal deaths in the United States, we must encourage doctors to work together with midwives, and share the primary care of low-risk pregnant and birthing women. Good scientific research has shown that when unnecessary interventions increase, women’s satisfaction with their birth experience decreases. When doctors are given all of the responsibility for primary care of normal, low-risk healthy birthing women birth often becomes a surgical procedure with a high rate of unnecessary intervention. Alternatively, there is considerable evidence-based research demonstrating that there are major advantages to out of hospital births for low-risk women.
The final solution in reduction of maternal and infant mortality is to evolve a new social and political form structure for the medical profession and for the alternative care of pregnant and birthing women. Maternity care needs make a move towards change which empowers women to be proactive in their care, and open to consider alternative methods of childbirth separate from the Western model of care.
Within this paper we have addressed many ideas for reducing the maternal mortality and morbidity rate in the United States. There are many benefits to reducing maternal deaths and improving choice in health care. First and foremost addressing this issue affirms the value of women in our society, and leads to empowerment and more long-term health opportunities for women. In strengthening the capacity of our health care system monetary expenditures will be reduced, increasing the industry’s financial ability to provide improved human resources, supplies and equipment; as well as solidifying a healthy infrastructure in health care. Providing basic maternal and newborn health services outside of the hospital saves about $3 per capita per year in a low-income setting, and about $6 in a middle-income setting. The total cost of saving a mother’s or an infant’s life when complications arise is about $230 per woman served in a low-income setting, or if surgery and hospitalization are required.
Two public health agencies actively involved in reducing maternal morbidity and mortality rates worldwide are the WHO (World Health Organization) and UNICEF. These two public health organizations reccomend one comprehensive, and four basic essential obstetric care facilities for every 500,000 in population. When taking into consideration the importance of providing adequate supplies, equipment and infrastructure, as well as efficient and effective systems of communication, referral and transport, options beyond the traditional medical hospitals are a positive option for populations residing in remote and rural areas, as well as travelling homebirth midwives.. Birthing homes, private providers and maternity waiting centers improve access to these populations.
WHO and UNICEF have determined that there are four effective ways to reduce maternal and infant mortality. I have taken these explanations directly off their website without editing:
1. “Encourage delayed marriage and first birth for adolescents. Girls ages 15-19 are twice as likely to die from childbirth as women in their 20’s. Those below the age of 15 are five times as likely. Secondary school education should be ensured by setting a minimum legal age of marriage of at least 18. First births can be delayed by postponing the onset of sexual activity and by using effective methods of fertility regulation. Efforts should focus on changing individual and societal motivations for early childbearing. Education and employment opportunities play a critical role in providing alternatives to early motherhood.”
2. “Address unwanted and poorly timed pregnancies and the health risks associated with them. Access to voluntary, safe, affordable, and appropriate family planning information and services is critical to reducing unwanted pregnancies and to reducing the risks of maternal mortality. Include an appropriate array of high quality, consumer-oriented family planning information, counseling, and services in benefits/service packages offered by public and private providers, and extend these services to hard-to-reach groups (youths, poor rural and urban people) through outreach and social marketing programs. For women who resort to abortion to end an unwanted pregnancy, it is important that abortion services are safe when allowed by law and also that post-abortion services are provided, including guidance on contraceptive methods to avoid future unwanted pregnancies. Compared with women who give birth at 9- to 14-month intervals, women who have their babies at 27- to 32-month birth intervals are 2.5 times more likely to survive childbirth. Ensuring birth intervals of at least 24 months is best for maternal survival and health.”
3. “Improve coverage and quality of prenatal and postpartum care. The World Health Organization has developed clear practice guides on maternal and newborn care that can reduce the health risks of and provide quality services during pregnancy, delivery and the postpartum/postnatal period. Prenatal care which includes prevention and/or timely treatment for anemia, malaria, HIV, high blood pressure and other complications is very cost-effective.”
4. “Build strong political commitment and enabling policies to ensure equal rights for women, and promote cross-sectoral linkages. These include reducing poverty; improving women’s education and nutritional status; improving water and sanitation, roads and infrastructure, and transportation; empowering women; and addressing traditional harmful practices such as female genital mutilation. The design of interventions needs to take account of forces outside the formal health system that are associated with maternal mortality risks. Domestic violence also contributes to poor maternal health outcomes. Providers need to be trained to recognize the signs of violence, to use appropriate approaches for treatment and counseling, and to involve communities. Promoting community involvement and participation increases awareness of pregnancy complications and support for seeking care.”
Another public health organization that is striving to reduce maternal outcomes is the “Global Safe Motherhood Initiative.” The mission as stated on their website states that the project was launched at an international conference in Nairobi, Kenya in 1987. Its goal was: “To draw attention to the dimensions and consequences of poor maternal health in developing countries and to mobilize action to address the high rates of death and disability caused by complications and pregnancy and childbirth.” The goal set during the conference, and later on adopted by several United Nations conferences, was to reduce maternal mortality worldwide by half by the year 2000. The goals set forth by this organization require a global commitment, which is difficult to enforce due to the many different cultures and societal beliefs throughout the world. Most of this organizations accomplishments are made through grass-roots efforts by smaller populations in each country. Having this goal is honorable, but it may take much longer for them to reach it, as it is already 2009, and the maternal mortality rates in the industrialized countries have gotten worse, and not better.
According to the National Center for Health Statistics, Minnesota’s standing on maternal mortality in the United States is 5th in the nation (http://hrc.nwlc.org/Status-Indicators/Key-Conditions/Maternal-Mortality-Rate.aspx). Only four other states have a better rating on the safety of birth. Minnesota’s birth community is growing by leaps and bounds. Birth support in Minnesota comes in many forms. Minnesota’s positive ranking nationally is influenced by the availability of health care, access to health care, as well as its diversity in health care providers. Minnesota has worked as a cooperating community in changing the birth culture within the state, and encouraging the adoption of law and practice to include births attended by doctors and obstetricians as well as Certified Nurse Midwives in a hospital setting or birthing center, and Certified Professional Midwives (some licensed and some not) in a homebirth setting. Minnesota also has the highest rate of doula attended births in the nation (Minnesota Childbirth Collective). As a result of these options and their availability, birth outcomes in Minnesota over the last five years have greatly improved. But the process to adopt legislation is still in progress. Out of hospital births are difficult to reimburse through insurance. Currently there is legislation being considered for doulas to be reimbursed by Medicare, but the state legislators are taking their time in adopting this law. The American Medical Association is now doing its best to make alternative midwifery care illegal, as it is obvious that they are feeling threatened by the positive birth outcomes in alternative birthing care outside the hospital. However, the changes that Minnesota has installed to this date are a prime example of how birth outcomes improve with persistence in pursuit of change, and variability and availability of care.
Bibliography
1. Armstrong, Penny & Feltman. “Wise Birth.” (1990:34).
2. Bernstein & Bryant, Texas Lay Midwifery Program, Six Year Report, 1983-1989. Appendix VIIIf. Austin TX: Texas Department of Health.
3. Blackwell Dictionary of Anthropology: Thomas Barfield, ed. Oxford: “On Childbirth.” Blackwell Publishers, 1996.
4. Davis-Floyd, Robbie E., “Birth As An American Rite of Passage,” 1992.
5. Goer, Henci. “Obstetric Myths Versus Research Realities: A Guide to the Medical Literature.” 1995.
6. Goer, Henci. “The Thinking Woman’s Guide to a Better Birth.” 1999.
7. The Global Safe Motherhood Initiative website. Retrieved December 7, 2009. http://www2.doh.gov.ph/safemotherhood/alpha_safemotherhood_initiative.htm
8. Goldsmith, Judith. “Childbirth Wisdom From the World’s Oldest Societies.” 1990.
9. Grantley Dick-Read. “Childbirth Without Fear: The Original Approach to Natural Childbirth.” Fifth Edition, 1984.
10. Harper, Barbara, R.N. “Gentle Birth Choices.” Rochester, Vermont. Healing Arts Press, 1994:52.
11. Jordan, Brigitte. “Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States.” 4th Edition. Revised and expanded. Prospect Heights, IL; Waveland Press, Inc., 1993:48.
12. Kitzinger, Sheila. “The Complete Book of Pregnancy & Childbirth: Week by Week, Month by Month: The Most Comprehensive and Authoritative Guide for Expectant Parents.” 4th Edition.
13. Kitzinger, Sheila. “The Midwife Challenge.” 1989.
14. Klaus, Marshall H., M.D.; Kennell, John H., M.D; Klaus, Phyllis H., M. Ed., C.S.W. “Mothering the Mother: How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth.” 1993.
15. Macfarlane, A.; McCandlish R.; Campbell R. “Choosing Between Home and Hospital Delivery: There is no Evidence That Hospital is the Safest Place to Give Birth.” British Medical Journal 2000, Mar. 18:320(7237):798.
16. National Center for Health Statistics. "Compressed Mortality File 1999-2004," CDC WONDER On-line Database, compiled from Compressed Mortality File 1999-2004 Series 20 No. 2J, 2007, available at http://wonder.cdc.gov/cmf-icd10.html, analyzed by Quality Resource Systems, Inc. Data for live births from 1999 through 2002 also come from the CDC Wonder on-line site. National Center for Health Statistics, Division of Vital Statistics, "Natality public-use data 1995-2002," on CDC WONDER On-line Database, November 2005, available at http://wonder.cdc.gov/natality.html, analyzed by Quality Resource Systems, Inc. The 2003 live birth data come from Joyce A. Martin and others., "Births: Final data for 2003," National Vital Statistics Reports 54 (2005). The 2004 live birth data come from Joyce A. Martin and others, "Births: Final data for 2004," National Vital Statistics Reports 55 (2006). http://hrc.nwlc.org/Status-Indicators/Key-Conditions/Maternal-Mortality-Rate.aspx
17. Population Reference Bureau. http://www.scdhec.gov/CO/PHSIS/Biostatistics/an_pubs/vms_2007.pdf
18. “Pro-Homebirth Editorial. British Medical Journal, Homebirth; BMJ No. 7068, Volume 313, Editorial Saturday 23, November 1996.
19. Shanley, Laura Kaplan. “Unassisted Childbirth.” Published by Bergin & Garvey, Westport, Connecticut, London, 1994; Chapters 1 & 2.
20. Steward, David. “International Mortality Rates-US in 22nd Place.” NAPSAC News, Fall-Winter, 1993, pages 36, 38.
21. Steward, David, Ph.D. (Editor). “The Five Standards of Safe Childbearing.” Marble Hill, MO NAPSAC Reproductions, 1997.
22. Tipton, Janet (Editor). “Is Homebirth For You? Six Myths About Childbirth Exposed.” Sandy, TX: Friends of Homebirth, 1990.
23. Wagner, M. “A Critique of: Bastian H. Keirse M., Lancaster P.; Perinatal Death Associated With Planned Home Birth in Austrailia: Population-Based Study.” British Medical Journal, Vol. 317, 8. August 1998.24. On-line article recovered December 6, 2009: “Why Address Maternal Mortality?” Public Health at a Glance: May 2009. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,contentMDK:20944136~menuPK:2656916~pagePK:64229817~piPK:64229743~theSitePK:672263,00.html
Friday, December 25, 2009
Preeclampsia Research Paper
Please visit my website to read about maternal and neonatal mortality, and how cesarean rates can be improved through the growth and increasing use of midwifery in the United States. If you are interested in reading it the web address is http://www.treasuredbirth.com/. It is a fairly long read, so grab a cup of coffee, or tea and get comfortable for some in-depth and interesting reading!
Tuesday, March 24, 2009
Midwifey Skills Lab to be Held in Prior Lake, Minnesota!
I am excited to announce a Midwifery Skills Lab to be held on May 21, 22, and 23rd in Prior Lake Minnesota! This lab is for beginning midwifery students to learn basic skills prior to committing to apprenticeship, or even for those apprenticing already to brush up on some of their basics! It will be given by Virginia Midwife Kristi Zittle, and hosted by yours truly. Contact me for more information!
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