Not Every Vaginal Birth is Natural

Rwina Balto

PhD Student, College of Nursing

March 23rd, 2021

The Shift in Natural Childbirth

In the past few years, consumers have shifted their terminology around birth and have begun to label their births differently. These days, when consumers ask for a natural childbirth experience, it turns that what they most often mean is that they want a vaginal birth.  As a midwife, when mothers tell me they want a natural birth, I view it as them wanting to labor without pain medications and to receive physical and emotional support from me. In midwifery, this is called 'Being 'with woman', where births are just like they were in the past, natural and without medical interventions.

Natural birth is still vaginal delivery but without medical interventions, while vaginal birth is not necessary a natural delivery because of the interference of technology. With global modernization and the vast growth in the economy, healthcare, and the population, technologies are becoming more available and accessible. Technology reached beyond operating rooms and made its way through labor and delivery units. While there are benefits to having a natural childbirth, there are also benefits to using advanced equipment, like having the ability to save a mother and her baby's life when complications occur. Yet, it is not necessary to use technology when labor is progresses on its own physiologically with hormonal cascades, and it could in fact be harmful. Labor interventions are widely used among obstetricians, and it is not their fault. It is just the way they were trained in medical schools. By obstetricians increasing the use of epidurals and narcotics during birth, inducing and augmenting labor with Pitocin, and using suction and forceps, they contributed to the major shift in birth terminology. All these methods could lead to a vaginal but not natural birth. Therefore, women’s understanding of natural childbirth has changed.

What is Natural Childbirth?

A natural childbirth occurs when a pregnant person gives birth without medical aid. In a natural childbirth, labor and delivery occurs without medications or monitors; however, the patient is assured of equipment availability in case anything goes wrong or becomes complicated. Natural childbirth involves having a baby physiologically by the power of the human’s innate capacity of the woman and baby. This is no different from how women used to give birth thousands of years ago. Women’s bodies respond to a hormonal cascade that starts the process of labor on its own. Naturally released Pitocin is responsible for the womb's contractions, moving the baby toward the birth canal. Moms then feel the urge to push until the baby is out. This birth is more likely to be safer and healthier, because there is no medical intervention that interrupts the physiological process for labor and delivery.

 

History

In the 1900s, women used to give birth at homes as hospitals were not widely available. Labor was attended by the traditional “Granny midwives;” their main duty was to support women during childbirth. Later, midwives have been replaced by doctors, especially among rich families. Following that, in 1910, Twilight anesthesia was found to ease pain and sleep during labor- morphine and scopolamine- medications that affect mothers' memory during birth and increase the risk of mothers and baby’s death.

Surprisingly, most doctors at that period of time did not have formal education. They forced deliveries by: using artificial Pitocin, cutting an episiotomy, and using a vacuum and forceps to deliver the baby. They then extracted the placenta, gave another dose of Pitocin to contract the uterus, stitched the cut they made, and they were done! All these interventions led to the emergence of infant deaths due to the associated injuries.

In opposition to the medicalization of childbirth, Dr. Grantly Dick-Read issued a book in 1942 explaining the benefits of natural childbirth and calling for the return to normal and the avoidance of harmful interventions. Following that in 1950, The National Organization for Public Health Nursing stressed pregnancy and birth as a natural process.

What It Was Like Giving Birth In Every Decade Since the 1900s

https://www.redbookmag.com/body/pregnancy-fertility/g3551/what-it-was-like-giving-birth-in-every-decade/

The Shift to Midwifery-led Care

With the recent increase in the rates of cesarean sections, inductions, and other interventions, it is time now to call for action and shift the paradigm to return childbirth to midwives as promoters of natural birth and better health outcomes. Only high-risk deliveries should be given to obstetricians so midwives can be in charge of all low-risk cases. In fact, countries like Finland, Sweden, and Norway have the highest survival rates for mothers and infants worldwide. Nordic countries' systems highly support the investment in midwifery education and foster industrialization and welfare development. Midwifery is one of the oldest professions, but it is still not fully recognized either by cultures or healthcare systems.

What is Modern Midwifery

A certified midwife provides comprehensive primary care services for women beginning in adolescence through menopause. They are competent to provide gynecologic and obstetric care, preconception, family planning services, care for women during pregnancy, childbirth, and the care postpartum. Their scope of practice also includes caring for newborns up to 28 days of life and treating male partners with sexually transmitted infections (American College of Nurse Midwives, 2021).

Public Awareness about Midwifery

          CesareanRates(2021)

The use of unnecessary medical interventions is resulting in poor health outcomes. Induction of labor and cesarean section rates are increasing and thus cause harmful effects to mothers and their babies (DeJoy, 2010). There is a need to further expand the midwifery workforce within healthcare systems and enhance public awareness about natural childbirth and midwifery practice as an available option for women (Newick et al., 2013). Research has shown that women tend to avoid midwifery services because they don’t understand the role of a midwife (Peprah et al., 2018). Therefore, promoting community education about midwifery care is fundamental in preventing harm and providing the best available care.

The view of natural childbirth has changed over the years and after the invention of medical technology. People used to perceive natural birth as a physiological process that only needs support from a birthing assistant or a traditional midwife without an obstetrician's attendance. Nowadays, obstetricians have taken control of the natural birthing process, and birth is still vaginal, yet not natural. The midwifery profession's return helps give back control to women and promotes the original concept of natural childbirth.

 

References

American College of Nurse-Midwives (2012). Definition of Midwifery and Scope of Practice. https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000266/Definition%20of%20Midwifery%20and%20Scope%20of%20Practice%20of%20CNMs%20and%20CMs%20Feb%202012.pdf

American College of Nurse-Midwives (2019). The Credential CNM and CM. https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000008158/Revised_CNM-CM-CPM_Comparison_Chart-December2019.pdf

BirthTOOLS.ORG (2021). What is Physiologic Birth?.
https://birthtools.org/What-Is-Physiologic-Birth

DeJoy, S. B. (2010). “Midwives Are Nice, But...”: Perceptions of Midwifery and Childbirth in an Undergraduate Class. Journal of Midwifery & Women's Health, 55(2), 117-123.

Krause, B & Sankey (2019). History and Culture of Birth in the U.S.
https://acnm-acog-ipe.org/wp-content/uploads/2019/07/History-and-Culture-of-Birth_-final-combine_Rev.pdf

Newick, L., Vares, T., Dixon, L., Johnston, J., & Guilliland, K. (2013). A midwife who knows me: Women tertiary students' perceptions of midwifery. New Zealand College of Midwives Journal, (47).

Pajalic, Z., Pajalic, O., & Saplacan, D. (2019). Women's education and profession midwifery in Nordic countries.

Peprah, P., Abalo, E. M., Nyonyo, J., Okwei, R., Agyemang-Duah, W., & Amankwaa, G. (2018). Pregnant women’s perception and attitudes toward modern and traditional midwives and the perceptional impact on health seeking behaviour and status in rural Ghana. International journal of Africa nursing sciences, 8, 66-74.

Redbook (2016). What it was like giving birth in every decade since the 1900s. https://www.redbookmag.com/body/pregnancy-fertility/g3551/what-it-was-like-giving-birth-in-every-decade/?slide=6

 

 

 

 

 

Health Literacy – Can We Really Measure It?

Kirsten E. Schmutz MSN/Ed, RN, CCRN-CSC

PhD Student, College of Nursing

June 3rd, 2021

    Over the past two decades, researchers and clinicians have been paying a lot more attention to health literacy[1]. But what is health literacy? To sum it up in a short, sweet sentence: health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”[2]  Seems simple enough, but there is so much that goes into health literacy: the patient’s ability to understand, interpret and apply information, the healthcare provider presenting information in a manner that is easy to understand, and cultural and societal influences, to name a few. The concept of health literacy is extremely complex and there are multiple models to describe it. Baker’s (2006) model is presented in Figure 1 as an example.

Why Health Literacy Matters

    If health literacy is so complex, why are so many big organizations like the Institute of Medicine and HealthyPeople2020 paying so much attention to it? Well, research studies show that the lower a patient’s health literacy, the worse their health outcomes. Some of these poor outcomes take the form of increased rates of hospital (re)admissions, alcohol and drug use, and depression; and lower rates of breastfeeding and engaging in preventative healthcare measures – like getting vaccinated or cancer screenings completed.[3]  All of these poor outcomes result in more money spent on healthcare. So, if healthcare providers can better identify patients with low health literacy, they can better intervene to prevent some of these negative health outcomes.

How to Identify a Person’s Health Literacy Level

            However, screening tools are rarely used in the clinical setting – they are mostly used for research purposes. And, while screening tools are quite skilled at identifying patients with low health literacy abilities, they don’t actually measure health literacy. Health literacy screening tools measure a patient’s ability to read, interpret, and apply words and numbers, but, as described earlier, that is only a small part of health literacy.1 A person can score 100% on a health literacy screening tool and still have poor health literacy. For example, I administered the Newest Vital Sign (a health literacy screening tool) to my husband, a quality chemical engineer with an MBA who likes statistics. He scored 100%. However, when I asked him what he took for his headache he said aspirin. We didn’t have any aspirin. What we did have was acetaminophen and he thought the two were the same.

             Now that we know why health literacy is so important, how do we go about identifying patients with low health literacy? One option is to perform a health literacy screening. A health literacy screening usually takes the form of a question/answer survey with the patient’s score indicating their level of health literacy. But, what screening tool should you use? Boston University and the National Library of Medicine put together a website called the Health Literacy Tool Shed to help healthcare providers and researchers narrow down the over 200 different health literacy screening tools to find the one that best meets their purposes.

Test Yourself!

Want to see what the Newest Vital Sign rates your health literacy as? Click here to take the test! Correct answers are provided at the bottom of this post.

What Does that Mean for Clinical Practice?

If health literacy screening tools don’t actually measure a patient’s health literacy abilities, is there any point to using them in clinical practice? Yes and no. Health literacy screening tools give providers an opportunity to empirically assess a patient’s ability to read and interpret words and numbers. If a person cannot read and interpret words and numbers, it will be extremely difficult for them to engage in activities like reading a prescription label or following pre-procedural directions without additional assistance. In this aspect the screening tool has helped significantly.

The hazard comes when a patient is able to read and interpret words and numbers well, and so scores well on the tool, but does not have a high level of health literacy – as illustrated by my husband. How do we screen those patients? The solution: health literacy universal precautions (HLUP). HLUP is not a screening tool, but is an assumption that all patients, regardless of sociodemographic information, will require some level of assistance navigating their health and the healthcare system.1 HLUP aides in catching those with low or moderate health literacy from falling through the cracks as the providers use the same techniques to assist those with low health literacy as those with moderate or high health literacy.

What Does that Mean for Research?

There is still a great deal that needs to be investigated regarding health literacy. Firstly, a screening tool that truly assesses health literacy, and not just elements of it, needs to be developed. Only then can researchers reliably and accurately assess health literacy in their participants to determine health literacy’s effect on health outcomes. The screening tools currently available do a fairly good job of this already, but they are incomplete, and so their use in research will also add an element of limitation.

Another aspect of health literacy that needs attention in research is the testing of HLUP. HLUP is highly advocated for by many health literacy scholars,1 but there is little evidence in the literature testing its efficacy. Until such evidence exists, the paradigm shift to HLUPs acceptance and implementation by researchers and providers will be delayed.

Parting Thoughts

Health literacy is a complex concept. While research still has far to go in evaluating health literacy, it has come a long way. The development of health literacy screening tools is helping to identify previously unrecognized low levels of health literacy. This recognition helps providers adjust their teaching and interventions to help improve patient outcomes. However, researchers and healthcare providers should use caution when using health literacy screening tools as they actually measure a patient’s ability to read and interpret words and numbers, not their ability to navigate their health and the healthcare system. If researchers develop a way to empirically measure health literacy, providers will more effectively and accurately identify a patient’s health literacy needs so as to provide better health education and interventions. Alternatively to a screening tool, if empirical research emerges to support HLUP, this will shift the health literacy paradigm in a new direction. There is much yet to be seen in the future of health literacy. 

 

Correct Answers to the Newest Vital Sign: 1) 1,000. 2) Up to 1 cup or half the container. 3) 33. 4) 10%    5) No. 6) It has peanut oil.

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  1. Baker, D. W. (2006). The meaning and the measure of health literacy. Journal of General Internal Medicine, 21(8),  878-883. https://doi.org/10.1111/j.1525-1497.2006.00540.x

  2. Institute of Medicine Committee on Health, L. (2004). In L. Nielsen-Bohlman, A. M. Panzer, & D. A. Kindig (Eds.), Health Literacy: A Prescription to End Confusion. National Academies Press https://doi.org/10.17226/10883 

  3. Dewalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. N., & Pignone, M. P. (2004). Literacy and health outcomes: A  systematic review of the literature. J Gen Intern Med, 19(12), 1228-1239. https://doi.org/10.1111/j.1525- 1497.2004.40153.x 

  4. National Library of Medicine. (2021, April 19). Health Literacy Tool Shed. Retrieved April 19, 2021 from  https://healthliteracy.bu.edu/all 

 5. SeekPNG. (n.d.). Magnifying glass scientist cartoon clip art – cartoon scientist magnifying glass [Clip Art]. 

Retrieved April 20, 2021 from https://www.seekpng.com/ipng/u2y3a9r5w7o0y3i1_magnifying-glass-scientist-cartoon-clip-art-cartoon-scientist/ 

Organ Procurement Organizations and Telehealth: The New Shift to Increase Organ Donation Authorizations

Natasha Ansari

PhD Student, College of Nursing

June 3rd, 2021

The Past and Present

    Organ Procurement Organizations (OPOs) currently reach potential donor families by in-person contact, and when this method is unattainable, then telephone conversations are the next method of choice. A real-life example looks like this: a patient is in the intensive care unit of a hospital and the nurse is charting in the patient’s electronic medical record (EMR). The neurological section shows a table of 5 clinical triggers:

1. Patient has a Glasgow Coma Score less than 5 without sedation or paralytics

2. Clinician discussion of brain death testing

3. Loss of any 3 cranial nerves on patient’s neurological examination

4. Clinician discussion of brain death testing

5. Patient’s family is mentioning organ donation

If the nurse selects “Yes” to any of these 5 options, the EMR is set up to either send an automatic page to the call center or prompt the nurse with the phone number to the call center. A conversation then takes place between the bedside nurse and the call center staff member – where patient information is exchanged. The call center then pages the on-call organ procurement coordinator to call the bedside nurse.

    The coordinator asks the nurse more in-depth questions regarding neurological examination, medications, and family perceptions. The coordinator obtains the family contact information and, depending on urgency of the case, will either make a phone call or try to be at the bedside to talk to the family in-person regarding organ donation. This approach, either in-person or via telephone, is called the initial approach. Bedside nurses are not allowed to discuss organ donation due to the sensitive nature of the topic – organ procurement coordinators are licensed social workers with additional training in regards to approaching families for the purposes of organ donation authorization.

Issues with the Current Method

The main issues of the current operating procedure that have been discussed amongst DonorConnect, Utah’s local OPO, are:

• Travel time of the coordinator to the hospital is 20 minutes to 3 hours long

• Family members impatient to wait for the coordinator

• Delayed withdraw of life-support for the patient

• With COVID-19, family was not at the hospital and/or coordinators are not allowed in the hospital

• Phone calls are impersonal and unstructured

With the rise of telehealth encounters amongst the COVID-19 pandemic, DonorConnect is interested in addressing these issues and changing the “norm” for the OPO coordinator’s initial family approach. You can find DonorConnect’s website by clicking on this image.

The Future - Knowns and Unknowns

Telehealth is now being introduced to DonorConnect as a more efficient and personal method of communication instead of telephone calls. An in-person initial approach will be the preferred contact method, however, when this is not possible or time is limited, then telehealth is a better approach compared to phone calls to the family. 

Barriers to this new shift include establishing software and hardware at each of the hospital locations, getting hospital administration and other stakeholders on board, teaching bedside nurses, teaching coordinators and empowering them to adopt this new approach, as well as empowering and teaching family members how to download the HIPAA-compliant software on their own devices. 

Currently, a pilot study is being conducted with DonorConnect to adopt telehealth as the second-line of approach for the coordinators receiving referrals in their affiliated hospitals – especially focusing on the rural hospitals which require more travel time. 

Consequences that one can foresee with this paradigm shift are technology issues, family members unable to connect due to not owning a device capable of downloading applications, and bedside clinician scheduling conflicts.

As for the potential impact of this shift: OPOs and society have the opportunity to achieve more organ donation authorizations. The impact on the coordinators is achieving a more personal connection then a phone call can provide. The same goes for the family members - feeling heard, empowered, and valued over a telehealth connection instead of phone call – also the ability to include many other family members on the call.

Unanswered questions for this shift include the real impacts – satisfaction scores of clinicians, coordinators, and family members utilizing this approach versus telephone and how they compare. That is the objective of the pilot study that is being conducted at this point in time. 

Telehealth is here to stay and its potential has only just begun. This telehealth and OPO relationship is the perfect example of how one can visualize technology assisting humans and the possibility of making a huge impact on organ donation and saving thousands of lives.

This photo is used with the permission of Dr. Safdar Ansari – shown here in the top left corner (4/13/2021)

If you would like more information regarding OPOs and hospital collaboration – click on this image

 

Balancing Mom’s Mental Wellness During COVID-19 

Marcia Williams

PhD Student, College of Nursing

University of Utah 

Moms and Pregnant Women

1 in 5 pregnant women and new mothers experience perinatal depression and anxiety (PDA).  Is it hormones, lack of sleep, lack of support, genetics, or a traumatic delivery that makes this condition problematic?  Yes, very likely all of these factors interact although scientists are still trying to understand why prevalence remains unchanged despite available resources.  Most of the time these symptoms resolve on their own; however, mothers giving birth during the COVID19 pandemic are at greater risk for complications from this commonly experienced condition.  Any mom can see if have PDA by taking this short quiz here (it takes less than 5 minutes).  If you or a friend take this test, print a copy to take to your provider’s office.  Simply taking the test has been effective in eradicating PDA, even without any additional interventions.

COVID19 and Mom’s Mental Health

The country is adjusting to a new normal that includes social distancing, change in plans, heightened anxiety, and increased childcare at home since March 2020.  Pregnant mothers and new moms absorb all of those problems and have other stressors as well.  Mom’s wonder if they can pass COVID19 on to their unborn babies during birth or breastfeeding.  Some scheduled office visits with providers may be completed by telehealth. The long-awaited anatomy ultrasound may now be completed with only the mother and not a partner.  During birth, the number of support persons is limited, and visitors may not be allowed to see the newest member of the family.  COVID19 changes exacerbates a commonly experienced problem with potentially devastating results and limited resources.

Sunshine Wellness Tool

Pregnant and new moms benefit from a tool created in collaboration with the Postpartum Support International Utah and the Utah Department of Health.  These tips contain advise for sleep, diet, support, activity, and personal development that combat PDA and can be used during COVID19.  A proactive approach to caring for mental health during pregnancy and postpartum can curb anxiety experienced by COVID19 and new parenting. 

Supportive actions

Family and friends need to know the difference between “Baby Blues” (normal hormonal fluctuations that leave after two weeks) and PDA.  Additionally, having helpline or telehealth resources that mothers can use right change outcomes for a family.  Mild to moderate PDA responds well to cognitive behavioral therapy and mindfulness training (and many of these are now offered in online groups).  Severe PDA may require medication prescribed by mom’s provider.  Providers of groups and prescribers across the country are listed on the Postpartum Support International website.

COVID19 Impact on Maternal Mental Health

Normally a time for showers, baby shopping, provider visits, and finding childcare, a new era is now in place that changes the trajectory for pregnant and new mothers.  Environmental and personal stressors may increase a mom’s susceptibility to PDA during COVID19. 

Maternal mental health can be challenged in another manner during COVID19.  Underreported, the true impact of Intimate Partner Violence (IPV) cannot be quantified but is suspected to effect 1 in 6 pregnant women and is more prevalent during pregnancy.  Stressors of job losses, children at home, and unrest is suspected to increase violence among pregnant and new mothers.  Without regularly scheduled in-person visits, women are less likely to be screened for IPV.  The outcome of IPV to mothers and infants include perinatal death, small for gestational age, and preterm labor (Alhusen et al, 2015)

We do not know when COVID19 restrictions and way of life will be erased from our daily routines, but we do know that mothers and their babies are currently at significant risk maladaptive mental wellness.  Screening for PDA, connecting with providers and family (digitally or in person), working on steps contained in the Sunshine wellness plan, and checking out supportive resources can change the course of a family.  It is hoped that adhering to these recommendations, mothers and infants can be appropriately screened and cared for during this is unprecedented time. 

References:
Alhusen, J. L., Ray, E., Sharps, P., & Bullock, L. (2015). Intimate partner violence during pregnancy: maternal and neonatal outcomes. Journal of women's health (2002), 24(1), 100–106. https://doi.org/10.1089/jwh.2014.4872

Brownridge, D. A., Taillieu, T. L., Tyler, K. A., Tiwari, A., Ko Ling Chan, & Santos, S. C. (2011). Pregnancy and intimate partner violence: risk factors, severity, and health effects. Violence against women, 17(7), 858–881. https://doi.org/10.1177/1077801211412547

Edinburgh Postnatal Depression Scale (2014).  Retrieved July 17, 2020.  http://perinatology.com/calculators/Edinburgh%20Depression%20Scale.htm

Hollier, L. (2020).  Coronavirus (COVID-19), Pregnancy, and breastfeeding, a message for patients. 

Intimate Partner Violence Screening. Content last reviewed May 2015. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/partner-violence.html

Perinatal depression.  U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health. (2020). NIMH Strategic Plan for Research Retrieved from https://www.nimh.nih.gov/health/publications/perinatal-depression/index.shtml

Thapa et al. (2020). Maternal mental health in the time of COVID-19 pandemic.  AOGS.
Useful links.  Postpartum Support International, Retrieved July 17, 2020.  https://www.postpartum.net/learn-more/useful-links/