 again because this changes as we go from session to session just a little bit of demographic information so first of all we're interested to know where which country you're in so i'll back to open that and we've watched this change as we follow the sun go around the planet so please let us know where you are let's give it a few seconds more for people to get in it's a nice lot of answers good thank you oh they're still coming in okay thank you i'll leave it there the next one we're interested in what you do so what is your main occupation or role and if you're going to give others it can be quite entertaining to see what other means for you so i'll give you an example oh i'm the only other that's all right that was simple oh no how are we nearly done still some people going in oh here's another other just to keep me company the majority of students yep okay thank you for that and last of all we're interested in where you're connecting from by which we mean what sort of organization location as opposed to your country so just bear with me while i clear some answers from last time we have got a bit of a spread this time yes we've had several sessions where it's a hundred percent home isn't it yes the Yale School of Nursing is gaining exclamation marks i think i think only had three well i wonder why that might be we might find out in a minute why that might be you might not be there's a surprise okay uh looks like we're about that okay oh no it's still a couple more right i'll leave it there thank you very much for your patience everybody um back to you linda okay thank you very much then it gives me very great pleasure to welcome professor holly kennedy who is professor of midwifery at Yale in Connecticut in the ufa she's an internationally known midwife researcher and past president of the american college of nurse midwives she is particularly interested in linking practice to outcomes barriers to evidence-based practice and shared decision making and she's speaking today about promoting healthy physiologic birth in the united states so over to you holly and thank you very much all right thank you linda so welcome to everybody i i see some of my students on some old friends she lived down there and kicked down and uh so i'm glad you're joining us uh today so um i um often do a a talk for my students that's about physiologic birth but i'm a little bit for this talk to to talk about what we're trying to do in the united states and not only in promoting healthy physiologic birth but also uh what we're doing as uh professional midwifery organizations uh and a little bit about the journey that we've taken in that so um first of all i just want to look at the objectives we're going to look at the work that the american college of nurse midwives manna which is the midwives alliance of north america and nacpm which is the north american uh north the uh associate the national association of certified professional midwives um we developed a consensus statement on normal physiologic birth a few years ago and i'm going to go through that and the process that we did and the recommendations and then take you down the journey from where we've gone since then um so when we took this on i became uh president-elect of the american college of nurse midwives in 2009 and it became president in 2010 and um i took on as one of my initiatives is to to really um take our organization further in promoting uh physiologic birth healthy birth um as something that we were experts at and um that i wanted us to be known for and we looked at um other normal birth statements around the world and really felt one we had did not have a document but we also felt that some of the documents that we had seen were lacking the at the same time uh in the context of us midwifery um we had a bit of um uh i guess disconnect is one word but we had several factions of midwives that were not particularly getting along well together and um i felt that it was divisive and really felt that we needed to um begin to work together on a very different level so i invited the midwives alliance of north america and the national association of certified professional midwives uh to join us give you a little bit of feedback or a little bit of background for those of you that aren't um don't know about us midwifery we basically have several routes to midwifery uh we have um through nursing and i would say probably the majority of the midwives in our country are what we would call nurse midwives and they're educated both in the discipline of nursing and midwifery and then we have certified midwives who also come through ac and m routes uh and they are more direct entry midwives and don't come through nursing but they take the same certification exam that certified nurse midwives do and then we have uh certified professional midwives who um are um focused primarily on home birth and uh take a national certification um uh for for their um profession so um so what i did was we invited um members from the three organizations together as what we believed were the experts in normal birth and we developed a task force so we had 21 individuals from the u.s midwifery organizations and then people that came from other childbirth advocacy and consumer groups um to reach a consensus uh statement on a definition for normal birth and the practices that best support its achievements our goal was to um uh to really have a statement that was uh grounded not only from the work of of all of us together but also from the evidence so um uh we also wanted to identify measurable benchmarks to describe the optimal processes and outcomes reflective of normal physiologic birth um we wanted to look at what factors facilitate or disrupt normal physiologic birth based on that evidence and then to create a template for system changes through clinical practice education research and health policy and ultimately improve the health of mothers and infants while avoiding unnecessarily unnecessary and costly interventions so that was our goal took us two years uh and this is what we found we had four key themes that provided the framework for the document so we had uh the definitions of normal physiologic birth i'm going to go back here for a minute because i think some of my slides so for some reason these slides aren't showing up so i had two slides that explained our method uh we used the delphine method which is a research uh approach that that brings together a group of experts um in in a in an anonymous way of working together the delphine method was actually developed by the department of defense who to bring experts together but that would have different power bases so you might have a general that would out weigh just because the person's a general compared to maybe an engineer that was maybe of much lower rank and so that was developed to work on very difficult problems and so um the first thing that we did an anonymous survey with the 21 stakeholders to ask them to identify what they thought were important factors around normal birth and we we gave them a certain set of questions and then they um just wrote in and um then we used a qualitative method to analyze those and to start to parse out what we were seeing and then we brought those back as statements to the entire group and then the whole group anonymously ranked those as to how important they felt those were on a ranking of one to seven that that that statement should be in a consensus statement about normal birth uh it took us nine rounds to get to the final uh agreed upon statement and then we took that statement back to our three organizations to our boards of directors who had to then approve it um so so the areas that we saw were definitions of normal physiologic birth the mechanisms and outcomes of normal physiologic birth factors that influence it and recommendations for increasing it so these are the three organizations a c and m manna and n a c p m and this is the document itself and um i'm going to highlight this word normal because we spent a lot of time uh talking about this we took our preliminary findings on the road at our and at our national conferences and also at t m 20 i believe it was 2011 and presented it and then got feedback from um people in the audience um the word normal was somewhat uh divisive for some folks because if it people felt if uh if you weren't normal then you were abnormal and that didn't seem very right um and so we actually finalized the statement without the word normal in it and we had it was supporting healthy and physiologic childbirth and in the very last days of the um analysis we actually brought the word back in because we felt that it was an important adjective to talking about the physiology of childbirth so it wasn't that childbirth itself was normal or abnormal but it was about supporting the normal physiology so we did keep it in the end um this is where you can get it if you go on to to a c and m dot org come over to professional resources and the statement is right there it's also uh if you um put my name into pub med uh and put normal physiologic childbirth it will come up in an article that we did that we wrote about the actual process so the first area of the the statement is about defining the normal physiology of uh childbirth um and i just see oh kim thank you for for clarifying that you're right many cpms do attend birth and birth centers um so the normal physiology is characterized by spanish spontaneous onset and progression includes biological and psychological conditions that promote effective labor results in the vaginal birth of the infant and placenta results in physiologic blood loss um facilitates optimal newborn transition through skin to skin and keeping the mother and infant together and supports initial initiation of breastfeeding the fact we looked at the factors that we thought influenced normal physiologic childbirth and when you go to the article the statement itself each one of these areas is cited in terms of the evidence for for these statements so for the woman her own individual health status and physical fitness fitness autonomy and self-determination and childbirth her personal knowledge and confidence about birth including cultural beliefs norms practices and education about the value of physiologic birth fully informed shared decision making and access to health care systems settings and providers supportive of and skilled and normal physiologic birth you can have all of these things but if she's in a health care system that is not supportive then it's very hard to achieve it for the clinician it was very important that clinicians are educated knowledgeable competent and skilled and confident in supporting birth including helping helping women cope with pain there's a commitment to working with women through education to enhance their confidence and diminish their fear commitment to shared decision making and again working within an infrastructure supportive of normal physiologic for for the birth setting and the environment we believed it was important that every woman has access to midwifery care that there's adequate time for shared decision making with freedom from coercion no inductions or augmentations without an evidence-based clinical indication encouragement of nourishment as the woman desires and freedom of movement intermittent auscultation unless otherwise indicated maternity care providers skilled and non pharmacologic methods care that supports each woman's comfort dignity and privacy and respect for each woman's cultural needs now i want to just highlight that it is a continuum and i think some of you may know that i had the the pleasure of spending a year in in england studying their work on normal birth and the some of the takeaways i took from that experience was this commitment that that all women need a midwife and some women need an obstetrician too and that normalcy normality is a continuum and so that even though a woman might develop some aspects and in her in her health that might become less normal that there were still many things that we can do to support normalcy and and to support a woman's normal physiology um and that uh it takes real skill to do that so these were the recommendations that we made at the end of the document for policy education and research so that policies were introduced into hospital settings to support normal physiologic birth so if an intermittent auscultation was not an expectation for low risk women how how could you get that set into a policy um a real comprehensive examination and dissemination of evidence in care practices supportive of normal physiologic birth and i'm going to be talking about that in a minute and midwifery care as a key strategy to support normal physiologic birth increasing the midwife workforce and enhancing regulations and funding strategies to support their practice competency-based interdisciplinary education for maternity health care clinicians and students on the application of care that promotes normal birth so if you're a a physician or a midwife student and you've never really seen uh physiologic birth then how would you expect to know what it is so really very much trying to develop the competencies and supporting women in birth um and then development of a future research agenda on short and long-term effects of normal physiologic birth and i'm just going to digress for a minute on this is that i think most of you are familiar with the Lancet series on midwifery that came out last summer whether uh i'm working with my colleagues on that series on it on an additional paper that will be setting a research agenda for future midwifery research and this is clearly one of the issues that will be ranked on that on the agenda we're just getting ready to launch that to about a thousand different people around the world to have them rank it so what we've done so we we published that paper in 2011 and then developed an ongoing task force at the american college and your midwives and have launched now what we're calling a healthy birth initiative and these are some of the uh these are all downloadable to for anybody who wants to go on and see them and use them and and this is what it looks like so if you go to the professional resources area that i showed you earlier you go to this healthy birth initiative so what we have on this is we have a number of tools so for women we have a normal healthy childbirth for women families what you need to know in english and spanish from maternity brought providers we have a toolkit called birth tools and that has a compendium of evidence that promotes physiologic birth and various aspects that you can use in your in your birth setting and then we have a document per hospital policy makers payers and other organizations called birth matters and that one is actually available for purchase so i would encourage you to go on and explore a website and see all the different things that we have so then i want to end with what the other outcome was so in the two years that it took us with nana and acpm and the acpm and working together we began to trust each other i think in a very different way and to work together in a different way in 2011 we came back from durban south africa from the icm congress and where the icm passed their global standards for education regulation and association and i called the the seven midwifery so we have the the three organizations that i've been talking about our professional organizations we also have two certifying agencies for that manage the certification examination for certified nurse midwives and certified midwives that is acme and then meek certainly manages the certification for the certified professional midwives i'm sorry i said that wrong it's amcb for the nurse midwives and certified midwives and norm which is the north american registry of midwives for cpm we also have two accrediting agencies who accredit the education and that's acme and meek so that's seven organizations so we we brought those organizations together three years ago for our first meeting we had five representatives from each organization and we began to talk about the issues in midwifery in the united states and how we could bring ourselves together so that we would have a collective voice and we've had facilitated meetings we just had our third one last weekend and have i'm just i think all of us have felt like it is a historic moment in the united states of the the work that we are doing together so i think i'm going to end it on that and open it up to your questions thank you very much okay thank you very much does anybody have any questions hi do you want to to actually speak i think so if she still would like to speak rather than i can answer it via the chat box please put your hand up again but otherwise you might see in the chat box some of the comments that have been made so far holly yes i'm so i'm going through them so uh so i'm not sure what sherry is screaming about but uh but i i if she wants to tell us i that would be great and i thank you i it's lovely to see all these my friends on this on this call um so heidi said sad to see ob nurses who don't have experience with normal birth you know that is so institution specific you know i've i've had the good fortune to work at various institutions and i can tell you i've been in some hospitals where the obstetrical nurses are just fabulous and they do support normal birth um and and i've been in others where they it's it's been less that way because the norm has just been everybody's on monitoring and etc but i believe that um at least in the united states the first critical mass to support to convince about the importance of normal birth of the supporting the physiology of your body for normal birth and why that has good outcomes for both the mother and the baby are women women want to do the right thing for their their baby so really working with them to help them understand that and then working with their wherever they're going to be giving birth um to help that happen this in our country the second critical mass are nurses because in all hospitals there are obstetrical nurses and if we can get obstetrical nurses to um we don't have the what we don't have the power of the the people power to have a midwife for every woman at this point hopefully someday we will but so anyway that's the case on the obstetrical nurses oh thank you kim for doing the the link i tried to do that on my power point i couldn't get it to work um she was saying she wants to endorse that every woman needs a midwife yes yeah um you know i um i was in some of the high-risk cases that i observed when i was in the uk i was so impressed with the midwifery care in in those cases so even though a woman was having an obstetrician manage her as she was critically ill was something the midwife was there working with her and helping her on on all the other aspects are there questions i think perhaps they're being typed into the chat box more than anything else excuse my fog in my throat does anybody wish to ask so i believe the question or there's a comment there's a comment there from sue right so so so it in the us it is um and my us colleagues feel free to jump in if you want um around the turn of the uh century around around 1900 the last century midwives were pretty well eliminated by medicine and uh and partly that's because we were a nation of immigrants and the midwives were not organized so they came from different countries they spoke different languages and they they simply weren't organized and so it was relatively easy to get rid of them and then uh around 1920 we started to see uh some organized efforts to bring them back but it's it's been a long hard slog to to uh to get them we we attend just under 10 percent of births in the united states um and um and it's just that medicine has a much stronger hold here but this is the good i think the good news um the american college of obstetricians and gynecologists told us last weekend that they really are looking to midwifery as to be a solution for the future because they do not have enough um residents coming into obstetrics um and they are predicting and the change of mix has um there are many many more women now than men in obstetrics and they have a different um uh work pattern so they you know they come out of school they um finish their residency they tend to have a baby and then they tend to want to work part time so they're predicting by 2020 to be 8 000 obstetricians short so we have to do our work to to begin educating more midwives so carline um i i would that that's a great question about what what really drives changes and i would say uh in large developed countries or other countries so the the third article in the lancet series for midwifery um is an to me it's an exceptionally interesting article they looked at um the countries that had this the steepest drop in maternal mortality and then they compared those to the countries who had an increase in midwives uh and in midwifery care and then they looked at the various factions um that in in the country to see if they could understand what what what were the drivers what what was driving change and it was different but a lot of it had to do with political will uh a recognition that there was a problem and that they needed to um uh increase midwifery and if you look at that there's a they have some very good bar graphs and they show um uh the increase in the midwifery workforce and the increase in the health care infrastructures a really important one um so um the and that that particular paper was focused more on low and middle income countries i think in the united states the drivers are in in high income higher developed countries the drivers are a lot about health care economics other thoughts dev walker are you still on because i know you've you've um had some interest in this in terms of the us as well yes you're still here somewhere the other thing in the in the united states that drives education is um it costs it's very expensive to educate midwives and there's very little government um funding for it whereas uh in medicine there's a lot of government funding um for medicine whom has some work to do on that so it looks like carlene's typing oh good i'm like glad you liked them kim so so many of the ngo funding for global health is focusing on community workers and birth attendance not on midwives sadly i would agree carlene and that was one of the the um drivers for doing that lent its ears on midwifery to to really be able to show that when you look at how we define mid midwifery and we really talked about midwifery more than midwives is that uh it is about what we do and um at the end of the day midwives do that best but um it is it is a reality that many countries are focusing on community workers and and um we really need to be working across those countries to to try to get them to focus on midwifery and and educating midwives yes uh katherine i would agree um the american the american college of obstetrician and gynecologist last month um officially um i don't know what was the word they used and not adopt but um they said endorsed the icm global standards so that was a huge thing for them to do one of the things um for those of you that aren't from the united states we have 50 states and we have 50 different kinds of regulations for midwives so certified nurse midwives are are um licensed in all 50 states but certified midwives and certified professional midwives are not certified professional midwives i think are in 29 now um so one of our goals is to get common language that legislators in all those 50 states can understand and uh agreement on that so we've been working on them using the delphi method um to achieve to develop a consensus statement on principles from all the legislation and that's and we've done that with the seven organizations so that's another example of of how you start with something small and how how you get to it um so most of that's that is what we're trying to do um i do get the feelings that throughout the world we're kind of um on a on a on a road back upwards you know how for probably 10 15 20 years ago we were all worried that midwifery everywhere was going to disappear of death we're quite lucky in the uk with our midwifery um but even here we were worried about it and we were beginning to talk about obstetric nurses instead and we were saying at that point we're on the cusp we're on the cusp and i do feel myself that there's definitely we have got an upward slant going now and that we need to just keep gathering speed and we'll get this sorted do you agree i i do i totally agree we need to be out there really working with women on this you know um you know women have driven change uh in in maternity care i mean since queen victoria received ether you know the and then all women wanted it um so if if we can help women understand that uh spontaneous labor is healthy it's healthier for her baby um rather than doing and and elective induction uh why vaginal birth is good for her baby um because most mothers want the right thing for their babies um and that means really knowing what they're reading knowing what they're watching um because there's a lot of terrible childbirth education books out there and a lot of terrible baby channels on television we have them too but of course we have a royal baby a new royal baby here today a little a little princess and it is rumored i don't know if we will ever discover this is true but it is rumored that kate middleton catherine sorry um has been pursuing a nice normal natural birth and has been um looking towards midwifery care but i don't suppose we'll ever discover um whether that's true or not so maybe those rumors will add a little bit to the flame of normality right right maybe we can get her to be the whatever you call it that princess anna is now to the royal college of midwives patron oh did you know catherine uh did that so the bill passed in maryland uh yes we knew about that um so this was it this was a really good bill and this was also an example of midwives and obstetricians working very well together you'd expect her to have a three-hour labor melissa seeing she um it's not that long since she had the last one and that wasn't very long either i don't think so i guess that would be nice wouldn't it chris just you to come up with that one um yeah good size baby too yeah smaller than last one though i'm sure they said it was a little bit smaller not that's got anything to do with anything eight three facebook is covered with pictures of this new baby really yep they even had an extended news bulletin you probably had those in them in the usa as well but had an extended news bulletin that went on for about an hour and a half while they were waiting for her to come out of hospital because it was we were told that she was coming out early and um she was delayed and they eventually had to kind of move on to the next item i believe i got fed up watching it anyway oh it's just a royal baby you know yes i agree chris no election i haven't heard anything about the election all day wow fabulous um anyway do you got any more pertinent questions other than about kathryn musselton sorry no i'm just laughing at all these comments that's why i'm trying to bring them back on track we've got we've time for another couple of minutes of discussion um we have the midwives for all coming next holly and they're talking about the lancet series of midwifery as well okay is that petra yep she's here in the box petra and jonah here for doing the next session the final session okay great there's some great initiatives going on in the world at the moment yeah so what's the percent of home births in new zealand thank you sarah eight percent that's quite good wow what is it here about two percent or something if we're lucky alice and ewing do you know independent midwife yeah we're we're under we're there's a private message for you from kim lane in the um chat box down the bottom if you have time to kind of do alice and art says aye and the lovely scottish accent it's only two percent well i think we seem really to be um moving away from the topic or rather losing um things to discuss uh so if anybody's got any more um questions specific to holly rather than a bit of chatting can you put them up right now and then we'll be able to um move on hi i just had a quick look for the home birth stats for new zealand and it hovers at about um 4.9 percent but in some areas where um there is a very strong home birth association and home birth midwives it's as high as 12.5 percent oh good thank you okay i think everybody seems to be winding up a little bit so it just um falls to me then to say thank you very much um holly for coming on and discussing this um topic which is very uh important for women everywhere really um so thank you very much and thank you i'll just go through a final few um slides in a moment is there anything final you wish to say holly no thank you uh for inviting me and um tetra i wish i could stay on for the next one but i have to run to another meeting um and uh all of you to if you have any questions to um you know get in touch with me it's it's holly dot kennedy at yale dot edu i'll type it in here well that's an easy one to remember and well to to reassure you you will be able to probably by tomorrow knowing how efficient the net is to go on tomorrow or the next day onto the website and find the recording of the next session and all the other sessions as well so thank you very much for your interesting um presentation um i'll just quickly go through our last few slides so to remember to turn off record which i will do just now