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Letter of Recommendation Template
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"What the Numbers Say" by Tiffaney Isaacson (March-April 2002) presented powerful information supporting natural childbirth, midwives, and breastfeeding. A more complete picture would have included a discussion of homebirth and direct-entry midwives, even if "hard" national statistics are not yet available. As president of Citizens for Midwifery (CfM), a national consumer-based organization working to ensure that the Midwives Model of Care is available to everyone and in all settings, I would like to clarify a few points that have been brought up in letters in the May-June 2002 issue.
The Certified Professional Midwife (CPM) credential is relatively new; the first credential was awarded in 1994. A major statistics project (all births attended by all CPMs in 2000) is, in the analysis stage and will be published when complete. The statistics project of the Midwives Alliance of North America (MANA) is longer and open-ended, but is voluntary. It will have more value when the results can be compared to the CPM study. These studies have been carried out with small grants and donations, as it is very difficult to get funding for projects that involve unlicensed providers.
Author Tiffaney Isaacson used National Vital Statistics Reports (paid for with your tax dollars) regarding certified nurse midwives (CNMs). A major reason why federal statistics are not available for direct-entry midwives (including CPMs, licensed midwives, and other midwives)is because the legal status for such midwives varies from state to state (ranging from legal to legally unrecognized). The national template for birth certificates indicates if the birth was attended by a CNM, but does not permit other types of midwives to be noted. The National Center for Vital Statistics uses birth certificate data for compiling its reports; therefore, non-CNMs generally wouldn't be included in the reports.
This problem has been recognized by the American Public Health Association. Its October 2001 resolution "Increasing Access to Out-of-Hospital Maternity Care Services through State-Regulated and Nationally-Certified Direct-Entry Midwives" encourages several federal departments to add the CPM as a separate category on birth certificates. However, we won't have "acceptable" national statistics for homebirth midwives until CPMs also are legally recognized in every state. Citizens for Midwifery provides information about midwifery and encourages grassroots actions to improve access to midwives and the Midwives Model of Care. This work includes providing public education and supporting state organizations that are working to change laws affecting midwives. Find out about CfM, the Midwives Model of Care, and the status of midwives in various states at the CfM website, www.cfmidwifery.org
SUSAN HODGES
President
Citizens for Midwifery
I have a question regarding the accuracy of some statistics published in "What the Numbers Say." Do women who have had multiple children but have never breastfed have a better advantage over breast cancer than women who have breastfed children for 12 to 24 months? What Mothering printed:
Percent reduction in breast cancer risk among parous (having borne one or more viable offspring) women who have never lactated: 61
Percent reduction in breast cancer risk among parous women who breastfed for 12 to 24 months: 53
LYN
E-mail
My question involves the statistics about cerebral palsy and electronic fetal monitoring. Your percentages quoted on page 40 make no sense. They seem to say that 73 percent of children with no abnormalities on fetal monitoring were diagnosed with cerebral palsy. Did you mean that 73 percent of children diagnosed with cerebral palsy had no abnormalities on fetal monitoring? Then you say 48 percent of children with abnormalities on fetal monitoring who were delivered via cesarean were diagnosed with cerebral palsy. And taking the third statistic "backward," you say that 64 percent of children with abnormalities on fetal monitoring who were delivered via cesarean section were diagnosed with cerebral palsy. So not only do the last two seem exorbitantly high, they disagree with each other.
ANNE MONTGOMERY, MD, IBCLC
Olympia, Washington
Tiffaney Isaacson responds:
To Lyn:
Do women who have had multiple children but have never breastfed have a better advantage over breast cancer than women who have breastfed children for 12 to 24 months? The statistic should read "Percent reduction in breast cancer risk among parous women who have ever lactated." These statistics in this particular study are comparing breast cancer incidence in women who have breastfed against those who have not. All in all, it's yet another reason that breast is best.
To Anne Montgomery:
Did you mean that 73 percent of children diagnosed with cerebral palsy had no abnormalities on fetal monitoring? That is correct. Seventy-three percent of the children who were diagnosed with cerebral palsy didn't have abnormalities that showed while undergoing fetal monitoring. This statistic includes children who were delivered both vaginally and via c-section.
Then you say 48 percent of children with abnormalities on fetal monitoring who were delivered via cesarean were diagnosed with cerebral palsy. This is also correct. Forty-eight percent of children with abnormalities on electronic fetal monitoring (EFM) who were delivered via c-section were still diagnosed with cerebral palsy. In other words, there were warning signs of cerebral palsy, a c-section was done, and the condition of cerebral palsy was not averted.
And taking the third statistic "backward," you say that 64 percent of children with abnormalities on fetal monitoring who were delivered via cesarean section were diagnosed with cerebral palsy. So not only do the last two seem exorbitantly high, they disagree with each other. The third statistic is also correct. Thirty-six percent of children who had abnormalities on EFM, who were delivered by c-section, did not have cerebral palsy. The third statistic does not agree with the first because the third includes only c-section deliveries, while the first includes vaginal and c-section deliveries. The most valid point from the article (K.B. Nelson et al., "Uncertain Value of Electronic Heart Rate Monitoring in Predicting Cerebral Palsy," New England Journal of Medicine 334 [March 1996]: 613-618)is that EFM is being overemphasized as a method to avert cerebral palsy and that our overemphasis has in turn caused a number of unnecessary c-sections. To quote the authors of the article, "The focus on a relatively rare but severe outcome, cerebral palsy caused by asphyxia during delivery, may have diverted clinical and research attention from an exploration of factors other than birth asphyxia that can contribute to maldevelopment or injury of the infant's brain." EFM is a tool, one that caregivers may opt to use during a delivery.
When it is used as the sole basis for decision making, it can steer us in the wrong direction.
In "What the Numbers Say" it states that the World Health Organization (WHO) recommends weaning at age 2. My understanding is that WHO has given the age of 2 as a worldwide average for when weaning occurs, but not as a recommendation of when to wean. This is much like the American Academy of Pediatrics recommendation to breastfeed for the first year and for as long afterward as both mother and child desire. It is not a recommendation for when to wean a child, but rather for a minimum of how long to breastfeed. I think that this should be clarified.
AMY RAGOZZINO
Peabody, Massachusetts
COPYRIGHT 2002 Mothering Magazine
COPYRIGHT 2003 Gale Group
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