Monthly Archives: July 2008

OK, I’ll bite

Another case of my comment on a site getting too long and turning into a post.

Hi, TBTAM! One of my favorite blogging ob/gyns had a post up about women breastfeeding each other’s babies in order to feel a sense of community.

I was involved in a discussion about this online with a bunch of mothers, the majority of them having breastfed at one point or another, after the Katrina disaster. I can attest that, like many moms I spoke to, my breasts hurt when I heard of babies dying because their moms didn’t have formula for them.

I am not making any sort of commentary on why these women chose (or didn’t choose) to formula feed, that is a question for another day, and no judgment is intended towards baby feeding choices.

I am just saying that we all agreed that our first instinct when hearing these stories was that we would have breastfed those babies if given the opportunity. Now, this is an extreme situation.

Interestingly enough, we all said that we would be comfortable breastfeeding another baby, but would be uncomfortable having our baby breastfed by someone else. However, none of us had been in a situation in which we would need our infant fed and we could not provide for them, so that kind of a judgment call may change depending on the circumstances.

An interesting side note, a poster on that message board said she breastfed a baby she was babysitter because she felt sorry for the baby for being only fed formula. This was without the mother’s permission, in fact, deliberately without it. There was an uproar about it being extremely unethical.

I trained with a midwife whose nanny used to breastfeed her babies if she was stuck at a prolonged labor. She was very comfortable with the practice, and encouraged babies with problems latching on to be nursed by more experienced mothers to see if it was a mother’s milk supply problem or a suckling problem.

Of course, our mothers were screened for hepatitis, STDs including HIV, etc. But, a negative screening is not a guarantee of a lack of risk of passing on something with adverse effects on to the baby. Drugs can concentrate in breast milk, even legal ones. She could have a new infection or even an existing one that wasn’t screened for. Allergic babies can have severe allergic reactions to foods eaten by the breast feeder.

These are also extremes, however, just like the Katrina example. Not very likely.

The same birth center participates in a milk donation project. The mothers are screened, and the milk is processed by a pharmaceutical company that prepares it into a supplement for babies in NICU. I am spacing out on the name of it right now. I am exhausted. I was at a medical conference this weekend, and back to school this morning at 8 a.m.

I was given the opportunity to breastfeed another woman’s baby once. I felt extremely honored to be given the opportunity. The mother was a close, close friend of mine, one I have known since childhood. I have lived with her. I was her doula.

She and her baby were having a very hard time establishing a breastfeeding relationship. We are not sure what the problem was, because she couldn’t have had more support or tried harder. She is now guessing it was due to the baby’s short frenulum. When I say she tried everything, I mean it, and it included letting me try nursing her baby once and seeing if we could figure anything out by that. I could tell the baby had a weak suck, but I didn’t know if it was because she was so much younger than my child was, or if it was something with the latch.

There are definite ethical and medical reasons why it is taboo in this society and it doesn’t happen commonly. Like any other health decision, it should be entered to with a good deal of consideration. Just doing it for some sort of companionship would not be worth the risks, in my judgment.

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Outed in Nashville!

I am at the Medical Students for Choice (MS4C) leadership training in Nashville. I was in a crowded elevator with one of their organizers, and we were chatting about how much we liked the hotel staff at the annual meeting we went to earlier in the year in St. Paul, Minnesota.  When I told her my porter story, she gave me a funny look and said, “Do you have a blog?”

“Uh, yeah, you know it?”

“We all read it!” she said, and then other people in the elevator started laughing, and someone asked me for the name of the blog. If any of my elevator mates have searched the blog and found it, uh, “Hi!”

When we got to the staff room, I was outed to a few more staff members who hadn’t put a face to the blog.

I am a little embarrassed and a little proud.

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Please vote against the fringe

Aol News and U.S.News and World Report both have polls up regarding the proposed HHS rule that defines a fertilized egg as a human being, mistakenly equates some forms of birth control as abortion, and supports health care practitioners who want to work in a field in which they can refuse birth control to people.

(What’s wrong with radiology, right wing docs and nurses? Oncology? WWJD? Wouldn’t He choose infectious disease? What about the lepers? Get out of family practice and ob/gyn if you don’t support birth control, a health care decision that 98% of women will choose at least once in their reproductive years.)

Anyway, I know they are just unscientific polls, but those are both large media conglomerates. The numbers are overwhelmingly supportive of a women’s right to choose birth control and discouraging this ridiculous definition. I hope the results are used throughout the AOL and USN&WR universe.

(Hat tip, RH Reality Check)

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Angry enough to write?

Feel free to write to Secretary Leavitt about the proposed rule defining a fertilized egg as a human being, pregnancy starting from contraception, and attempting to guarantee front line health care jobs to people who agree.

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Head exploding quietly…

I have had more than one person ask me what I thought of the recent proprosed rule from the Department of Health and Human Services.

Trust me, I have been following the story. Many of the blogs I subscribe to have been addressing it: feministing (they get the best photo accompaniment award), feministe, women’s health news, and RH reality check. Many of these sites have more than one post on the subject, and many have excellent link lists of other posts or news articles on the subject.

I have actually been silently seething about this for quite a while. I forget where I heard or read about the head of the HHS family planning department, Dr. Susan Orr, stepping down to supposedly distance herself from this nonsense. In fact, I wrote about it in this post, which was an assignment I turned in for my Culture and Health Class. The report linked her sudden resignation to a rumored new rule from the department that clearly came straight from her radically anti-reproductive choice group, the Family Research Council, one she apparently wanted to distance herself from when it hit the fan, so to speak.

But, I came back from vacation with less than six hours to spare before my first day of class, and we will be taking our second test in two weeks Monday morning. So, please forgive me for letting this one brew a bit. I have been rather afraid to touch it, since I have so much to say and so little time and emotion to spare on it. And the emotion is there, trust me. This gets me angry to the pit of my stomach.

This proposal has some very clear, unabashed goals. First of all, it intends to deny women health services. Instead of working to improve access to birth control and family planning services for women, it wants to find new and creative ways to deny health care based on a narrow, minority view of women’s health. The federally funded programs they are targeting will include every public clinic that serves underserved women. The very same clinics that distribute birth control to the vast amounts of women who couldn’t afford it otherwise. It would also affect a significant number of not for profit and private clinics that also choose to serve underserved populations, including Planned Parenthood, clinics at universities, and other independently run, but subsidized centers. In fact, I could easily see how it could extend to any clinic that accepts Medicaid, Medicare, or serves members of the U.S. Military. This has nothing to do with a private practitioner in a private offices making decisions about what practices she feels comfortable performing.

Secondly, it seeks to riddle federally funded health care sites with activists who subscribe to this narrow, non medically based world view. There are a lot of very pressing issues that the HHS could be dealing with right now. If you want a list, check out Healthy People 2010. I don’t see “allowing more fringe religious activists to deny health care to the underserved” on any of their lists of recommendations. It is not the role of the U.S. Government to protect the so called “right” of every political extremist to influence the way public policy is carried out. If the Family Research Council wants to make sure that people who are against reproductive rights are employed in this field, paid by federal grants, and then protected from discipline as they block the efforts to deliver reproductive health care, then they need to be funding legal campaigns. Why the HELL is the Department of Health and Human Services (and our tax dollars!) doing their dirty work?

Finally, about the definition. After some not very convincing background research, the rule proposes two dramatic definitions that would rock the medicoethical world if they became law. One would be to define pregnancy as beginning at the fertilization of the egg. Not only does this not agree with the definitions put forth by major medical groups like the AMA, AOA, ACOG or ACOOG, but it is a ridiculous definition, medically. That is not a measurable point, first of all. Implantation has biochemical markers. One of the reasons there are biochemcal markers is that the blastosphere makes contact with the woman’s body again. When the egg is released, it is released. We may not think of it as such, but many of our body’s various tubes contain areas that are NOT physiologically part of our body. Our GI tract, first of all, has a mucosal barrier. We choose what we absorb through that barrier from our food, and the rest never enters us physiologically. Same thing in the kidneys – we excrete in the kidney into the tubules, which go into the ureters. We don’t excrete from the urethral hole, out of our body. We may pee out of there, but that urine is already out of our physiological system. Once urine becomes urine, it is not us anymore.

Menstrual blood is not us anymore. A floating egg, fertilized or not, may reattach to us, or it may float on out. Women who do not take birth control, whether it is their choice or because right wing activists have fought tooth and nail to deny it to them, will be passing a lot more of these poor little blastospheres than women who are on birth control. My reproductive physiology teacher estimated that less than 10% of fertilized eggs implant. I have read many other statistics that say 30% of these implanted eggs will be a spontaneous miscarriage during the first trimester. I would think most women would want more research on miscarriage than the eggs that pass through without symptoms of cramping and heavy bleeding, especially women who are habitual aborters and desperately would want to stay pregnant.

It would seem to me that this focus on passed eggs is like focusing research on infectious disease on the bugs that aren’t virulent and don’t infect us. No one cares about the E. coli that doesn’t get us sick, and there is plenty of that about. It’s the type that does physiologically affect us that I would hope the CDC will be researching and tracking.

This definition is specifically intended to throw suspicion on the major forms of birth control. Although no major medical organization, and not even physicians who are against abortion agree that the pill or the IUD are abortifacients, the radical anti-choice movement has fought to confuse the discussion on this.

One self-identified “pro-life” physician writes:

“One may get an idea of the frequency of conception on hormonal contraceptives by considering the ectopic (tubal) pregnancy rates. The ectopic rate in the USA is about 1% of all pregnancies. Since an ectopic pregnancy involves a preimplantation blastocyst, both the “on pill conception” and normal “non pill conception” ectopic rate should be the same- about l% (unaffected by whether the endometrium is “hostile” or “friendly.”) Ectopic pregnancies in women on hormonal contraception (except for the minipill) are practically unreported. This would suggest conception on these agents is quite rare. If there are millions of “on-pill conceptions” yearly, producing millions of abortions, (as some “BC pill is abortifacient” groups allege), we would expect to see a huge increase in ectopics in women on hormonal birth control. We don’t. Rather, as noted above, this is a rare occurrence. “

So, using an incorrect definition of pregnancy and then encouraging incorrect discussion of the physiology of birth control is another clear yet unspoken goal of this rule.

Finally, the rule seeks to define the fertilized egg as a “human being”. This is a very troubling definition ethically. Please note the statistics above about theoretical implantation rates of these so-called beings. How about those thousands of frozen embryos, in limbo in fertility labs across the country? How about physicians that do choose to do surgical abortions – of unwanted embryos, of molar pregnancies, of anencephalic fetuses. Are they murdering human beings? Really? Performing the most common surgery in the country? 30 to 40% of women of childbearing age, according to the Guttmacher institute, will ask her doctor to murder a “human being”? The Lancet, in its special issue on global women’s health, asked for more access to human being murder to save women’s lives? No, it didn’t, and this kind of ridiculous inflammatory language makes me sick. And, any adopted legislation, especially authored by the HHS, would be a precedent for incremental laws restricting access to birth control, emergency contraception and terminations.

The only silver lining I can see in this is that I have to do a speech in a few weeks to recruit the first year students to Medical Students for Choice. This should help. I hope it also helps light a fire under every woman who thinks that Republicans and Democrats are the same on Reproductive Rights.

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Beautiful, indeed

Fortuitous is one of my favorite words. Not only is it fun to say, but it is inherently such a good thing when something fortuitous happens.

I am the president of the student interest group for obstetrics and gynecology this year (SAOG). (Eep!) And, I am vice president of our chapter of the American Medical Women’s Association (AMWA) and Medical Students for Choice(MS4C).

Notice a pattern here?

I decided to change our charity group this year for SAOG. We raised money for the Komen foundation last year. I definitely think breast cancer research is a good cause. However, breast cancer is not normally diagnosed or treated by ob/gyns. It is diagnosed by radiologists and pathologists and treated by oncologists.

So, I wanted to switch to a charity for repairing obstetric fistulas. One of the physicians who came to speak to us, a gynecological oncologist, travels to repair fistulas once a year. I just ran it by my exec board, and then Rachel posted about the movie “A Walk to Beautiful”. I already have one board member say that she didn’t think it was a compelling enough charity. (She and I don’t see eye to eye on very much – her favorite SAOG lecture from her first year was someone discussing labiaplasty and other plastic surgery on the vagina). I think showing the video during a lunch meeting will be a good idea.

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My pretend grant application

I am taking a grant writing class. I want to collate outcome statistics for the birth center where I trained in Miami. Here is the background research section of my assignment so far. This will be pretty long, so if you’re into that kind of stuff, enjoy. I am not going to spend any time fiddling with the formatting. Sorry, it looked great in Word. It is hell to read in this format. I am hoping to use this for a real grant application, and hopefully get a research fellowship.

Maternal morbidity and mortality, especially that of women of color and/or low socioeconomic status, is a problem in the United States. Despite skyrocketing rates of medical interventions in labor and delivery, including the majority of labors being artificially induced or augmented1, infant mortality in the United States is ranked 25th among industrialized nations. The maternal mortality rate in the United States has not fallen since 1982, nor have disparities of maternal mortality between African American mothers and white mothers. The national maternal mortality rate for African American mothers is three to four times the rate of white mothers2, and this discrepancy is reflected in the maternal mortality rates in Miami-Dade county. In fact, in some recent years, the maternal mortality rate for non whites in Miami-Dade county has been more than ten times that of whites, reaching about 50 per 100,000 twice in the past decade.3
Other indicators of maternal and infant health have been outlined by the Healthy People 2010 as maternal and infant child health objectives, spearheaded by the U.S. Department of Health and Human Services. Along with maternal and infant mortality rates, the report recommends reductions in cesarean section rates, which have topped 30% nationally. 4 This increase has occurred without a corresponding decrease in Neonatal Intensive Care Unit (NICU) admissions.5 without reductions in low birth weight and preterm deliveries, and increases in early prenatal care and initiation and continuation of breastfeeding. All of the maternal and infant health outcomes under surveillance in the report are stratified according to race, and all show similar disparities between African Americans and whites.6 These disparities are all either identical or magnified in Miami-Dade County.7
Forty two years ago, Scottish epidemiologist Archie Cochrane awarded a “wooden spoon” to obstetrics in his book Effectiveness and Efficiency: Random Reflections on Health Services, a dubious honor awarded by use of treatments without scientific justification. His criticism inspired the development of the Cochrane Pregnancy and Childbirth Database, an online database evaluating evidence-based medical practice. Unfortunately, even with this source of data for justifying interventions, it seems that many standard practices prevalent in typical hospital care are not indicated for nor supportive of a healthy, normal birth. Jennifer Block laments in her 2007 book, Pushed: The Painful Truth About Childbirth and Modern Maternity Care:

A common theme emerges in the history of obstetric care: procedures and devices developed for the treatment of abnormality rather quickly become routine practice in the name of prevention, and then simply in the name of speeding up and ordering an unpredictable, at times tedious, process. 8

If our goal is to improve maternal and child outcomes, using evidence based care is our best chance at results. Although the Cochrane database is a valuable tool for evaluating randomized studies of single treatments, birth does not occur in a vacuum. If actual institutions are achieving better outcomes, there are lessons to be learned from retrospective studies of successful protocols and practices. This is especially true of patient sample groups with disadvantaged and ethically diverse patients.9
The model of midwifery care has been examined as an alternative to the prevalent paradigm of labor and birth in hospitals. Midwives are twice as likely to care for minority clients.10 Several studies have indicated that births attended my midwives have improved outcomes for low risk patients, even disadvanted patients.11 In fact, not only was midwifery attended births and maternal outcomes among the medically underserved researched in Miami-Dade county, but specific practices, distinct from typical hosptial practices in the United States, were described in the study protocol Study subjects were match controlled to patients at a typical tertiary care center at an adjoining hospital. Patients delivering at the birth center did not have access to regional or general anesthesia, so they were not administered epidurals. No induction or augmentation of labor were performed. Women were encouraged to drink and eat lightly, and were encouraged to move around and change positions during labor. This was made easier by the practice of intermittent auscultation. In the tertiary hospital, as it is in virtually every hospital in the United States, control matched mothers were tethered to a constant external fetal monitor.12 Despite significantly fewer interventions, outcomes were the same between the two groups of low risk, predominantly African American women.
Analysis of protocols and practices in successful institutions can help lead reform in birthing practices, and can avoid the expense and possible negative outcomes of unecessary interventions. Use of metanalysis of controlled studies of individual practices can be field tested in actual real world settings. For example, the Cochrane database review of continuous external fetal monitoring (EFM), more specifically called Continuous cardiotocography (CTG), concludes:

“While specific abnormalities of the fetal heart rate pattern on CTG are proposed as being associated with an increased risk of cerebral palsy (Nelson 1996), the specificity of CTG for prediction of cerebral palsy is low with a reported false positive rate as high as 99.8%, even in the presence of multiple late decelerations or decreased variability (Nelson 1996).

Concerns have been raised about the efficacy and safety of routine use of continuous CTG in labour (Thacker 1995). The apparent contradiction between the widespread use of continuous CTG and recommendations to limit its routine use (RCOG 2001a), indicates that a reassessment of this practice is warranted.”13

Comparisons of continuous monitoring and intermittent auscultation, which involves regular monitoring of fetal heart tones with a handheld Doppler device, have mixed results. The Cochrane review reports a higher risk of neonatal seizure with intermittent auscultation, but no increased risk of NICU admission, cerebral palsy, low Apgar score (a rating of neonatal well being), or perinatal death. EFM was linked to higher risk of cesarean section and operative vaginal delivery, especially in low risk women.The comparison review concludes:

There is a reasonable consensus of opinion that continuous electronic fetal monitoring
should be reserved for women whose fetuses are at high or increased risk of cerebral palsy, neonatal encephalopathy or perinatal death.

The article continues to say that for every neonatal seizure attributable to intermittant monitoring, doctors would be performing eleven cesarean sections.14 Yet, EFM continues to be required in the vast majority of hospital births. It is less common in freestanding birth centers.
Similar conclusions are drawn about the type of birth procedures found in the majority of hospitals in general, termed “active management”. Active management includes induction and augmentation of labor, EFM, and early amniotomy (breaking of the amniotic sac to increase contractions). The Cochrane report on active management warns that a low threashold for early intervention is “not without its risks”, and suggests the frequency of these complications should be better quantified.15 These interventions are specifically outlawed in freestanding birth centers in Florida.16
Other common interventions with dubious efficacy in Cochrane reviews are significantly less common in birth centers than in hospitals. Epidural anesthesia has been linked to longer labor, use of oxytocin, malposition of the fetal head, increased risk of fetal distress, cesarean section, instrumental vaginal delivery, need for neonatal resucitation, maternal hypotension and maternal and neonatal fever.17 Having mothers spend the majority of the first stage of labor in a supine position, practically mandated by the use of EFM and epidurals, has also been linked to potential adverseevents. Lying on her back can compromise maternal blood flow, cardiac function, and the blood supply to the uterus. Studies showed that contractions slowed and weakened when the woman is lying down, and resulted in negative fetal acid-base outcomes.18 Freedom of movement and alternative delivery positions have been shown to decrease episiotomy (an operative incision in the vaginal linked to severe tears), perineal tears, and operative vaginal birth, but increases maternal blood loss.19 Induction of labor is warned to increase maternal and fetal distress, increased cesarean section, and may lead to uterine rupture.20 Restriction of food and fluids, which are replaced with intravenous (IV) therapy for the entirety of labor and birth in almost all hosptial births is more than just restrictive and inconvenient for women. The Cochrane review of this practice questions any medical justification for its widepread application. IV therapy is associated with hypoglycemia in the newborn, immobilization of the mother, fluid overload, maternal stress, and does not provide required nutrients for labor and delivery.21
Some practices that are frequently found in midwifery based care, but not in typical hosptial care, are also reviewed in the Cochrane database. Continuous support of a woman in labor, usually provided by a trained birth attendant called a doula, has been shown to have numerous benefits, including women who were more satisfied with their birth experience, reduced cesarean section rate, increased spontaneous vaginal birth, slightly shorter duration of labor, less use of analgesia or anesthesia, and reduced maternal fear and stress, without any plausible risks. The report concludes that continuous labor support “should be the norm, rather than the exception.” Costs of private doula services maybe a barrier to access for lower income women. Some hospitals have started to fund doula services.22
Although the reviews in the Cochrane database emphasize the need for randomized controlled trials of single interventions, pregnancy, labor and birth continue in real communites without randomization. Successful care with improved maternal outcomes and reduced intervention can be a guide for effective care for similar populations, or a guide for protocols for intervention studies in nearby hospitals. It is not one intervention, but the general atmosphere of drastically over treating labor and birth that seems to be the problem. As one review warns, “any effect on caesarean section rates from a policy of active management is as a result of the combination of interventions rather than the individual interventions.” Midwives and freestanding birth centers do not have an exclusive claim on expectant management of labor and birth. Even with use of continuous support during labor, the reviewers recommendations indicate that:

“Policy makers and hospital administrators in high income countries who wish to effect clinically important reductions in inappropriately high caesarean rates should be cautioned that continuous support by nurses or midwives may not achieve this goal, in the absence of other changes to policies and routines.”

Using a combination of evidence based reivews, retrospective analysis of successful programs already serving the target population, and selective ethical randomized trials, maternity care and outcomes can improve, even in demographically high risk populations.

References

1. Declercq ER et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbirthing Experiences. New York: Childbirth Connection; 2006.
2. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health. 2 ed. Washington, D.C.: U.S. Government Printing Office; 2008.
3. Rivera L, Leguen F. Vital and Morbidity Statistics 2003. Miami-Dade County Health Department; 2008.
4. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health. 2 ed. Washington, D.C.: U.S. Government Printing Office; 2008.
5. Resnik R. Can a 29% cesarean delivery rate possibly be justified? Obstet Gynecol 2006 April;107(4):752-4.
6. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health.
7. Riviera et al, Vital and Morbidity Statistics 2003.
8. Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge: De Capo Press; 2007.
9. Raisler J, Kennedy H. Midwifery care of poor and vulnerable women, 1925-2003. J Midwifery Womens Health 2005 March;50(2):113-21.
10. Declercq ER et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbirthing Experiences.
11. Raisler and Kennedy, Midwifery care of poor and vulnerable women.
12. Scupholme A, McLeod AG, Robertson EG. A birth center affiliated with the tertiary care center: comparison of outcome. Obstet Gynecol 1986 April;67(4):598-603.
13. Alfirevic Z. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006 April 24;(2).
14. Devane D. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews 2004 September 16;(2).
15. Wei SQ. Early amniotomy and early oxytocin for delay in first stage spontaneous labor compared with routine care. Cochrane Database of Systematic Reviews 2007 June 21;(2).
16. Birth Center Licensure Act, XXIX, Florida Legislature, (2007).
17. Anim-Somuah M. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005 August 16;(2).
18. Lewis L. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2002 August 26;(2).
19. Gupta JK. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2003 April 25;(2).
20. Singata M. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2002 August 2;(2).
21. Hofmeyr GJ. Methods for cervical ripening and labour induction in late pregnancy: generic protocol. Cochrane Database of Systematic Reviews 2000 February 15;(2).
22. Hodnett ED. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007 April 18;(2).
23. Brown H. Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database of Systematic Reviews 2004 April 27;(2).
24. Hodnett, Continuous support for women during childbirth.

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