Adonis Diaries

Archive for June 18th, 2016

Are Midwives Making a Comeback in the U.S?

When Kelly LeGendre found out in 2012 that she was pregnant with her first child, the Arizona resident, then 34, knew she needed to seek prenatal care.

Unlike most American mothers, LeGendre didn’t seek out an obstetrician. Instead, she opted for a midwife.

For LeGendre, the decision was a no-brainer: “I wanted minimally invasive prenatal care and a completely natural childbirth experience,” she explains.

She’d known several women who had positive birth experiences with midwives; meanwhile, some mothers who had gone the traditional physician route told her they had been urged to accept interventions that LeGendre didn’t want, like genetic testing, early induction of labor, or IV antibiotics during labor.

LeGendre is part of a small but growing minority of American mothers opting for midwives over obstetricians:

In 1989, the first year for which data is available, midwives were the lead care providers at just 3 percent of births in the U.S. In 2013, the most recent year for which statistics are available, that number was close to 9% 

The Atlantic shared this link

Opting for midwives over obstetricians (from 2015)|By Jamie Santa Cruz

The growing popularity of midwifery care is partially a response to rising Caesarean rates, says Eugene Declercq, a professor of community health sciences at Boston University who studies American maternity care.

Currently, around a third of all births in the U.S. are Cesarean sections, a number far higher than the World Health Organization-recommended target of 10 to 15 percent.

The inflated rate is due in part to longstanding misperceptions in the U.S. medical community about how quickly labor should progress and when medical intervention is necessary.

According to Declercq, the high rates of surgery and other unneeded interventions have led to increased interest in the midwifery model, which is lower-tech, less invasive, and less inclined toward intervention without a clear medical need;

a 2011 study in the journal Nursing Economics found that births led by midwives in collaboration with physicians are less likely to end in a C-section than births led by obstetricians alone.

According to Ginger Breedlove (fitting name?), the president of the American College of Nurse-Midwives, the real reason for this difference is in the approach to care: Midwives typically promote patience with the natural progress of labor and discourage intervention to speed the birth process. “It’s a different model,” she explains.

Popular media is also playing a role in the rising popularity of midwives, Breedlove says. The 2008 film The Business of Being Born and TV shows like the BBC’s Call the Midwife, for example, are helping to subtly reframe the concept of midwifery in the American mind, moving it from a fringe profession to something closer to mainstream.

Though still a relative novelty in the U.S., midwife-led maternity care is the norm in other developed countries, including most of Europe.*

In England, for example, midwives are the lead care providers at more than half of all births. (There, midwife care is considered fit even for royalty; last month Kate Middleton gave birth to her daughter Charlotte under the care of two midwives.)

“In England, what they say is, ‘Every mother deserves a midwife, and some need an obstetrician, too,’” Declercq says.

One of the major differences between obstetricians and midwives is the philosophies that ground their training, Breedlove says. Medical education is fundamentally disease-based and curative; as a result, “[OG-GYNs’] focus is more on the sick woman who either has healthcare needs through the lifespan or has complex obstetric needs,” she explains.

In midwifery, by contrast, training focuses on caring for the majority of mothers who have healthy, low-risk pregnancies.

Childbirth is accordingly seen as a natural occurrence, not a medical event, and midwives emphasize the importance of prenatal education and developing a strong relationship with their patients. “[It’s] very personalized, high-touch, low-tech care,” Breedlove says.

As a result, Declercq explains, midwives tend to ask different questions about birth than do other medical professionals.

For example, in most physician-attended hospital births in the U.S., mothers are hooked up to continuous electronic monitoring equipment to track the baby’s heartbeat and identify possible signs of distress.

A 2006 review of three decades’ worth of data, however, found that continuous monitoring offered very little benefit for the majority of births—it was correlated with “reduction in neonatal seizures,” the authors wrote, “but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being”—and was actually associated with a higher rate of C-sections and vaginal deliveries with forceps. Midwives, because of their training to intervene only when it’s medically necessary, tend to question the necessity of continuous monitoring and typically favor intermittent monitoring instead, Declerq says.

The curative skills of a physician are critically important for women with genuine medical needs, Breedlove says, but it can be detrimental to mothers when the physician model “over-medicalizes” normal, healthy pregnancies.

“When you begin intervening at high levels for no medical indication, as with premature induction, elective Cesareans, and forcing women to stay in bed and not ambulate during labor,” she says, “you begin to create a cascade of domino responses that intervene with normal physiologic processes and change the outcome of birth.”

Today, tensions still linger in some parts of the U.S. (In 2010, for example, a group of Oregon midwives filed a lawsuit against the Oregon Health Licensing Agency, alleging that the birthing center where they worked had been the target of baseless investigations.)

At the organizational level, however, the last few years have seen dramatic efforts at collaboration between the two professions.

In 2011 and again in 2014, leading organizations in each field—the American Congress of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM)—released a joint statement emphasizing the importance of both physicians and midwives in American healthcare and the value of collaboration, rather than competition, between the two. (The subject of home birth remains a point of disagreement, with ACOG continuing to oppose the practice.)

“There are no significant drawbacks and many benefits to engaging with midwives to join our care teams,” says Mark DeFrancesco, the president of ACOG.

Collaboration is becoming a matter of some urgency, he explains, due to the growing national physician shortage.

Some areas of the country already lack enough obstetricians to meet demand, and the U.S. will be short an estimated 9,000 obstetricians by 2030.

“We need to be able to care for America’s pregnant women, and as long as the number of obstetricians remains plateaued, part of the answer lies in midwives,” says DeFrancesco, who himself works with certified nurse-midwives (CNMs) in his private obstetrics practice in Connecticut.

Historically, there have been multiple paths to entry into midwifery, a fact that’s long been a point of concern for doctors: Certified nurse-midwives (CNMs), who complete an extensive nursing education culminating in a graduate degree, can practice legally in all 50 states.

But 28 states also allow “direct-entry” midwives, who may enter the profession through an apprenticeship to a more experienced midwife. As a result, the term “midwife” has no standardized meaning in the U.S. “There’s a great deal of confusion,” says Breedlove.

But that situation is changing, and new educational requirements are on the horizon.

Since 2010, the International Confederation of Midwives, which represents midwife organizations in approximately 100 countries, has advocated for a standardized minimum level of training for all midwives, not just in the U.S. but globally. The initiative has received widespread support from the major midwifery organizations in the U.S.

Efforts like these, Breedlove says, are important for dispelling stereotypes and bringing midwifery further into the mainstream. Soon, she hopes, “the general public will hear ‘midwife’ and not think ‘hippie, exclusive home birth, uneducated, far-out alternative option.’ But they’ll hear the word ‘midwife’ and it will be like ‘nurse anesthetist’ or ‘neonatal nurse practitioner’—someone who is qualified within their scope of practice and an essential part of the healthcare team.”

That’s a change in status that DeFrancesco fully supports. As the field of obstetrics continues working to improve health outcomes for mothers and their babies, he says, midwives have their own wisdom to offer: “This is a prime opportunity to not just collaborate with midwives, but also to learn from them.”

Puppy Dog Luck (2005)


Puppy dog Luck was searching for a master.

I found him.  He is following me.


You have a project.

A project to stay healthy;

To conserve the environment,

To get excellent grades in all your courses this semester,

To keep the workplace safe,

To be accepted at a select University.


You don’t need to be consciously aware of the reasons

For adopting a specific project.

Might as well not know the reasons:

You might drop your project if you realize

That your main reason is not that noble or worthwhile.


You like your project very much;

You are interested, excited, motivated.

You study, research and investigate your project.

You question people, listen carefully to the ideas of people around you,

At home, in a bar, in a restaurant, almost everywhere.

You get carried away when talking about your project.


Somehow your project is taking flesh, it is materializing.

Your life has a savor; you are smiling, laughing and feel glorious:

And luck is following you

Like a shadow.


Praying, fasting, doing penitence might make you a lucky person;

Being constantly interested in a life project will.

Go ahead, attract luck and befriend him.

Luck is sniffing every person

Regardless of color, race, religion or political affiliation.

Applying Math to test Parkinson syndrome in 30 sec?
Parkinson’s disease affects 6.3 million people worldwide, causing weakness and tremors, but there’s no objective way to detect it early on.
Applied mathematician and TED Fellow Max Little is testing a simple, cheap tool that in trials is able to detect Parkinson’s with 99 percent accuracy — in a 30-second phone call.

Max Little. Applied mathematician

Max Little is a mathematician whose research includes a breakthrough technique to monitor – and potentially screen for – Parkinson’s disease through simple voice recordings. Full bio

I do applied math, and this is a peculiar problem for anyone who does applied math, is that we are like management consultants. No one knows what the hell we do. So I am going to attempt today to try and explain to you what I do.

0:25 dancing is one of the most human of activities. We delight at ballet virtuosos and tap dancers you will see later on.

 ballet requires an extraordinary level of expertise and a high level of skill, and probably a level of initial suitability that may well have a genetic component to it.

neurological disorders such as Parkinson’s disease gradually destroy this extraordinary ability, as it is doing to my friend Jan Stripling, who was a virtuoso ballet dancer in his time (or Muhammad Ali).

So great progress and treatment has been made over the years. However, there are 6.3 million people worldwide who have the disease, and they have to live with incurable weakness, tremor, rigidity and the other symptoms that go along with the disease, so what we need are objective tools to detect the disease before it’s too late. (Can it be cured if detected early?)

We need to be able to measure progression objectively, and ultimately, the only way we’re going to know when we actually have a cure is when we have an objective measure that can answer that for sure.

frustratingly, with Parkinson’s disease and other movement disorders, there are no biomarkers, so there’s no simple blood test that you can do, and the best that we have is like this 20-minute neurologist test. You have to go to the clinic to do it. It’s very costly $300, and that means that, outside the clinical trials, it’s just never done. It’s never done.

1:44 But what if patients could do this test at home? Now, that would actually save on a difficult trip to the clinic, and what if patients could do that test themselves, right? No expensive staff time required.

what I want to propose to you as an unconventional way in which we can try to achieve this, because,  in one sense, at least, we are all virtuosos like my friend Jan Stripling.

 here we have a video of the vibrating vocal folds.

Now, this is healthy and this is somebody making speech sounds, and we can think of ourselves as vocal ballet dancers, because we have to coordinate all of these vocal organs when we make sounds, and we all actually have the genes for it. FoxP2, for example.

And like ballet, it takes an extraordinary level of training. I mean, just think how long it takes a child to learn to speak. From the sound, we can actually track the vocal fold position as it vibrates, and just as the limbs are affected in Parkinson’s, so too are the vocal organs.

on the bottom trace, you can see an example of irregular vocal fold tremor. We see all the same symptoms. We see vocal tremor, weakness and rigidity. The speech actually becomes quieter and more breathy after a while, and that’s one of the example symptoms of it.

these vocal effects can actually be quite subtle, in some cases, but with any digital microphone, and using precision voice analysis software in combination with the latest in machine learning, which is very advanced by now, we can now quantify exactly where somebody lies on a continuum between health and disease using voice signals alone.

 these voice-based tests, how do they stack up against expert clinical tests? We’ll, they’re both non-invasive.

The neurologist’s test is non-invasive. They both use existing infrastructure. You don’t have to design a whole new set of hospitals to do it. And they’re both accurate.

 in addition, voice-based tests are non-expert. That means they can be self-administered. They’re high-speed, take about 30 seconds at most. They’re ultra-low cost, and we all know what happens. When something becomes ultra-low cost, it becomes massively scalable.

So here are some amazing goals that I think we can deal with now. We can reduce logistical difficulties with patients. No need to go to the clinic for a routine checkup. We can do high-frequency monitoring to get objective data. We can perform low-cost mass recruitment for clinical trials, and we can make population-scale screening feasible for the first time.

We have the opportunity to start to search for the early biomarkers of the disease before it’s too late.

 taking the first steps towards this today, we’re launching the Parkinson’s Voice Initiative. With Aculab and PatientsLikeMe, we’re aiming to record a very large number of voices worldwide to collect enough data to start to tackle these four goals.

We have local numbers accessible to three quarters of a billion people on the planet. Anyone healthy or with Parkinson’s can call in, cheaply, and leave recordings, a few cents each, and I’m really happy to announce that we’ve already hit six percent of our target just in eight hours.

4:43 Tom Rielly: So Max, by taking all these samples of, let’s say, 10,000 people, you’ll be able to tell who’s healthy and who’s not? What are you going to get out of those samples?

Max Little: Yeah. So what will happen is that, during the call you have to indicate whether or not you have the disease or not.

You see, some people may not do it. They may not get through it. But we’ll get a very large sample of data that is collected from all different circumstances, and it’s getting it in different circumstances that matter because then we are looking at ironing out the confounding factors, and looking for the actual markers of the disease.

TR: So you’re 86 percent accurate right now?

ML: It’s much better than that. Actually, my student Thanasis, I have to plug him, because he’s done some fantastic work, and now he has proved that it works over the mobile telephone network as well, which enables this project, and we’re getting 99% accuracy.

5:30 TR:  People will be able to call in from their mobile phones and do this test, and people with Parkinson’s could call in, record their voice, and then their doctor can check up on their progress, see where they’re doing in this course of the disease.

Numb at the Magnitude of the Unknown (Part 1, June, 2004)

It was May of 1975.  I had just graduated in Physics from the Lebanese university.

I secured a student visa to the United States of America. I was to study English for the summer at a university in Oklahoma.

I did not know then that there was more than one university in Oklahoma. The trip was not that urgent, but the civil war in Lebanon started to look serious.

My inborn stubbornness clenched the deal and off I left. It was my first trip away from family and home. I learned later that my mother played the fundamental role of convincing my father that it is time that I learn to be on my own.

My mother told me that the night I flew away my father cried his eyes out in his bed.

My father offered me $5,000. Two Lebanese pounds at the time was worth one dollar (Now, a single dollar is worth 1,500 LP)

I stayed in Paris for a couple of weeks visiting a student relative of mine. At the airport, no one searched me or welcomed me.

Before I exited the airport, an agent asked to search my luggage. Why me? No, it was Not a random search. I had to rearrange everything in my beaten suitcase.

Even then, France pinpointed specific passengers to be searched.

My cousin Nassif happened to be vacationing in England with a girlfriend. I met my friends Ghassan and Moussa who helped me rent a room where they stayed at a university complex for foreign students.

I toured Paris alone in metro and mostly on foot. Paris was gorgeous.

Breakfasts were delicious at the university low-ceiling breakfast restaurant .

There was another restaurant for lunch and dinner

Breakfast was the time to see all the various international students. The smell of fresh coffee, milk, bacon, eggs and fresh bread was appetizing.

The buffet was scattered with many varieties of fruits and drinks.

( I still dream of waking up to such a breakfast environment)

I landed first at New York at Laguardia airport. We were flying over the Oklahoma Territory, 22 hours after leaving Paris. We still had one hour to land.

It was pitched dark outside and I might have been feeling cold in the plane. One stewardess might have realized my haggard quietness.

An angel, no more than twenty years old, blonde, blue eyed, beautiful with a refreshing smile, and compassion transparent in her welcoming face.

She brought me a blanket without any request on my part and suggested to bring me some orange juice.

I felt then that it is okay to live in America and to know Americans. I wished I told her that I was scared, terrified, and numb at the magnitude of the unknown waiting for me.

I wished I told her that I needed to throw myself at her mercy and be helped.

I was lacking conversational skills and lacking practice in English.

I was not basically a social guy, though I enjoyed being among crowds.

Friends suffered me on account of my quietness:

I painfully resigned myself to the aura of bookish knowledge.




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