Community Welln…Actices Ppt

Community Wellness Community Wellness Through Improved Through Improved Maternity PracticesMaternity Practices

José J. Gorrín, MD, MPH, FACOGJosé J. Gorrín, MD, MPH, FACOGProfessor and DirectorProfessor and Director

Ana M. Parrilla, MD, MPH, FABMAna M. Parrilla, MD, MPH, FABMAssociate ProfessorAssociate Professor

Maternal and Child Health ProgramMaternal and Child Health ProgramGraduate School of Public HealthGraduate School of Public HealthUniversity of Puerto RicoUniversity of Puerto Rico

What is a Puerto What is a Puerto Rican?Rican?

One gets to be a Puerto Rican by One gets to be a Puerto Rican by various means. You are Puerto Rican if various means. You are Puerto Rican if you are born in Puerto Rico. You are you are born in Puerto Rico. You are Puerto Rican if your parents are Puerto Puerto Rican if your parents are Puerto Rican, even if you have never visited Rican, even if you have never visited the island, have never eaten the island, have never eaten arroz y arroz y habichuelas, habichuelas, and have never spoken a and have never spoken a word in Spanish. You can be a second word in Spanish. You can be a second or third generation Puerto Rican of or third generation Puerto Rican of mixed marriage, be acculturated to mixed marriage, be acculturated to American culture, but when asked, you American culture, but when asked, you say proudly, say proudly, “I am a Puerto Rican.”“I am a Puerto Rican.”

Gontran Lamberty

Historical overviewHistorical overview

The XIX century – agrarian society – The XIX century – agrarian society – birth as a family event – the traditional birth as a family event – the traditional midwifemidwife

Early XX century – high rates of fetal Early XX century – high rates of fetal and maternal mortalityand maternal mortality

Post WWII – health care reform – the Post WWII – health care reform – the medical model – hospital births, MD as medical model – hospital births, MD as main provider – main provider –

Change of paradigmChange of paradigm

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

Percent of Live Births Attended Percent of Live Births Attended by CNMs in the USA 1989-2000.by CNMs in the USA 1989-2000.

Vaginal

Total

Declercq E. Births Attended by CNMs in the US. Journal of Midwifery & Women’s Health 2003, 48, 83-4.

The Present Situation The Present Situation

Non-compliance with evidence-based Non-compliance with evidence-based obstetricsobstetrics ShavingShaving EnemaEnema IV fluidsIV fluids Withholding of oral nourishmentWithholding of oral nourishment Artificial rupture of membranesArtificial rupture of membranes Induction of laborInduction of labor Electronic fetal monitoring (78%)Electronic fetal monitoring (78%) Indiscriminate use of episiotomy (79-88%)Indiscriminate use of episiotomy (79-88%)

Tendency of Tendency of Episiotomy Use in USAEpisiotomy Use in USA

0

10

20

30

40

50

60

70

% Episiotomy 64 61.1 55.6 47.2 32.7

1980 1985 1990 1995 2000

%

2000 National Hospital Discharge survey: Annual Summary with detailed diagnosis and procedure data, Vital Health Statistics 13(153), 2002

The Present Situation The Present Situation (cont.)(cont.)

Widespread use of pharmacological Widespread use of pharmacological methods of pain reliefmethods of pain relief

Excessive rates of cesarean section Excessive rates of cesarean section and low VBAC ratesand low VBAC rates

Routine separation of mother and Routine separation of mother and her childher child

Inadequate support for Inadequate support for breastfeedingbreastfeeding

Tendencies in Cesarean Tendencies in Cesarean Section rates in Puerto Rico Section rates in Puerto Rico & USA& USA

15

20

25

30

35

40

45

CS - PR 31.6 31.3 31.6 31.2 29.7 31.5 33.4 35.1 37.8 39.1 42

CS - EEUU 22.6 22.3 21.8 21.2 20.8 20.7 20.8 21.2 22 22.9 24.4

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

National Vital Statistics Reports 49(13), 2001

%

Tendency of VBAC rates in Tendency of VBAC rates in Puerto Rico and USAPuerto Rico and USA

0

5

10

15

20

25

30

CS - PR 8.3 8.59 8.9 5.9 4.7

CS - EEUU 21.3 22.6 24.3 26.3 27.5 28.3 27.4 26.3 23.4 20.6 16.4

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

National Vital Statistics Reports 49(13), 2001

%

Evidence-based Evidence-based Research to Support Research to Support Ob PracticesOb Practices

Supine position – maternal hypotension, Supine position – maternal hypotension, placental insufficiency, placental insufficiency, pain, pain, labor, labor, depressed neonatesdepressed neonates

Maternal choices – analgesic effect, Maternal choices – analgesic effect, need need for drugs, shorter labor, better neonatefor drugs, shorter labor, better neonate

Shaving and enema – not supported – Shaving and enema – not supported – uncomfortable, humiliating, unnecessaryuncomfortable, humiliating, unnecessary

IV fluids – a surgical view - unsupportedIV fluids – a surgical view - unsupported


AROM – usually not indicated – IFM AROM – usually not indicated – IFM not valid excuse – eliminates not valid excuse – eliminates hydrostatic protection and barrier hydrostatic protection and barrier vs infectionvs infection

Induction – underreported - Induction – underreported - risks of risks of hyperbilirubinemia, need for drugs, hyperbilirubinemia, need for drugs, maternal stress, C/S, iatrogenic maternal stress, C/S, iatrogenic prematurity – WHO <10%prematurity – WHO <10%


EFM – promises unfulfilled – CP EFM – promises unfulfilled – CP rates unimproved after 30 years – rates unimproved after 30 years – routine use routine use not recommendednot recommended by by AAP/ACOG - AAP/ACOG - C/S rates, C/S rates, prolongued labor, prolongued labor, maternal maternal mobility, mobility, pain, pain, exhaustion, exhaustion, negative effect on initiation of negative effect on initiation of breastfeedingbreastfeeding


Pharmacological analgesia – Pharmacological analgesia – obstetrical and neonatal negative obstetrical and neonatal negative effects known for years - effects known for years - risks of risks of maternal fever, Apgar scores <7, maternal fever, Apgar scores <7, separation of mother/infant dyadseparation of mother/infant dyad

Cesarean section – USA HP 2010 Cesarean section – USA HP 2010 15.5% primary and 37% VBAC - 15.5% primary and 37% VBAC -

Recommended Public Recommended Public Health StrategiesHealth Strategies

Prenatal empowerment for the Prenatal empowerment for the pregnant couplepregnant coupleLegislation to authorize Legislation to authorize professional midwives as professional midwives as independent providersindependent providersDOH regulations for obstetrical DOH regulations for obstetrical practices and servicespractices and servicesThe Mother Friendly Childbirth The Mother Friendly Childbirth InitiativeInitiative

Coalition for Improving Coalition for Improving Maternity Services (CIMS)Maternity Services (CIMS)

The CIMS Mission The CIMS Mission

“…“…promote a wellness model of promote a wellness model of maternity care that will improve birth maternity care that will improve birth outcomes and substantially reduce outcomes and substantially reduce costs.”costs.”

““This evidence-based mother-, baby-, This evidence-based mother-, baby-, and family-friendly model focuses on and family-friendly model focuses on prevention and wellness as the prevention and wellness as the alternatives to high-cost screening, alternatives to high-cost screening, diagnosis and treatment programs.”diagnosis and treatment programs.”

Whereas:Whereas:

Current maternity and newborn Current maternity and newborn practices that contribute to high practices that contribute to high costs and inferior outcomes costs and inferior outcomes include the inappropriate include the inappropriate application of technology and application of technology and routine procedures that are not routine procedures that are not based on scientific evidence.based on scientific evidence.

Whereas:Whereas:

Increased dependence on technology Increased dependence on technology has diminished confidence in has diminished confidence in women’s innate ability to give birth women’s innate ability to give birth without interventions.without interventions.

The integrity of the mother-child The integrity of the mother-child relationship, which begins in relationship, which begins in pregnancy, is compromised by the pregnancy, is compromised by the obstetrical treatment of mother and obstetrical treatment of mother and baby as if they were separate units baby as if they were separate units with conflicting needs.with conflicting needs.

Whereas:Whereas:

Although breastfeeding has been Although breastfeeding has been scientifically shown to provide scientifically shown to provide optimum health, nutritional, and optimum health, nutritional, and developmental benefits to developmental benefits to newborns and their mothers, only a newborns and their mothers, only a fraction of US fraction of US (and Puerto Rican)(and Puerto Rican) mothers are fully breastfeeding mothers are fully breastfeeding their babies by the age of six their babies by the age of six weeks.weeks.

Whereas:Whereas:

The current maternity care The current maternity care system in the USA does not system in the USA does not provide equal access to health provide equal access to health care resources for women from care resources for women from disadvantaged population groups, disadvantaged population groups, women without insurance, and women without insurance, and women whose insurance dictates women whose insurance dictates caregivers or place of birth caregivers or place of birth

CIMS PrinciplesCIMS Principles

Normalcy of the Normalcy of the birthing processbirthing process

Birth is a normal, natural and Birth is a normal, natural and healthy processhealthy process

Women and babies have the Women and babies have the inherent wisdom necessary for birthinherent wisdom necessary for birth

Babies are aware, sensitive human Babies are aware, sensitive human beings at the time of birth, and beings at the time of birth, and should be acknowledged and should be acknowledged and treated as suchtreated as such

Normalcy of the Normalcy of the birthing processbirthing process

Breastfeeding provides the optimum Breastfeeding provides the optimum nourishment for newborns and infantsnourishment for newborns and infants

Birth can take place safely in hospitals, Birth can take place safely in hospitals, birth centers and homesbirth centers and homes

The midwifery model of care, which The midwifery model of care, which supports and protects the normal birth supports and protects the normal birth process, is the most appropriate for process, is the most appropriate for the majority of women during the majority of women during pregnancy and birthpregnancy and birth

EmpowermentEmpowerment

A woman’s confidence and ability A woman’s confidence and ability to give birth and to care for her to give birth and to care for her baby are enhanced or diminished baby are enhanced or diminished by every person who gives her by every person who gives her care, and by the environment in care, and by the environment in which she gives birthwhich she gives birth

EmpowermentEmpowerment

A mother and baby are distinct yet A mother and baby are distinct yet interdependent during pregnancy, birth interdependent during pregnancy, birth and infancy. Their interconnectedness is and infancy. Their interconnectedness is vital and must be respected.vital and must be respected.Pregnancy, birth and the postpartum Pregnancy, birth and the postpartum period are milestone events in the period are milestone events in the continuum of life. These experiences continuum of life. These experiences profoundly affect women, babies, profoundly affect women, babies, fathers, and families, and have fathers, and families, and have important and long-lasting effects on important and long-lasting effects on society. society.

AutonomyAutonomyEveryEvery woman should have the opportunity woman should have the opportunity

to:to:

Have a healthy and joyous birth Have a healthy and joyous birth experience for herself and her family, experience for herself and her family, regardless of her age or regardless of her age or circumstancescircumstances

Give birth as she wishes in an Give birth as she wishes in an environment in which she feels environment in which she feels nurtured and secure, and her nurtured and secure, and her emotional well-being, privacy, and emotional well-being, privacy, and personal preferences are respectedpersonal preferences are respected

AutonomyAutonomyEveryEvery woman should have the opportunity woman should have the opportunity to:to:

Have access to the full range of options Have access to the full range of options for pregnancy, birth, and nurturing her for pregnancy, birth, and nurturing her baby, and to accurate information on all baby, and to accurate information on all available birthing sites, caregivers, and available birthing sites, caregivers, and practicespracticesReceive accurate and up-to-date Receive accurate and up-to-date information about the benefits and risks of information about the benefits and risks of all procedures, drugs, and tests suggested all procedures, drugs, and tests suggested for use during pregnancy, birth, and the for use during pregnancy, birth, and the postpartum period, with the rights to postpartum period, with the rights to informed consent and informed refusal informed consent and informed refusal

AutonomyAutonomyEveryEvery woman should have the opportunity woman should have the opportunity to:to:

Receive support for making Receive support for making informed choices about what is informed choices about what is best for her and her baby based best for her and her baby based on her individual values and on her individual values and beliefs.beliefs.

Do no harmDo no harm

Interventions should not be applied Interventions should not be applied routinely during pregnancy, birth, or the routinely during pregnancy, birth, or the postpartum period. Many tests, postpartum period. Many tests, procedures, technologies and drugs carry procedures, technologies and drugs carry risks to mother and baby, and should be risks to mother and baby, and should be avoided in the absence of specific avoided in the absence of specific indications for their use.indications for their use.

If complications arise during pregnancy, If complications arise during pregnancy, birth or the postpartum period, medical birth or the postpartum period, medical treatments should be evidence-basedtreatments should be evidence-based

ResponsibilityResponsibility

Maternity care practice should be based Maternity care practice should be based not on the needs of the caregiver or not on the needs of the caregiver or provider, but solely on the needs of the provider, but solely on the needs of the mother and child.mother and child.

Each hospital is responsible for the Each hospital is responsible for the periodic review and evaluation, periodic review and evaluation, according to current scientific evidence, according to current scientific evidence, of the effectiveness, risks, and rates of of the effectiveness, risks, and rates of use of its medical procedures for use of its medical procedures for mothers and babies.mothers and babies.

ResponsibilityResponsibility

Society, through both government and Society, through both government and the public health establishment, is the public health establishment, is responsible for ensuring access to responsible for ensuring access to maternity services for all women, and maternity services for all women, and for monitoring the quality of these for monitoring the quality of these

Individuals are ultimately responsible Individuals are ultimately responsible for making informed choices about the for making informed choices about the health care they and their babies health care they and their babies receive.receive.

Ten Steps of the Ten Steps of the Mother-Friendly Mother-Friendly Childbirth Initiative Childbirth Initiative

For Mother-Friendly Hospitals, For Mother-Friendly Hospitals, Birth Centers, and Home Birth Birth Centers, and Home Birth ServicesServices

Step 1Step 1

Offers all birthing Offers all birthing mothers unrestricted mothers unrestricted access to the birth access to the birth companions of her companions of her choice, including choice, including fathers, partners, fathers, partners, children, family children, family members and friendsmembers and friends

Step 1 - Step 1 - continuationcontinuation

Offer all birthing Offer all birthing mothers unrestricted mothers unrestricted access to continuous access to continuous emotional and emotional and physical support from physical support from a skilled woman – for a skilled woman – for example, a doula, or example, a doula, or labor-support labor-support professionalprofessional

Step 1 - Step 1 - continuationcontinuation

Offers all Offers all birthing birthing mothers mothers access to access to professional professional midwifery caremidwifery care

Step 2Step 2

Provides accurate descriptive and Provides accurate descriptive and statistical information to the statistical information to the public about its practices and public about its practices and procedures for birth care, procedures for birth care, including measures of including measures of interventions and outcomes.interventions and outcomes.

Step 3Step 3

Provides culturally Provides culturally competent care – that is, competent care – that is, care that is sensitive and care that is sensitive and responsive to the specific responsive to the specific beliefs, values and beliefs, values and customs of the mother’s customs of the mother’s ethnicity and religionethnicity and religion

Step 4Step 4

Provides the birthing Provides the birthing woman with the woman with the freedom to walk, move freedom to walk, move about and assume the about and assume the position of her choice position of her choice during labor and birth during labor and birth (unless restriction is (unless restriction is specifically required) specifically required) and discourages the and discourages the use of the lithotomy use of the lithotomy positionposition

Step 5Step 5

Has clearly defined policies Has clearly defined policies and procedures for:and procedures for: Collaborating and consulting Collaborating and consulting

with other maternity serviceswith other maternity services Linking the mother and baby to Linking the mother and baby to

appropriate community appropriate community resources, including resources, including breastfeeding supportbreastfeeding support

Step 6 Step 6

Does not routinely employ practices Does not routinely employ practices and procedures that are unsupported and procedures that are unsupported by scientific evidence, such as:by scientific evidence, such as: ShavingShaving EnemasEnemas IV fluidsIV fluids Withholding nourishmentWithholding nourishment Artificial rupture of membranesArtificial rupture of membranes Electronic fetal monitoringElectronic fetal monitoring

Step 6 Step 6 – continuation– continuation

Other interventions are limited as Other interventions are limited as follows:follows: Induction rate of 10% or lessInduction rate of 10% or less Episiotomy rate of 20% or less, with a Episiotomy rate of 20% or less, with a

goal of 5% or lessgoal of 5% or less Total cesarean rate of 10% or less Total cesarean rate of 10% or less

(15% in tertiary care hospitals)(15% in tertiary care hospitals) VBAC rate of 60% or more with a goal VBAC rate of 60% or more with a goal

of 75% or moreof 75% or more

Present situation in Present situation in several countriesseveral countries

Until 1970 – almost universal Until 1970 – almost universal practice in first birthspractice in first birthsSome countries ca. 2000:Some countries ca. 2000: Holland Holland 8%8% FranceFrance 28.2%28.2% BelgiumBelgium 28.4%28.4% USAUSA 32.7%32.7% HungaryHungary ca. 100% ca. 100% Puerto RicoPuerto Rico 79.3%79.3%

““The episiotomy is a The episiotomy is a ritual of genital ritual of genital

mutilation in western mutilation in western obstetrics”obstetrics”

Maternal risks of a Maternal risks of a Cesarean sectionCesarean section

5-7 x maternal mortality5-7 x maternal mortality

Complications during and after Complications during and after surgery:surgery:

Trauma to bladder, uterus and blood vessels 2%Trauma to bladder, uterus and blood vessels 2% Hemorrhage: 1-6% require transfusionsHemorrhage: 1-6% require transfusions Anesthesia accidentsAnesthesia accidents Thrombotic phenomena 6-20/1000Thrombotic phenomena 6-20/1000 Pulmonary emboli 1-2/1000Pulmonary emboli 1-2/1000 Paralytic ileus 10-20/ 100, 1% severeParalytic ileus 10-20/ 100, 1% severe Infection 50% greater rateInfection 50% greater rate


10% have difficulties performing 10% have difficulties performing normal activities 2 months laternormal activities 2 months later25% report pain as their main problem25% report pain as their main problem2x greater risk of hospitalization2x greater risk of hospitalizationNegative emotions, low self-esteem, Negative emotions, low self-esteem, sense of failure, loss of control, post sense of failure, loss of control, post traumatic stress syndrome, fear and traumatic stress syndrome, fear and anxietyanxietyLower probability of wishing another Lower probability of wishing another pregnancypregnancy


Long term risks:Long term risks: Pelvic painPelvic pain Painful coitusPainful coitus Bowel problemsBowel problems

Increased risk of: infertility, Increased risk of: infertility, miscarriage, placenta previa, abruptio miscarriage, placenta previa, abruptio placenta and premature birthplacenta and premature birthRisk of uterine rupture - 1/500 vs Risk of uterine rupture - 1/500 vs 1/1000 in women without uterine scars 1/1000 in women without uterine scars (including planned repeat CS)(including planned repeat CS)

Hazards of a C/S to the Hazards of a C/S to the babybaby

50% more likely to have low Apgar 50% more likely to have low Apgar scoresscores5x more likely to require respiratory 5x more likely to require respiratory assistanceassistance4x more likely to be admitted to NICU 4x more likely to be admitted to NICU for respiratory problems for respiratory problems 1-2% will be cut during the surgery1-2% will be cut during the surgeryIatrogenic prematurity Iatrogenic prematurity 4x more likely to develop persistent 4x more likely to develop persistent pulmonary hypertension, a life-pulmonary hypertension, a life-threatening situationthreatening situation

Hazards of a C/S to the Hazards of a C/S to the babybaby

More likely to have difficulty More likely to have difficulty forming an attachment with forming an attachment with mother due to the mother’s mother due to the mother’s situationsituation

Less likely to be breastfedLess likely to be breastfed

Hazards of elective Hazards of elective repeat C/Srepeat C/S

2x greater risk of maternal death2x greater risk of maternal deathOld scar increases the likelihood of Old scar increases the likelihood of surgical injurysurgical injuryGreater risk of ectopic pregnancy Greater risk of ectopic pregnancy (leading cause of maternal mortality in (leading cause of maternal mortality in 11stst. trimester). trimester)Placenta previa:Placenta previa: 4x with 1 C/S 4x with 1 C/S 7x with 2-3 C/S7x with 2-3 C/S 45x with 4 or more C/S45x with 4 or more C/S

Hazards of elective Hazards of elective repeat C/Srepeat C/S

Abruptio placenta 4xAbruptio placenta 4x

Placenta accretaPlacenta accreta 1/1000 with 1 previous C/S1/1000 with 1 previous C/S 1/100 with more than 1 C/S1/100 with more than 1 C/S

More hemorrhages, transfusions, More hemorrhages, transfusions, blood clots and infectionblood clots and infection

More difficult post partum recoveryMore difficult post partum recovery

Step 7Step 7

Educates staff in non-drug Educates staff in non-drug methods of pain relief, and does methods of pain relief, and does not promote the use of analgesic not promote the use of analgesic or anesthetic drugs not or anesthetic drugs not specifically required to correct a specifically required to correct a complicationcomplication

Step 8Step 8

Encourages all mothers Encourages all mothers and families, including and families, including those with sick or those with sick or premature newborns or premature newborns or infants with congenital infants with congenital problems, to touch, problems, to touch, hold, breastfeed, and hold, breastfeed, and care for their babies to care for their babies to the extent compatible the extent compatible with their conditionswith their conditions

Step 9 Step 9

Discourages Discourages non-religious non-religious circumcision of circumcision of the newbornthe newborn

Are there risks with circumcision?

Bleeding and hemorrhageBleeding and hemorrhage

Infections Infections

Anesthesia complications Anesthesia complications

Surgical failure, including loss of Surgical failure, including loss of the glans or of the penis the glans or of the penis

DeathDeath

Many circumcised men Many circumcised men suffer from:suffer from:

Extensive scarringExtensive scarringRedundant skin tags Redundant skin tags Bleeding from the scar Bleeding from the scar Penile curvature Penile curvature Painful and tight erections Painful and tight erections Impotence Impotence Sense of personal violation Sense of personal violation Sense of mutilation Sense of mutilation Every Every circumcised male loses some circumcised male loses some sensitivity in the glans penissensitivity in the glans penis

““Routine circumcision is Routine circumcision is not a medical or social not a medical or social issue. It is a sexual issue. It is a sexual principle and a human principle and a human rights principle.rights principle.""

Frederick HodgesFrederick Hodges

Male and female Male and female circumcision should be circumcision should be aggressively attacked aggressively attacked as an act of mutilation as an act of mutilation

and sexual violence and sexual violence against boys and girls.against boys and girls.

Step 10Step 10

Strives to achieve the Strives to achieve the WHO-UNICEF “Ten WHO-UNICEF “Ten Steps of the Baby-Steps of the Baby-Friendly Hospital Friendly Hospital Initiative” to promote Initiative” to promote successful successful breastfeedingbreastfeeding

Ideals vs. Reality in USA & PRIdeals vs. Reality in USA & PR BirthsBirths

WHO WHO RecommendatioRecommendatio

nsns

CIMS CIMS SuggestionsSuggestions

USA 2001 USA 2001

(4 million)(4 million) PR 2001PR 2001

(57,000)(57,000)

Birth Birth AttendantsAttendants

Midwives for normal pregnancy

& birth

Access to professional

midwifery care

Physicians 91.4%91.4%

(3.6 million)

Physicians 99.8%99.8%

Place of birthPlace of birth Out of Hospital preferred

Where mother prefers

Hospitals 99.1%99.1%

(3.9 million)

Hospitals 99.7%99.7%

Electronic Electronic Fetal Fetal

MonitoringMonitoring

Not routine Not routine 84.8%84.8% (3.3 million)

78%78% (in 1997)

Drugs in LaborDrugs in Labor Not routine Only for complications

80%80% Not available

Programa de Salud de la Madre y el Niño, Escuela Graduada de Salud Pública, Recinto de Ciencias Médicas, Universidad de Puerto Rico 2003.Modified from: Ideals vs. Reality in US Births. BirthNet 2001.

Ideals vs. Reality in USA & PRIdeals vs. Reality in USA & PR Births Births

continuationcontinuation

WHO WHO RecommendationRecommendation

ss

CIMS CIMS SuggestionsSuggestions

USA 2001 USA 2001

(4 million)(4 million) PR 2001PR 2001

(57,000)(57,000)

Induction of Induction of LaborLabor

10% or less 10% or less 20.5%20.5% (819,000)

6.6%6.6% (in 1997)

Stimulation of Stimulation of LaborLabor

Not mentioned 10% or less 17.5%17.5% (702,000)

16.6%16.6% (in 1997)

EpisiotomiesEpisiotomies Systematic use not justified

20% or less, with a goal of

5% or less

32.7%32.7% (944,000)

79.3%

Cesarean RateCesarean Rate 10-15% 10-15% 24.4%24.4% (978,000)

42%42%

Breastfeeding Breastfeeding after birthafter birth

Immediately Within an hour of birth

68.4%68.4% During hospital stay

not necessarily immediately

54.3%54.3% During hospital stay

not necessarily immediately

Programa de Salud de la Madre y el Niño, Escuela Graduada de Salud Pública, Recinto de Ciencias Médicas, Universidad de Puerto Rico 2003.Modified from: Ideals vs. Reality in US Births. BirthNet 2001.

It’s time to get some

respect for mommy

and for me!…

HUM!

I am not an advocate for frequent changes in I am not an advocate for frequent changes in laws and constitutions. But laws and laws and constitutions. But laws and

institutions must go hand in hand with the institutions must go hand in hand with the progress of the human mind as that becomes progress of the human mind as that becomes more developed, more enlightened, as new more developed, more enlightened, as new

discoveries are made, new truths discovered discoveries are made, new truths discovered and manners and opinions change. With the and manners and opinions change. With the change of circumstances, institutions must change of circumstances, institutions must

advance also to keep pace with the times. We advance also to keep pace with the times. We might as well require a man to wear still the might as well require a man to wear still the coat which fitted him when a boy as civilized coat which fitted him when a boy as civilized society to remain ever under the regimen of society to remain ever under the regimen of

their barbarous ancestors. their barbarous ancestors.

Thomas JeffersonAuthor of the Declaration of Independence of the United States of

America

““La mujer es la La mujer es la fragua, la unidad de fragua, la unidad de la raza, la unidad de la raza, la unidad de una civilización, la una civilización, la

unidad de un unidad de un pueblo.”pueblo.”

Don Pedro Albizu CamposDon Pedro Albizu Campos

Hanna

Ana Sofía Marla Pedro Alberto

Cristina

Las tetas – Salinas, Puerto Rico

Community Welln…Actices Ppt

Health & Medicine