Frontier Bound this past week enrolled 49 students with an almost even split between CNEP and CFNP students. I interviewed several students at random to give you a flavor of those enrolled in each program.

Reina Pat Ellis came to us from Hawaii via Omaha, Nebraska where she just completed her BSN. Reina was an indigenous midwife in a very rural area of the big island of Hawaii for 31 years and I was curious about why she was taking the step to be a nurse-midwife at this time.

Reina had known that she wanted to be a midwife when she was 5 years old. While playing with her girlfriend, she came upon a book belonging to her friends’ mother, a midwife from Britain. In that book, she saw a picture of a midwife’s hands holding the emerging head of a baby at birth. The image was deeply emblazoned on her mind and when she became of age she went to that midwife and asked how her to teach her how to become a midwife. The midwife handed her the book and told her to pray for guidance as she opened it. For two years, Reina studied with the midwife weekly and began to attend births. However, it seemed that every time she opened the book she would learn of another complication, which then played out, in her practice. She asked the midwife why she was having so many problems with the women she cared for and the midwife replied that she is being tested for being a midwife is a work that requires courage, knowledge and skill.

Over the years, Reina attended many women who had no one to turn to for care – sometimes as many as 10 -12 a month. She apprenticed five students, three of whom became nurse-midwives. She always yearned to be a nurse-midwife. Therefore, she enrolled in nursing school to prepare for becoming a Certified Nurse-Midwife. During her senior year, she was asked to leave because she attended a home birth. There were no regulations prohibiting her from doing this so she was devastated by the decision. Nevertheless, people kept encouraging her not to give up and to go to Frontier for she would love it there. Seven years later, she enrolled in nursing at the University of Nebraska. Upon completion of her BSN at age 51, (she is not the oldest student to enroll at Frontier) Reina is on her way to realizing the fulfillment of her long years of yearning to be a nurse-midwife.

Reina said that by coming to Frontier she has learned that there are people who truly believe in midwifery and the mission of caring for and serving women. She feels she ahs come home. Reina will return to Hawaii and wants to make it possible for others to come to Frontier for there is truly a frontier there in the care of underserved women and families.

During the course of the week of orientation, many students express that they feel like they have “come home’ to a company of people who truly care about what is happening to women in childbirth and are doing something about it. One student asked if I thought we could keep this spirit alive as we grew to a much larger number of students. I replied that we know that is one of our challenges and continually work on ways to prevent the program from losing the spirit of Mary Breckinridge and the many others who brought us to this point in time.

Roberta Ward is a CNEP graduate of 2002 who has returned to study to be a Family Nurse- Practitioner. Her grandmother was an indigenous midwife in Yakutat, a small, isolated village north of Juneau Alaska... Her mother is a Community Health Practitioner there. With complete support of her husband (she wanted me to mention that for without his support she could not do it), she is enrolled in the FNP track to learn more - broaden the spectrum of women’s health, family health and particularly mental health to eventually work in one of the outlying villages of Alaska,. She is hoping that Level 3 will be less stressful this time. Last time she left Alaska on the last plane out of Anchorage on September 11, 2001. She arrived in Hyden via Seattle, San Jose, Dallas, Knoxville, and Louisville and by car rental to Hyden, 2 days after Level 3 started.

Jennelle Sperchinger came to the United States from Zambia, Africa in 2002 to go to nursing school in Georgia as the first step toward becoming a nurse-midwife. She currently works in a burn unit for there are many serious burn patients in Zambia and she wanted to learn how best to care for them with the limited resources available. Children get too close to the fire or they are victims of accidental boiling water spills. (Reminiscent of Mary Breckinridge’s account of the accidental injuries to children in Kentucky) Jennelle grew up in Zambia, the daughter of missionary parents. She knew two midwives in Zambia, one from Britain one from America. She hope to work in one of a number of clinics set up by the church in outlying areas where there is no one to staff them. The maternal and infant mortality in those areas is very high. Midwives do all the normal births in Zambia. Jennelle found Frontier on the internet while in nursing school. She feels it is the perfect program for her because it is well rounded and it will teach her how to set up and run a clinic.

When I asked Jennelle what her salary would be in Zambia, she replied, nothing – I didn’t go into nursing to make money. She has a brother who is learning to be a pilot for the missionary transport fleet that takes people and supplies to and from the villages. (I flew with that group when I went to Haiti). A second brother died at age 11 in Zambia of unknown causes – “there was no way to do an autopsy.”

Every student has a unique story. I wish I could share them all with you. I think you can see why the students inspire us to keep moving the mission to educate nurses in midwifery and family nursing practice. We should be exporting midwives not war!

If you like these stories, we will try to capture more at the next Frontier Bound. Let us hear from you. Tell us your stories!!!

If you have been to the School in the past year, you have no doubt become acquainted with the family of cats that have taken up residence here. For those of you who do not know, last spring a beautiful black mother cat brought her three little black kittens here, and they have made their home here since.

Many of the visitors we have had here have asked us about these cats, about how they came to be here, who feeds them, and, as always, what we plan to do when these cats have kittens. For all of you who wondered, Leslie County P.A.W.S., or Program for Animal Welfare, is helping us to keep our kitty family from growing. P.A.W.S. is the brainchild of Anna Carey, whom some of you might remember from her various positions within the Frontier Nursing Service organizations.

Stray cats have been a problem in Hyden for sometime, as they are in many places where the cat population is allowed to grow unchecked. We hadn’t noticed, here, until the problem presented herself, and her three kittens, on our doorstep.

As much fun as these kitties are to have around, we knew that their numbers would increase exponentially if we did not have the cats sterilized. Last fall, we were able to trap (yes, trap – these cats are wild) the three kittens and have them spayed. It was a good thing we did, because all three were girls. However, the mother cat eluded us, and in the meantime had two more kittens. I trapped one of the kittens and took him to my house. His name is Bonaparte, and he is doing well. The other, named Clorox because she looks like someone splattered bleach all over her, is still here, but I will be trapping her to take to my brother soon.

We managed to catch the mother cat, finally, and have had her spayed, thanks to a contribution from P.A.W.S. This program hopes to make it possible, through donations and facilitation of state funds, to help people in our community get their animals spayed and neutered.

ur kitties here are lucky – they have all of us to feed and care for them. Animals in your community may not be so lucky, and that is why, if you can, you should help your local animal welfare society, by donating of your time, money, or other resources. It’s not as expensive as it seems; every little bit, whether it be a couple dollars or a couple cans of food, can help. And, if you, like us, are happy to see that P.A.W.S. helped our school’s cat family, then show P.A.W.S. you care – the next time you are here in Hyden, leave a little donation with me, or with Billie Couch. P.A.W.S., and our little cat family, will appreciate it!

Now that you have a topic for your research project, it’s time to actually do the research. This does not, despite what you may have heard; have to be the hardest part of the project.

Before you even go to Google (and don’t deny that you Google things, everyone does it), an online database, or even the index of a textbook, think of all the different ways your topic can be expressed. Some topics will be fairly straightforward, and there may be only one or two ways that this topic can be expressed. These topics, however, are quite rare.

Think, for instance, of this topic: adolescent experience of pregnancy. If you do a database search for “adolescent experience of pregnancy,” you will probably find a respectable number of search results. However, if you also search “teen AND pregnancy AND adaptation,” chances are you will find several search results that you did not find in the first search. In other words, think of all the different words that can be used to express your topic, and search all of them.

After you have made your mental list of all the ways to look for your topic, you are ready to begin searching. The first thing to remember is this: the more resources that you use, the better your project will be. That begins with the databases you choose to begin your topic search.

Databases are, just as the name implies, bases full of data. However, not all databases work in the same way. Some, like Ebsco or Proquest, search for exactly what you type in. Others, like PubMed, use a thesaurus (lists of similar terms) that searches not only for the exact word or phrase you put in, but for any other term or phrase that could be used to describe the same thing – i.e. hypertension AND high blood pressure.

Some students use one database, Ebsco, for example, and become married to it. They never think to search for information on any other database. This kind of searching behavior limits the parameters of what you will find. If there are 4 databases available to you, search all 4. You will be surprised at the differences you will see in your results. This will also keep you from becoming frustrated when that Ebsco search doesn’t yield the number of results that you need!

And speaking of databases – are you using them to their fullest abilities?

Take trusty Ebsco for example. If you are only choosing the Medline and Cinahl databases when you are doing a search, then you are missing out! When you choose databases, think carefully about all the different aspects of your topic, and choose all the databases that could cover that topic. For example, if you are searching for information about the adolescent experience of pregnancy, don’t stop at just Medline and Cinahl. Also choose Academic Search Premier, which indexes a wide array of journals in medicine, psychology, sociology, and education, PsychInfo and Psychology and Behavioral Sciences Collection, which index journals in psychology, psychiatry, counseling, and mental health fields, and, ERIC, the educational index (it’s a good idea to search ERIC anytime you are researching a topic related to school-aged children and young adults).

When you find that perfect article in Ebsco, don’t forget to use the subject headings within the article abstract to help you search for similar articles. Just click on the subject heading that is closest to your subject, which will open up a new search results page. If you still don’t find what you want, just go up to the search fields, leave Ebsco’s pre-entered subject heading in the top field, and then put some more words to narrow the subject down in the next one.

ProQuest has a similar feature, only it’s easier; when you find the article of your dreams in ProQuest, subject headings you might find useful will be listed on the search results page. Don’t rule out using these to help guide the research process.

PubMed can also help you to use the best articles you find to get the rest that you need. When you find the articles you need in PubMed, don’t forget to click on the “related articles” link that is always just to the right of either the citation or the abstract. These are articles that are similar in subject matter to the article they are tied to.

Once you have found one or two articles that are exactly what you are looking for, make your life much easier by looking at the works the authors of these articles have cited. Use these articles, if you need to. In fact, if you can find three articles, in most cases, you can find the rest of the sources you will need by seeking out the sources cited in the three articles.

Don’t just stop at journal articles when doing research – don’t forget about books, and, even, in some cases, websites. The easiest way to find books is to go to the First Search database in the library website’s “Literature Searching” page. You can also find books cited in some of the articles you have found, or in a textbook that has an entry about your topic. You can even use a textbook, if it’s known to be an authority in the field you are researching.

Last, don’t forget websites. But be careful – not just any website will do. Check out these tips for evaluating a website’s veracity:

• What is the address? If it ends in .gov, you’re safe. The gov means it’s a site sponsored by the US Government. If it ends in .edu, it comes from a school, and you are probably safe, too – but check to make sure it isn’t a student’s work you are looking at (see “Who wrote this?” for more info on this). If it ends with .org, that means it is a recognized organization – however, just because an internet service domain provider recognizes this organization doesn’t mean you should. Have you ever heard of this organization? Is this organization trustworthy? Most of the time – unless there is really compelling evidence to the contrary - you should stay away from .coms.
• What does the page look like? Is it well organized? A page with information worth using will always be well-organized. Is information easy to find? If not, stay away. Is there contact information for the person, school, or organization clearly listed? If not, beware; someone with well-researched information will be more than happy to let the world know that she is responsible for it. Are there advertisements? If so, what for? If you are greeted with a barrage of pop-ups for free services, close the internet windows and step away from the computer – you won’t be using this site!
• Who wrote this? Most websites provide some information about who wrote the content contained within its pages. Is there an author’s name somewhere on the page? What can you find out about the author? If there is no info about the author on the page, Google the author. If her credentials are impressive, then use it. If no author is listed, unless it is a page sponsored by an organization – i.e. the American Heart Association – or school whose information you know you can trust, then don’t use it.
• When was this written? After you have established that the site and the author are bonafide, look at the date. If there’s not one, forget about using this information – you have no idea when it was produced. Has the page been updated recently? If not, the information is probably stale.

If you are wondering what websites are left after you narrow your choices down according to these standards, then take heart. Medline Plus ( http://medlineplus.gov/ ) is a great starting place for finding reputable websites, as is The National Library of Medicine (http://www.nlm.nih.gov/), and the National Institutes of Health (http://www.nih.gov/).

ext time, we will discuss how to sort through the research, once you’ve got it….

Francie Likis, FSMFN Faculty and CNEP Class 20 Graduate, received the Gary Stewart Scholarship for Research in Public Health on September 9, 2005 at the Association of Reproductive Health Professional’s Annual Meeting. This award goes to an outstanding public health graduate student who proposes a significant research project that addresses a pressing current issue in the field of public health, especially as it may pertain to reproductive health, and related public welfare issues. Francie will use the scholarship for her dissertation research.

The primary purpose of her research is to learn about North Carolina certified nurse-midwives' emergency contraceptive pill knowledge, attitudes, and practice patterns, and the factors that influence these. The secondary purposes are to describe characteristics of CNMs practicing in North Carolina, and the contraceptive methods they discuss with and prescribe for their patients.

Easy European Chicken Salad (20 servings)

1. 5 whole fryers, cut in pieces/or 20 chicken breasts
2. 2-3 bunches of purple grapes, cut in half
3. 50oz. sweet pickle relish
4. 3 bottles of Durkee's Famous Sauce
5. 10 stalks of celery, chopped fine
6. 1 bunch green onion, chopped fine
7. 8 boiled eggs, chopped
8. mayonnaise
9. curry powder

Boil the chicken in salted water until done (don't overcook chicken, as it will become tough.)

Let cool then dice. Mix all ingredients together, adding the amount of mayonnaise needed to make a smooth blend. Sprinkle with curry powder. OPTIONAL: Sprinkle the top with toasted silver almonds.

On August 24 thru 29, 2005, the Frontier School of Midwifery and Family Nursing hosted the largest Frontier Bound that we have seen in over 10 years. A wonderful group of new students graced us with their presence for five days. The group was made up of 24 nurse-midwifery students, 22 family nurse-practitioner students and 1 women’s health nurse practitioner student for a grand total of 47 students. This is the largest group of family nurse practitioner students that we have had at any Bound since the program started in 1999. The WHCNP program is our newest program and word about that program is slowly getting out. We are getting more and more inquiries to the program every day. We are happy to say that our recent accreditation by the Southern Association of Colleges and Schools has certainly had an effect on inquiries and enrollments.

Our alumni received the “You Should Be Catching Babies” card in the mail in June 2005. This card encouraged alumni to give this card to an exemplar nurse who they thought would be a great midwife. The card included a coupon for the recipient entitling then to $25.00 off the application fee. To date, we have received two coupons back from applicants. If you still have you card, get it out now and give it to a deserving nurse. Thanks to all of you for building the profession. Our quarterly marketing reports show us consistently that most students first hear about our programs from graduates. Good work Alumni!!!

On September 15, 2005 the Frontier Nursing Service sponsored a Ralph Stanley Concert at the Nixon Center in Hyden, Kentucky. This was one of the many events scheduled to celebrate 80 years of the FNS providing health care services to the people of the region. FNS, realizing that we could have never done all of the good work that has been accomplished during this past 80 years without the support of the people, wanted to do something special for the community.

For those of you who don’t know too much about Bluegrass Music, Ralph Stanley is known as one of the best banjo pickers and tenors in the industry today. He has performed Bluegrass Music for over 55 years. He is a composer, plays both banjo and mandolin and has produced many CDs. He is also a member of the Grand Ole Opry.

Level Three Students Cathie DeLee and Pam Stubblefield Enjoy Bluegrass Music

Many staff from the School enjoyed the Concert.

Sue Stone and Julie Marfell had their picture taken with Ralph Stanley

Thank you for inviting me to speak- and congratulations to all of you. Did you ever think you would get here? Congratulations to your families and friends who I know supported this endeavor ( it’s really over ) as well as the faculty and staff of the Frontier School of Midwifery and Family Nursing, the BOD the whole FNS. It really is a group effort and I can appreciate the effort that you all have put forward to arrive at this day.

When I asked my husband Jack what he thought I should talk about he said “About 10 minutes” so I will take his good advice and be brief.

As a new graduate in 1974, I had very concrete goals. I wanted Clinical Experience with other people around to help me –especially for sewing up the tears, shoulder dystocia and pp hemorrhage and inserting IUDs!

Great doctor Jim Brew who believed that midwives were best for women and even more radically that healthy women could deliver as safely at home as in the hospital. He was a blessing and he was gutsy.

There are physicians who want to help you succeed. They have done so much to move midwifery forward often in the face of great personal pressure from their colleagues. Charley Mahan is one of those physicians who has always promoted nurse midwifery. We all need to remember those docs when we complain about the ones who aren’t so helpful.

I have one clinical pearl and some political pearls to pass along.

The clinical pearl is called Stop Look and Listen.
(before you cross the street use your eyes, use your ears, and then use your feet) It works for midwives and NPs. You will make fewer mistakes if you SLL.

Stop-Before you engage the patient; pause and redirect all your attention to the person on the other side of the door. Stop that chatter in your head (write it down if you need to and do it later). Make it a habit. Your attention is for this woman, this family right now.

Look- Make eye contact what do you see? What impression do you get? Take it all in. Is she cautious, afraid, relaxed, tense, angry, disconnected, in pain? Is she alone or with someone and what can you learn from that person.How is she dressed, what is the body language? If there are children there how do they relate to each other. It is important. And Sometimes how a person looks and what they say are contradictory.

Listen- No matter how important the information we would like to give her it is secondary to the information she has for us.   
Ask “What would you like to talk about today?” And give her a minute to get it together. Don’t worry about the chart focus on her. Everyone has concerns and even if you do not get one right away she will be pleased that you asked and eventually she will tell you what is on her mind. Then she is freer to listen to what is on your mind.

When dealing with health problems, about 80% of the time people know what is wrong with them. Some think they shouldn’t say anything because that’s your job. So if you want to make the correct diagnosis ask the person what she thinks is wrong. What do you think this is? Listen-maybe they won’t have the technical words but they have a good idea and they know they need help. So listen for the answer. You will be considered brilliant diagnostician..
Stop Look and Listen for the answer-it is simple and it works.

Now the Political Pearls
.
I actually live in Washington DC which is a federal city and not part of any state. And you may not realize that although we can vote for President of the US we do not have any voting representation in the US Congress .  No Senators  represent us (you all have two) and we have non-voting Congresswoman (Eleanor Holmes Norton) in the House of Representatives. We pay both federal income tax . When you can’t vote you realize what you have lost. I have a sticker on my car “No taxation without representation” A half a million people living in our nations capitol we are disenfranchised. That fires my interest in politics.
We also have the highest infant mortality rate in the country-worse than some 3rd world countries. I think there is a connection

I know that health care policy and politics play an enormous role in how midwives practice. It defined my scope of practice and it will define yours. I predict that one day soon you will soon look up from your clinical practice and ask “What, where, why, how and who is making clinical practice difficult for me and the women and families I am trying to serve ??

Who made the rules governing billing, contracts, credentialing, productivity, scope of practice,  licensing, malpractice insurance, and other barriers to providing the kind of care you are envisioning today.

On that fine day you will begin your lifelong learning in the field of policy /politics/ financing of health care. Knowledge is power and being connected politically at the local level can have enormous advantages for you and the families you serve.

So after a year of emersion in your clinical practices, I think some of you will dive into the political scene where you live and others will stand around the edges trying to sort out what is happening. This is a good thing.

Register to vote. Make your office or your website a place where your families can register to vote. Join with other groups to make changes. Get involved in the local chapter, the BON, other like minded groups of NP  Beyond that…

Question candidates for office. Do they support CNMs and NPs. Do they support health care for the uninsured?  If YES, send them money. Volunteer to work on their campaigns. If they win you have an ally in the state legislature.

You all are so good at communicating with people you will be wonderful in the political mix as well. People will respect your expertise as a health care provider. They will believe you because you are a nurse (and people believe that nurses are overworked and underpaid). When they realize that you are a nurse-practitioner or a nurse-midwife and you care for the underserved, you are the voice of experience, reality and reason.

Kitty Ernst and Ruth Lubic have been exemplar leaders for us. If they can do this and work the political system, so can we.

 There are a lot of nurses who are state legislators.  In New Hampshire, Charlotte Houde-Quimby is nurse-midwife state Representative. She and a college friend of mine Eileen Flockhardt were both elected in 2004. Eileen called me recently to tell me how impressive Charlotte was speaking in support of making “Plan B” available in New Hampshire! This saves the state money and it is safe. So we have Eileen who had a midwife attended birth (me) and Charlotte speaking out for midwives in NH.

We have only 49 states left! Then we can get some sensible health care legislation passed, like health insurance that covers all Americans-  In 2004,  over 45.8 million people were uninsured in the US.

In the next 10 years if each midwifery education program (there are 42) graduated two midwives/NP, who won state legislative seats we could make our voices heard across the country. We could talk about the cost of health care and the consequences of having such a huge number of uninsured people.

 Here are the consequences for having so many uninsured people in the US.

A new study by Families USA says that by the end of 2005, nearly 48 million people will be uninsured. That Now Exceeds the Cumulative Population of 24 States and the District of Columbia. That is a national disgrace!
 
We know that people without insurance wait longer to get care if sick, and come in through the ER door where they pay about 1/3 of their bill out of pocket.  Who pays the rest of the bill?

The remaining sum (almost $ 43 billion for 2005) is primarily paid by two sources: roughly 1/3 by government programs and two thirds is paid by people with health insurance through higher premiums: all of us.

To get more personal, in Kentucky by the end of 2005,
 The total cost for the uninsured after their out of pocket contributions will be $679 million dollars.

The cost for a family policy will be $1,086 HIGHER in 2005 to cover the costs for the uninsured.

More people become uninsured in KY each year. By the end of 2005, 601,000 Kentuckians will be uninsured. By 2010,  that number will climb to 668,000.

These are very troubling numbers that need to be addressed. This will not go away. We need to bring everyone into the health care system and we need to provide appropriate evidenced based care to the US population. We can do better for less costs. We spend more per capita on health care than any other country in the world and we remain at about 16th in infant mortality among developed countries. We must do better.

CNMs and NP get outcomes equal to physician outcomes,  they cost less to educate, and employ and use fewer unnecessary costly resources saving money for the system. State legislators need to understand these issues.

Health care costs are driving the decisions on state and federal programs. You can educate legislators and create new opportunities for yourselves and for the families you serve. You are truly tomorrow’s leaders.  Go for it.

The entire faculty was in attendance as well as the FSMFN Board of Directors. The number of graduates able to attend the ceremony this year was small; only 18 out of a total of 71 graduates in attendance. But when you added in all of their proud family members, we had a crowd of over 200 in the Community Center. There were many tears and memorable comments from the family and friends as the graduates slowly marched into the auditorium to Pomp and Circumstance. “I see her, I see her”. “Isn’t she beautiful?”

Marion McCartney, CNM, Director of Professional Services at ACNM gave the graduation speech. That is published elsewhere in this newsletter. Awards were given to Sheridan Skarl for her participation in the Student Council and Amy Burger for her work as the Mi Amiga Coordinator. Nena Harris received the Kitty Ernst Leadership Award.
Everyone looked beautiful and very well educated in their caps and gowns. 

At the end of the ceremony, the multi media team played two DVDs; the first was a photo CD of all the graduates of 2005 in their various experiences during their time as a student at Frontier. The music was “I Will Remember You”. Next they played our old standard video “It’s In Every One of Us”. I believe we all shed a few tears of happiness.

After graduation, there was a reception with snacks and a beautiful cake. And not to be forgotten, many students came up to the School with their families and rang the chapel bell. The whole town of Hyden knows that the students at Frontier are either starting their studies, starting their clinical experience or finishing their education when they hear the FSMFN chapel bell ringing. It was a joyful day.

Developing a Better Understanding of How Natural Disasters Can Affect Pregnancy

Natural disasters such as hurricanes, floods, earthquakes and tsunami’s affect millions of people each year.  Lives are lost, loved ones are separated or missing and psychological trauma is inevitable.  Now imagine that you are pregnant and the magnitude of the situation becomes even greater.  This is exactly what happened to Jill.  Jill was 32 weeks pregnant, with her first child, when Hurricane Katrina struck.  Jill was a college professor at a university in New Orleans.  She was forced to relocate because her house was located in a flood zone.  She and her husband drove for over 2 days to get to New Hampshire so that they could stay with her parents.  Her parents live in a 1 bedroom house so Jill and her husband were staying in the basement.  Once the storm had cleared, it was evident that their home and all their belongings were destroyed.  The city she had once called home was devastated.  She is now homeless, jobless and expecting her first child in 8 short weeks.  Because Jill’s mother is well connected in the community, Jill was able to get into see a midwife and establish prenatal care in the area.  Jill’s only other risk factor, during this pregnancy, has been with depression.  Jill is not the only pregnant woman who has been displaced by a natural disaster, therefore, this paper will explore the affects of natural disasters on pregnancy and if post traumatic stress disorder is real concern for these women.

Hurricane Katrina occurred just after Labor Day in September 2005.  The expanse of this natural disaster reached over multiple states; devastating homes, communities and entire cities.  This particular disaster displaced over hundreds of thousands of people.  Survivors of the hurricane spent long hours, in over crowded shelters, that weren’t adequately set up to handle amount of people within them.  Others were forced to their rooftops until they could be rescued.  And still others found themselves on a deserted patch of highway (Voelker, 2005).  The American Psychiatric Association and The American Red Cross sent mental health professionals to the shelters in order to provide professional services to the survivors.  Most of the work was crisis intervention.  Long term work to help these victims will need to be ongoing because mental health repercussions for thousands of overwhelmed survivors likely had not yet surfaced (Voelker, 2005).

The immediate aftermath of a natural disaster can leave people scrambling around for food, shelter, safety, and water.  This can pose a real threat for pregnant women and newborns in particular.  Finding drinking water and food that is not contaminated can be difficult or near impossible.  The survivors will need to be educated on how to decontaminate the food and water prior to consuming it.  If the water is contaminated it may contain bacteria that could cause a serious intestinal disease (March of Dimes, 2005).

It will also be important to avoid the areas affected by the hurricane.  The mere act of walking in the contaminated water can expose the pregnancy to toxic waste or bacterial infections.  If a pregnant woman is exposed to a toxic substance, and is concerned, there is a hotline number posted for them to call on the March of Dimes website.  It is imperative that rescue workers are knowledgeable about the resources available to help protect the women and children in events of natural disasters.

For most women, pregnancy is a time for hope, excitement, and exploration.  Pregnancy also signals change.  Change to one’s body, lifestyle and family.  These changes often add stress to ones life.  However, stress is not always bad.  Stress, when managed properly, “can provide us with the drive to meet new challenges” (March of Dimes, 2005). Pregnancy is also a time when concern is heightened, as a natural instinct, to protect their unborn child.  If a threat, such as a natural disaster, is added to their situation then feelings of stress can build.  Natural disasters can evoke feeling of fear, anxiety, guilt, depression, shock, anger, helplessness, hopelessness and emotional numbness (Young, Ford, & Watson, 2005).  However, increased stress in pregnancy can potentially cause some serious health problems such as:  lowered resistance to infectious diseases, high blood pressure, and heart disease.  “Studies also suggest that high levels of stress may pose special risks during pregnancy, such as, preterm labor and low birth weight” (March of Dimes, 2005).  However, it is important to understand that people react differently to different situations. 

The most common symptom of a traumatic event is anxiety (Foa, Hembree, Riggs, Rauch, & Franklin, 2005).  People who have been exposed to natural disasters often see the world as filled with danger, causing their bodies to constantly be on alert.  This feeling often becomes uncomfortable if it occurs over a long period of time (2005).  These emotions and symptoms, if left untreated, are precursors for a condition referred to as Post Traumatic Stress Disorder (PTSD).

Post traumatic stress disorder, according to the DSM IV is defined as a, psychiatric disorder characterized by a wide range of symptoms that have developed in response to a significant and overwhelming stressful incident or from chronic exposure to intolerable stressful conditions.  The individual experiences the stressful incident or incidents as a life-or-death threat to his or her safety and personal integrity.  He or she often witnessed death or extremely horrendous conditions in which the life or integrity of others is threatened or actually occurs (Mahan, 2004, pg 1245)

PTSD can be difficult to recognize and treat because everyone experiences life differently.  However, there are common factors that can influence the development of PTSD.  The first factor to consider is the persons’ developmental level at the time of exposure to the traumatic event (2004).  Children do not typically have the life experiences necessary to buffer the traumatic event and put it into perspective.  Therefore understanding where the person was developmentally during the trauma will go a long way in helping to diagnose and treat PTSD.

The second factor to look at is what the person’s length of exposure was.  The literature shows people are less likely to develop long term effects after a short exposure to a traumatic event versus a long term persistent exposure (such as ongoing abuse) (Mahan, 2004).   The next factor to examine is the person’s temperament and personality.  A person’s personality and temperament can either buffer the experience or potentiate it (2004).  In addition to considering a person’s personality is to consider their family history of psychiatric illness.  A family history of psychiatric illness can predispose a person toward developing PTSD (2004).

Other additional factors that may influence how a person reacts to a traumatic event is the person’s proximity to the event, the severity of the experience, the nature of the traumatic situation and the availability of help immediately following the tragedy.  It has been shown that early intervention can help minimize the development or the severity of PTSD (Mahan, 2004).   It is also important to remember that not everyone exposed to a traumatic event will develop PTSD.  Some people are more vulnerable to stress while other people are more resilient to different stressors (2004).

The clinical presentation for people suffering from PTSD fall into three different types:  re-living the experience, avoidance of the situation and being in a state of increased arousal (CDC, 2005).  The first symptoms of reliving include,

flashbacks, nightmares, and extreme emotional and physical reactions of the event. 
Emotional reactions can include feeling guilty, extreme fear of harm, and numbing of
emotions.  Physical reactions can include uncontrollable shaking, chills or hear
palpitations, and tension headaches (CDC, 2005).

The second types of symptoms include avoidance of situation.  These include:  “staying away from activities, places, thoughts or feeling related to the trauma or feeling detached or estranged from others” (CDC, 2005).  The final groupings of symptoms include those of increased arousal.  This can be characterized as, “being overly alert or easily startled, difficulty sleeping, irritability or outbursts of anger, and lack of concentration” (2005).  In addition to the above listed symptoms, other symptoms that have been linked to PTSD include, “panic attacks, depression, suicidal thought and feelings, drug abuse, feeling of being estranged and isolated, and not being able to complete daily tasks” (2005).

Common strategies used to reduce normal stress in pregnancy should be reinforced after an exposure to traumatic event.  Such strategies include:  eating properly, getting proper rest, and exercising regularly. If these strategies do no prove to be effective, then additional measures will need to be taken.  Any person showing signs of PTSD should be referred to a therapist for psychotherapy.  If therapy is not working then pharmacologic interventions may be necessary to treat the underlying condition be it anxiety or depression.  Also close monitoring for suicidal ideation is imperative.  Ideally, recognition of the problem will be the key to finding the right treatment options for the individual.  Careful surveillance by the health care provider, after a natural disaster, can go a long way to minimizing the long term consequences to the woman and her family.  Due to the significance of these natural disasters and their affects on pregnancy, a variety of studies have been done to look at what a role natural disasters play during pregnancy.  A few of these studies have been summarized below in an attempt to develop a clearer understanding of what role natural disasters can play during pregnancy.

One study looked at the morbidity and pregnancy outcome of those women involved in the Taiwan 921 earthquake (Chang, Chang, Lin, & Kuo, 2002).  What they found was that increased stresses may be associated with higher rates of psychiatric morbidity (2002).  The research also revealed that PTSD symptoms were more prevalent in women, preschool children and elderly over 65 who were exposed to extreme stresses (2002).  The most significant pregnancy related morbidity was found to be an increase in low birth weight infants.  They attributed the low birth weight to “maternal history of abdominal injury, spouse casualty and instability in living conditions” (Chang, Chang, Lin, & Kuo, 2002, p. 143).

Another study by C. Loveland Cook et al. examined PTSD in pregnancy paying closer attention to women in the lower socioeconomic environment.  What their study revealed was that posttraumatic stress disorders “significantly increased the probability of alcohol abuse and dependence.  Neuroendocrine changes associated with chronic stress influence maternal-fetal health, including maternal vulnerability to hypertension and increased susceptibility to infection (Loveland Cook et al. 2004, p. 715).  The study also revealed that women with PTSD had more pregnancy related complications such as:  ectopic pregnancies, miscarriages, hyperemesis, and preterm contractions.  In addition, they also found that the “underlying mechanisms of how this disorder affects these outcomes are unknown” (Loveland Cook et al. 2004, p. 715).   The study also stresses the importance of screening for risk factors of PTSD during pregnancy.  “Identification of risk factors in this study demonstrate that women with posttraumatic stress disorder were 5 times more likely to have a major depressive episode, 3 times more likely to have generalized anxiety disorder, and more then 6 times more likely to have a history of multiple traumatic events (Loveland Cook et al. 2004, p. 716).  Some of the approaches used to help these women, according to the research, included:  offering supportive counseling, teaching stress reduction techniques, initiating support groups, supporting continuity of care with the same provider, scheduling more frequent visits, and initiating telephone calls between visits (2004).  Another study by Holly Kennedy and Emily MacDonald recognized the importance of developing a birth plan for women suffering from PTSD (2002).  They found that a birth plan would place some control back to the woman during labor (2002).

Another big decision to make following a natural disaster is whether or not to relocate after the event.  In the case of Hurricane Katrina, most survivors were not given the option of returning to their home and relocation was their only alternative.  One research study looked at the affects of relocating after a natural disaster.  What they found was that “relocating did not diminish the prevalence of PTSD in the adults who witnessed the earthquake and were displaced” (Najarian et al., 2001, p. 521).

The findings suggest that remaining at the site of the disaster was associated with a quicker recovery and healing (2001).  They go to report that, “relocated adults are at particularly high risk for depression in addition to PTSD and a variety of other psychiatric symptoms” (Najarian et al., 2001).  The study results suggest providing direct aid to the victims, maintain them in their natural environment and expedite the reconstruction process (2001).

References
CDC. (2005). Coping with a traumatic event. Retrieved October 15, 2005, from http://www.cdc.org

Chang, H., Chang, T. C., Lin, T. Y., & Kuo, S. S. (2002). Psychiatric morbidity and pregnancy outcome in a disaster area of Taiwan 921 earthquake. Psychiatry and Clinical Neurosciences, 56, 139-144.

Foa, E. B., Hembree, E. A., Riggs, D., Rauch, S., & Franklin, M. (2005, February 8). Common reactions to trauma. Retrieved October 16, 2005, from http://www.ncptsd.va.gov/facts/disasters

Keeney, G. B. (2004). Resources for providing care for women and infants in disasters and low resource settings. Journal of Midwifery & Women's Heath, 49(4), 42-45.

Kennedy, H. P., & MacDonald, E. L. (2002). "Altered consciousness" during childbirth:  Potential clues to post traumatic stress disorder? Journal of Midwifery & Women's Health, 47(5), 380-382.

Loveland Cook, C. A., Flick, L. H., Homan, S. M., Campbell, C., McSweeny, M., & Gallagher, M. E. (2004). Posttraumatic stress disorder in pregnancy:  Prevalence, risk factors, and treatment. The American College of Obstetricians and Gynecologists, 193(4), 710-717.
Mahan, N. S. (2004). Posttraumatic Stress Disorder. In T. M. Buttaro & J. Trybulski (Eds.), Primary care a collaborative practice (2nd ed., pp. 1245-1250). St. Louis: Mosby.

March of Dimes. (2005, October 5). Hurricane Recovery. Retrieved October 16, 2005, from http://www.marchofdimes.com

Najarian, L. M., Goenjian, A. K., Pelcovitz, D., Mandel, F., & Najarian, B. (2001). The effect of relocation after a natural disaster. Journal of Traumatic Stress, 14(3), 511-526.
Voelker, R. (2005). Katrina's impact on mental health likely to last years. Journal of American Medical Association, 294(13), 1599-1600.

Young, B. H., Ford, J. D., & Watson, P. J. (2005, July 8). Survivors of natural disasters and mass violence. Retrieved October 16, 2005, from National Center for PTSD Web Site: http://www.nctptsd.va.gov/facts/disasters/fs_survivors_disaster.html

The American College of Nurse-Midwives held an invitation only summit in Arlington, Va. on September 9 and 10. The meeting was called by the ACNM Board of Directors in response to growing concerns that the future supply of CNMs and CMs will not meet the expanding need for women's health and obstetric care in the US, particularly for vulnerable populations. Key stakeholders including certified nurse-midwives, certified midwives from a variety of settings, student nurse-midwives, one obstetrician/gynecologist, representatives from HRSA and the National Rural Health Association were present. The task was to explore methods to increase the effectiveness of midwifery education in the US. The meeting was lively with much discussion centered on how to increase the number of nurse-midwives graduating each year as well as prepare excellent graduates to respond to identified health care needs of women. A report of the proceedings is expected to be released by ACNM in the near future. Nena Harris, a current student in the CNEP program was one of two students invited to attend the summit.

Amy Marowitz always knew she wanted to be a midwife. Yet the journey along her chosen career path has followed a circuitous route that has taken her from her native Ohio to western Leelanau County, from the bustle of Midwest academia to a remote Indian reservation, and from the prevailing nursing philosophy of childbirth as medical crisis to an outlook that embraces this most natural rite of passage.

In college, Amy at first declined the expected option of nursing school, feeling it would be “too prescribed; a hoop to jump through”. Instead, as an anthropology student at the University of Michigan in the late 1970s, she found freedom to explore the rich worlds encompassed in diverse societies, traditions and points of view.

“You learn about the importance of cultures, and how that affects human behaviors,” Amy says. Now, “As a practitioner of midwifery, you see that there is more than one right way,” to approach a woman and her family in the birthing process, to support her and help ensure a positive experience. Such a respectful attitude might seem alien in the prevailing allopathic (MD) world of obstetrics and gynecology, where “Doctor knows best,” is still the norm, and technology plays an ever-increasing role in determining a birth’s outcome.

“The clock is the biggest invention that has affected how the birthing process is perceived,” she states. “A lot of ‘rules’ of practice in labor and delivery in hospitals is based on 1950s statistical research. Often there’s no science to support the many rules,” such as when a woman should push during labor.

The 1970s saw a dramatic rise in midwife-attended births, as the feminist, back-to-the-land, and consumer movements all helped educate women about their bodies, their babies and their rights as health care patients. After completing her degree at U-M, Amy headed to St. Louis University in an accelerated RN program, She attended home births for a year under the guidance of Detroit-area lay midwifery pioneer Kathy Nunez, but eventually decided to return to school for an advanced degree in nurse-midwifery at the University of Colorado.

“We [nurse-midwives] have a foot in both worlds. It’s a very complex place to be,” she explains. Lay or direct-entry midwives primarily attend home births, as well as offer some prenatal and post-natal care to mother and child. Nurse-midwives, with their clinical and academic background, typically work in hospitals or birth centers. Amy acknowledges that there are some conflicts between the two branches, but points out the validity and need for both.

“Philosophically, I’m more aligned with direct-entry midwifery,” she explains. “But to be able to move around the country and get a job in a hospital or birth center, there are more job opportunities,” for certified nurse-midwives, as well as more scope for related health practices, like family nursing.

Amy worked at St. Joseph Hospital in Ann Arbor, and for the Indian Health Service in the Navaho Nation in Arizona, before hearing the call of northern Michigan, where she’d vacationed as a child at Camp Innisfree (now Camp Leelanau-Kohana).

“Oddly, in the early 1990s, there were only two obstetricians in Traverse City,” Amy says. “Munson Hospital decided to start a midwifery service, and I was hired in 1992,” along with fellow Innisfree alumna and nurse-midwife Nancy Gallagher. In northern Michigan, Amy was also destined to meet and marry Glen Arbor’s own Ron Kramer, a social worker who now works for the state. By a strange coincidence, Ron’s cousin Pat Kramer was a leading figure in Ann Arbor’s midwifery movement of the 1980s, although she and Amy had never met downstate.

Midwifery, whether practiced by direct-entry or nurse-midwives, is an intense, demanding profession. The term literally means to be “with woman,” and midwives spend a great deal of time with their clients during births, sometimes as long as a couple of days. Increasingly, Amy found the rigors of her practice to be incompatible with her desire to be a more hands-on parent to her daughter Addie, then two. In 1994, she had begun working part-time as an online instructor through the Frontier School of Midwifery and Family Nursing, based in Hyden, Kentucky. In 1997, she quit her half-time job at Munson to teach nearly full-time for Frontier out of her home office on Wheeler Road.

“My work is intellectually challenging, which I love, although I do miss some of the intensity of attending births. I love how my job fits with my life, how I can do it at different times of the day,” around parenting Addie and now Eli, age six. “Of course, the thing I like least about it is also the lack of boundaries,” a common issue with those who work at home.

Amy feels fortunate to be affiliated with Frontier, a preeminent institution that has educated nurses in maternal and family health care issues since the 1920s. Founded by Mary Breckinridge, a wealthy Southern aristocrat (whose own tragedy of losing two children led her to a lifetime of service in the remote Appalachian region), Frontier’s visionary mission was first carried out by British-trained nurses on horseback. In the 21st century, Frontier now reaches women all over the world via cyberspace, offering master’s degrees in nursing in both midwifery and family health, and sending desperately needed expertise into rural and underserved areas both here and abroad.

“The school is amazing, with a huge variety of people, age spread, social backgrounds, and points of view,” Amy exclaims with the ardor of the anthropologist.

Her teaching focuses on the intrapartum, or labor-birth phase of pregnancy, with academic courses that build a solid foundation of knowledge for students, using actual case studies, online forums, and tools such as life-sized models of a female pelvis and fetus (students later go on to clinical studies all over the country that are monitored by Frontier). A big part of Amy’s teaching involves identifying “normal” labor to birth attendants.

“Most of my students have been labor and delivery nurses, but they don’t know what a normal, non-interventionist birth looks like,” she states. Even with nurse-midwives, “there’s enormous pressure on them to perform inductions [forcing labor], fetal monitoring and epidurals. Hospital obstetrical culture is very powerful; even if you don’t believe in it, it’s hard not to go along with traditions” that have taken on the verity of second nature.

Yet she sees hope for the future, even as she looks back along a personal and professional path shaped in ever-widening spirals. As a result of Frontier’s accreditation in 2003 to offer masters’ degrees, Amy now finds herself back in the role of student. Revisiting her anthropology roots, she’s in the process of earning her PhD online, studying international health science, and plans a dissertation on midwifery-related issues.

“It’s broadened my perspective,” she says, and mulls the enticing possibility of someday traveling to Africa, to train midwives and study firsthand the cultures she’s come to love through her academic learning.

“It’s not what I ever imagined I’d do originally,” with midwifery, Amy concludes. “Although I miss attending births and having that impact on one woman’s experience, I can do so much more,” says the educator, mentor, and lifelong student of humanity, gazing from her window on the world in rural Leelanau County.