On today’s podcast, we will be sharing with you an excerpt from a live webinar featuring Dr. Rebecca Dekker all about debunking the myths of Premature Rupture of Membranes, GBS, & Waterbirth.
- The Updated Evidence on Premature Rupture of Membranes – There are two new meta-analyses on GBS– but they have limitations and cannot be applied to countries that screen and treat GBS. New guidelines are included from ACNM, ACOG & the Association of Ontario Midwives.
- The myths on GBS – We review what the microbiome is, the influence of probiotics, and why antibiotics are used.
- How Waterbirth can be used for labor – We covered the differences in association guidelines of waterbirth, as well as, reviewed the significant results for the risks and benefits of waterbirth from the largest and highest-quality study on waterbirth to date!
This podcast breaks down the topics for parents and professionals to be informed and empowered!
Resources and References
Russell, N. J., Seale, A. C., O’Driscoll, M., et al. (2017). “Maternal colonization with Group B Streptococcus and serotype distribution worldwide: Systematic review and meta – analyses.” Clinical Infectious Diseases 65 S2: S100 – 2111. Steer, P. J., Russell, A. B., Kochhar, S., et al. (2020). “Group B streptococcal disease in the mother and newborn — a review.” Eur J Obstet Gyneco Reprod Biol 252: 526 – 533. Conway, D. I., Prendiville, W. J., Morris, A., et al. (1984). Management of spontaneous rupture of the membranes in the absence of labor in primigravid women at term. Am J Obstet Gynecol , 150(8), 947 – 951. Morales, W. J., & Lazar, A. J. (1986). Expectant management of rupture of membranes at term. South Med J, 79(8), 955 – 958. Pintucci , A., Meregalli , V., Colombo, P., et al. (2014). Premature rupture of membranes at term in low risk women: how long should we wait in the “latent phase”? J Perinat Med, 42(2), 189 – 196. Shalev, E., Peleg, D., Eliyahu, S., et al. (1995). Comparison of 12 – and 72 – hour expectant management of premature rupture of membranes in term pregnancies. Obstet Gynecol , 85(5 Pt 1), 766 – 768. Zlatnik , F. J. (1992). Management of premature rupture of membranes at term. Obstet Gynecol Clin North Am, 19(2), 353 – 364. Shaw – Battista, J. (2017). Systematic Review of Hydrotherapy Research: Does a Warm Bath in Labor Promote Normal Physiologic Childbirth? J Perinatal Neonatal Nurs . Hanson, L., Van de Vusse , L., Forgie , M., et al. (2023). “A randomized controlled trial of an oral probiotic to reduce antepartum group B streptococcus colonization and gastrointestinal symptoms.” Am J Obstet Gynecol MF. 5:100748. Hanson, L., Van de Vusse , L., Malloy, E., et al. (2022). “Probiotic interventions to reduce antepartum group B streptococcus colonization: A systematic review and meta – analysis.” Midwifery 105: 103208. Carter, S. E., Ong, M. L., Simons, R. L., et al. (2019). The effect of early discrimination on accelerated aging among African Americans. Health Psych 38(11), 1010 – 1013. Hutchings, M., Truman, A. W., Wilkinson, B. (2019). “Antibiotics: Past, present and future.” Current Opinion Microbiology 51: 73 – 80. Boyer, K. M. and Gotoff , S. P. (1985). “Strategies for chemoprophylaxis of GBS early – onset infections.” Antibiot Chemother 35: 267 – 280. Tuppurainen , N. and Hallman, M. (1989). “Prevention of neonatal group B streptococcal disease: intrapartum detection and chemoprophylaxis of heavily colonized parturients .” Obstet Gynecol 73(4): 583 – 587. Matorras , R., Garcia – Perea , A., Madero, R., et al. (1991). “Maternal colonization by group B streptococci and puerperal infection; analysis of intrapartum chemoprophylaxis.” Eur J Obstet Gynecol Reprod Biol 38(3): 203 – 207. Van Dyke, M. K., Phares, C. R., Lynfield , R., et al. (2009). “Evaluation of universal antenatal screening for group B streptococcus.” N Engl J Med 360(25): 2626 – 2636. Hannah, M. E., Ohlsson, A., Farine , D., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. N Engl J Med, 334(16), 1005 – 1010. Hannah, M. E., Ohlsson, A., Wang, E. E., et al. (1997). Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term: The role of induction of labor. Term PROM Study Group. Am J Obstet Gynecol , 177(4), 780 – 785. Imseis , H. M., Trout, W. C., & Gabbe , S. G. (1999). The microbiologic effect of digital cervical examination. Am J Obstet Gynecol , 180(3 Pt 1), 578 – 580. Middleton, P., Shepherd, E., Flenady , V., et al. (2017). “Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term.” Cochrane Rev. CD:005302. Delorme, Pl, Lorthe , E., Sibiude , J., et al. (2021). “Preterm and term prelabour rupture of membranes: A review of timing and methods of l abour induction.” Best Practices Research Clinical Obstet Gyncol 77: 27 – 41. Bovbjerg , M. L., Cheyney, M., & Caughey , A. B. (2021). “Maternal and neonatal outcomes following waterbirth: A cohort study of 17,530 waterbirths and 17,530 propensity score – matched land births.” BJOG 129 (6): 950 – 958. Taylor, H., Kleine , I., Bewley, S., et al. (2016). “Neonatal outcomes of waterbirth: A systematic review and meta – analysis.” Arch Dis Child Fetal Neonatal Ed, 101(4), F357 – 365. Vanderlaan , V., Hall, P. J., and Lewitt , M. (2017). “Neonatal outcomes with water birth: A systematic review and meta – analysis.” Midwifery 59.
- Read the New Evidence Based Birth® Signature Article on Anti-Racism in Health Care and Birth Work (and links to all the free handouts) here
- Check out the EBB Pocket Guide to Interventions here
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- Find an EBB Childbirth Class here
Dr. Rebecca Dekker:
Hi, everyone. On today’s podcast, you’re going to listen to a replay of a webinar where I debunk three myths about Group B Strep, premature rupture of membranes at term, and waterbirth. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi, everyone. Welcome to today’s episode of the Evidence Based Birth® Podcast. This is Dr. Rebecca Decker. Pronouns, she/her. I’ll be your teacher for today’s episode.
Today, I’m so excited to share this replay with you of a very popular webinar we hosted where we debunked myths on Group B Strep, premature rupture of membranes or when your water breaks, and waterbirth. Before we get started, I have an important announcement for you. We are opening applications for the Evidence Based Birth® Instructor Program in two weeks. The EBB Instructor Program is designed for experienced birth workers and healthcare workers who want to teach EBB continuing ed workshops, the full Evidence Based Birth® childbirth class or both. Applications open on Tuesday, June 6th and close on Monday, July 3. If you are admitted to the program, you can begin your studies in August of 2023. If you want to learn more, just go to ebbirth.com/instructor and sign up for one of our free Q&A webinars about becoming an instructor. Applications for this program only open once per year. If you want to train this fall to become an instructor and start teaching EBB classes, head to ebbirth.com/instructor right now to get an invitation to the Q&A webinar and find out more about how to apply. Now, I’m excited to take you to a replay of the webinar we did. If you didn’t get a chance to attend live, this was a really fun educational session where I took three myths that we’ve been seeing perpetuated online and debunk them with the research evidence. Without further ado, I’m going to take you to the recording and let you participate.Hi, everyone. Welcome to the webinar offered by Evidence Based Birth® this spring about the evidence on Group B strep, PROM, and waterbirth. Just a content note before we get started, Group B strep info can be upsetting to some. We’ll be talking about infections, medical interventions, and rates of newborn death and infection. I just want to give you a heads-up that when we get to the Group B strep and PROM side, we will be talking about that. The other thing I wanted to do real quick, I have a few polls. Go ahead and let me know if this is your first webinar with Evidence Based Birth®. I’d love to see how many new people are with us today. Welcome. We have a lot of new attendees. Just a little more than half of you are attending your first webinar with Evidence Based Birth®.
We offer these free webinars to the public twice a year, every April and October. The next question I wanted to know is, “What is your role in the healthcare field?” Are you a childbirth educator, doula, nurse, midwife, parent or parent to be, physician student, or other? Put other in the chat. We probably have some lactation consultants. For some reason, that’s not on the list. We have some students here, a nurse practitioner. Variety of therapists, birth assistants. Awesome. Okay. I’m going to go ahead and share the results with you all. It looks like a lot of you picked doula as your primary role in the healthcare system. Also, let us know in the chat if we have anybody who’s pregnant right now or is having their first baby. That’s always really exciting.I also love it when we can welcome grandparents. Sometimes we have grandparents attend our webinars. Let us know what you’ve got going on, if you feel comfortable sharing in the chat. Looks like we got a lot of people listening who are pregnant with their first, second, third, and even their fifth. Welcome, everyone. Another question I have for you all is, “How many of you have personally experienced premature rupture of the membranes, which is defined as water breaking before the start of labor?” Yes, no, or if not applicable to you. It’d be fun to see how many of us have personally experienced this. I know I experienced it with my first baby and did not experience it with my second and third.
We’re going to talk more about how this might change the labor or birth experience. It looks like about one out of four people who’ve been pregnant have experienced PROM. About half of you who’ve been pregnant have not. One more question I want to know, before we get started, just so I can know what’s going on in your lives, how common is waterbirth where you live? This is one you can pick more than one option. Is it only available at home births? Is it available in freestanding birth centers, one or two hospitals, or all of your local hospitals? If it is available in a hospital near you, tell us the name of that hospital or the city where you live. It’s fun to see where this is an option. Okay. Look like we got some people from the Netherlands, South Africa, Minnesota.
When I say waterbirth, I mean actually giving birth under the water. I see some hospitals listed that I know do not do waterbirth. For example, University of Kentucky, that’s in my hometown. They do not offer waterbirth. They do offer water labor. We’ll talk a little bit more about the difference between those two. Awesome. Okay. So most of you say that waterbirth is available at home births, about half of you at freestanding birth centers, and 42% of you say one or two hospitals nearby. That’s increased a lot in the last 10 years. We’ll talk a little bit more about why when we get to the waterbirth section. What we’re going to do today is debunk three myths about Group B Strep, PROM, and waterbirth. We’re going to dive into the research evidence.
I’m going to share with you statistics from actual studies to give you a sense for how we can use information to investigate different opinions that are offered online. So how will today’s webinar work? So I’ll be doing some teaching, and then at the end, we’ll do a Q&A. Our team will be collecting the questions and I will select a few to answer at the end. Unfortunately, with hundreds of people here, I cannot answer everyone’s question, but we do have a place that people can go to ask questions for those of you who become members of Evidence Based Birth®. So what I’m going to cover today, I’m going to talk specifically about the microbiome and Group B Strep. I’m going to talk about induction of labor for premature rupture of membranes, when your water breaks before the start of labor.
I’m going to conclude by talking about the benefits and risks of waterbirth. So are you ready to get started with the research and with the evidence? If so, give me a big yes in the chat box or whatever exclamation you want to use and we’ll get started. All right. We got hundreds of people who are like, “Yes, let’s get going.” Okay, let’s go. So what is GBS and how common is it? Group B is a streptococcus bacteria that lives in the intestines and anywhere from 8 to 35% of US can carry GBS when we’re pregnant.
Now, most of the time, this strep bacteria is physiological, which is a fancy way of saying it’s normal for your body, but it can cause infections when the immune system is suppressed, such as if you’re on chemotherapy or you’re elderly or have diabetes or if your immune system is immature, such as if you are a newborn. So early onset GBS disease is an infection of GBS that can occur on day zero to six days of life and it’s caused by Group B Strep gaining access to the amniotic fluid or the waters that the baby is floating around inside of you. This infection, this disease usually begins after the water breaks but before the birth. We know this because the majority of babies with early onset GBS disease are sick at delivery.
So they are born with this disease, the sickness, this bacterial sickness, and that’s why we know it typically happens before birth. So it’s not something that they’re necessarily catching right as they come out, but they’re catching it when they’re still up inside of you and the GBS has gained access to the amniotic fluid. What is PROM? So PROM is pre-labor or premature rupture of membranes. We call it PROM. It’s how it’s abbreviated. It’s identified when the water breaks before the start of labor. You can have term PROM, sometimes called T-PROM, which happens 37 weeks or later. You can have preterm PROM or P-PROM, which happens before 37 weeks. We’re going to be focusing on this presentation on term PROM, which happens about 10% of the time.
Then the graph I have on the right-hand side is showing this research statistics on how frequently you’ll go into labor within 12 hours, 24 hours, or 48 hours. So if your water breaks before the onset of labor at term, about half of you will go into labor within 12 hours on your own without needing an induction. 77% would go into labor within 24 hours and 90% would go into labor within 48 hours. On the other hand, it may take longer for you to go into labor if it is your first birth. We’re not sure why, but research shows that if it is your first time having a baby, there is a higher chance you might have to wait longer than 48 hours to give birth. About 20% chance that it will take longer than 48 hours for your contractions to start on their own.
Now, waterbirth is the other topic we’re going to be covering today. So water immersion in labor is when a person is in a tub of water during the first stage of labor, when you’re dilating up to 10 centimeters. Waterbirth is when you remain in the tub during the pushing phase in the actual birth of the baby. So the baby emerges under the water and then is lifted to the surface to take their first breath. Now, it may sound funny, but in research studies on waterbirth, they actually use the term land birth when they’re telling us that someone is born on dry land, not in a tub. So basically, if you’re giving birth in a bed or standing out of the water, that’s a land birth. Hydrotherapy is another term you see in the research. That could mean water immersion in labor and/or waterbirth.
It’s important to separate are we talking about water immersion in labor or waterbirth, because the two things can have different benefits and risks. There’s some overlap. Obviously, both of them, for example, may help with pain relief, but there’s different risks and benefits when we’re talking about the baby actually emerging underwater. One more thing before I dive into the three myths that I want to debunk is give you some tips for looking at information online. It’s really fascinating to me how fast information can spread on social media, even more so today with TikTok and our rapid spread of information and our short attention spans. So things go viral very quickly. Here are some tips that we teach in our Evidence Based Birth® Childbirth class for looking at information.
So is what the person is saying, does it sound too good or too scary to be true? For example, when I was in college, I got a phone call telling me that I had won an all-expenses paid trip to the Caribbean. This was really sounding good to me. Unfortunately, it was not true. On the other hand, you can use a lot of scary fear-based language and that also might not be true. Another hint is if they’re making claims without backing them up with references. Often this looks like stating an opinion as if it’s a fact. So they might spell off an opinion about what they think is reality, but it’s their opinion and they don’t preface it. They should say, “In my opinion,” or “I personally believe.” They just state it as if it’s a fact, but it’s really just their opinion.
Another red flag is if someone uses inflammatory language, if they say things are toxic or horrible or dangerous, you might think of some other example words that you could put in the chat. Whenever I hear those words, toxic, just red flags. I have to take a step back and ask, “Are they trying to manipulate my emotions or are they giving actual information?” Because toxic doesn’t really mean. Anything in this world could be toxic if you give it in large enough quantities. Then the final tip is to look at relative risk versus absolute risk and to teach people the difference between these things. So relative risks, an example would be like saying the risk of an infection is 50% higher or the risk of having a life-threatening injury is 50% higher.
When you hear that, you start to think it’s actually 50%, but that might not be true because relative risk, when you’re talking about 50% higher, you actually have to do a math equation to figure out what the actual or absolute risk is. So look at 0.3 per 1,000 is actually 50% higher than 0.2 per 1,000. Just to do a little math with you, half of 0.2 is 0.1. So 50% higher, so it would be 0.2 plus 0.1. That gives you 0.3 per 1,000 births. So it may sound scary, but when you look at the actual numbers, it’s still pretty rare. Oh, one last tip in terms of bad information, one thing that people like to do is they use the word always or never. It reminds me of like I’m always yelling at my kids, you don’t say, “We never get to do that” or “I always have to do this.” That’s not true. It’s almost never true.
I just used that word, never. So always or never are also red flag words. So has anything jumped out at you about what we’ve talked about so far? Go ahead and put it in the chat box and let us know. Anything jump out at you about the red flags for misinformation or waterbirth PROM or GBS? Okay, the use of absolutes. Would you include non-immersive hydrotherapy? Yes. So hydrotherapy can also include getting in a shower. So it doesn’t have to be immersion in a tub, although we’re usually talking about a tub. Okay, so let’s move on to GBS. We’re going to talk about a myth I’ve seen online. There’s multiple myths about Group B Strep because there’s a lot of bad information on social media.
There’s a lot of risks to getting your information from social media because there’s a lot of really well intending people that spread bad information. This is one example that happened on our Instagram page three weeks ago when we were talking about GBS and different strategies that researchers are studying. The myth that I boiled down to was it’s easy to prevent GBS and get rid of it permanently. This came up in this conversation where some people were hating on antibiotics and talking about how bad antibiotics are, how the use of antibiotics is outrageous. You can be positive one minute, negative the next, and you can treat and prevent this very easily with natural methods. So let’s talk about that. It is true that you can get a different test result for GBS.
You could test negative in one pregnancy, positive in another, or you may have differing results in the same pregnancy. So why is that? Well, we each have our own unique microbiome. The microbiome is the ecosystem of trillions of microbes, including bacteria and viruses. They live and coexist with you in certain parts of your body, such as your skin and your gut and your nose and your mouth and your genital and urinary tracts. So the different types of bacteria that live inside of you that make up your microbiome, they can have good effects, neutral effects, or negative impacts. So the ones that have good effects are usually called probiotics, meaning good bacteria. Now, not everyone has GBS in their microbiome. It’s about 8 to 35% of us.
It depends on where you live in the world, how common it is in the microbiome. If you screen positive for GBS and they test GBS by swabbing the vagina and a little bit into the rectum. So if they grow GBS on that culture, that means that GBS is present in your intestines and it was flourishing enough at the time of the test that it had migrated down to your rectum and/or vagina. So it is possible that you may not have GBS and so you always test negative. If your test results change and they are positive and then negative or negative and then positive, it’s likely because the GBS might be flourishing when you test positive and it might be present in such tiny amounts that it’s not present in your rectum or vagina when they screen you.
Now, it is true that the healthier your microbiome, in other words, the more probiotics or good bacteria you have, it makes your vagina more acidic. This is really good and healthy for you. When you have high levels of acidity in your vagina, the less likely you are to carry GBS in your birth canal because it creates hostile environment for GBS, which would be a good thing. So because of that, researchers have looked at giving probiotics supplements for reducing GBS. Can we take a pill with probiotics and see if that reduces your GBS when you get screened? So far, unfortunately, we do not have compelling research that taking probiotics can lower the risk of testing positive for GBS. There were some lower quality studies and they had mixed results.
So in 2023, researchers did a really high quality randomized trial, double-blind, placebo controlled. They enrolled 109 healthy people who were pregnant, randomly assigned them to receive probiotics or a placebo, and they were identical in look and taste and smell. They also measured how often people took them. People did a pretty good job of taking them, but not all the time. So about 50 to 60% of the time people remember to take their daily dose of probiotics. The rest of the time, they forgot. What they found is they found that the probiotic group had fewer gastrointestinal symptoms at the end of pregnancy, so they felt better, their stomachs felt better, but there was no difference in testing positive for GBS at 36 weeks. So it didn’t have an impact on the GBS test results.
Two problems with this study. I already mentioned people were forgetting to take their pills even though they were getting lots of reminders. Also, they thought they would have more people in the study who were GBS carriers, but for some reason, there are more people GBS negative at the start of the study. So they need to do a larger study with more people who carry GBS to see if this is effective. So is it possible to change your GBS results? I think yes, it’s possible. That does not mean it’s easy to alter your microbiome in such a powerful way. It also does not mean that the results are permanent, because if you stop taking probiotics or your diet is not as healthy, which is easy to happen during pregnancy, if you’re not feeling right, your results could change and the GBS could grow back and flourish again.
So that social media example I gave you where they were hijacking our thread and throwing all these statements around had a lot of false assumptions. So first of all, they were assuming that it’s easy, simple, and accessible to have healthy foods throughout your pregnancy and that is just simply not true. There are many places around the world and within your own communities where people do not have access to basic healthy food options or to probiotics. Another assumption they had is that racism is not interfering with your microbiome. When we recently updated our article on Group B Strep, we added a section about how the stress of racism and experiencing racism can alter your microbiome in a negative way.
So they were looking at this from a really privileged perspective that you have the money and the access and you’re not being stressed with racist stimuli. Also, they were assuming that natural interventions such as natural sources of probiotics or for example garlic, which is a natural antibacterial, will work every time. We don’t know that they work every time. We don’t have research on this yet, and they’re assuming that the effects will not wear off, because if you stop using something like garlic, then the antibacterial effects might wear off and then the GBS could grow back. So yes, it’s possible to change your results, but not in the way that those people on social media were making it sound like it’s this super easy thing to do.
What about antibiotics? That was another myth I thought about diving into, but it was just going to take me too much time. So there are both pros and cons to the use of antibiotics during labor to prevent GBS infection in newborn. We have all the information including the absolute risks and the statistical information that people want to hear on our two podcasts on this topic, also in our peer reviewed signature article. So you can access those at ebbirth.com/groupestrep or just look for the EBB Podcast 254 or 257, where we go into depth on the history of antibiotics, which is really fascinating, because we’ve actually as humans been using antibiotics from sources of nature for thousands of years. It’s only been in the last hundred years or so that they’ve become more easily accessible.
There are pros and cons with the use of antibiotics. So you can learn more about that and those sources. So if you have questions about GBS, go ahead and put them in the Q&A box, because I’m going to move on next to prom. So PROM is not a dance in this presentation. Although every time I talk about this subject, I don’t know if we have any other birth workers in the room. Whenever you use the word PROM, people just look at you and they expect you to start talking about a sparkly dress and a dance, but we’re talking about the kind that happens during pregnancy. So the myth that I want to talk about with PROM is that if you have term PROM and you don’t get induced, you or your baby will have an infection.
This was a YouTube video example that one of our researchers here at EBB sent to me. I thought it was a really good example of a video that had a large reach where there was some good information but it was mixed with information that could be a little bit misleading. So I’m going to read to you what this doctor was saying about PROM. I’m going to read the actual transcript from the video, just a paragraph of it. Okay. So this OB-GYN says, “You’ll come in to see your provider and we’ll start an induction of labor with Pitocin. We do that, because if women who break their water but labor doesn’t happen, wait, versus women who break their water and have an induction, the women who have an induction, both them and their babies are healthier.
Here are the stats. The amount of postpartum fever and chorioamnionitis are much slower in the women who had an induction. Also, lower rates of your baby having an infection or being admitted to the NICU and there’s no difference in C-section rates.” So go ahead and put in the chat. Let me note, when I was talking about those tips for looking at information, did anything jump out at you about what I just read out loud? Okay. So she said she was going to share statistics, but then she just used some vague terms like lower and much. If you listen to the whole video, there’s no actual numbers, no specifics, sounds too good to be true, you will be healthier. So will is an absolute, sounds like an opinion. Healthy is a relative term, no references mentioned, no numbers for comparison.
I think yeah, we’ll start an induction. So there’s an assumption that you don’t have a choice, this is what you will do because it’s healthier, and we have your safety in mind and you don’t. I also think it’s interesting that she says, “Women break their water” as if we’re doing it on purpose and we’re broken, naughty, pregnant women who are breaking our waters and then need to be fixed. Here’s the thing that overall, I think the video has good information. It’s just the way it’s framed and the lack of details and the lack of nuance.
So one of the things you’ll find when we talk about PROM is yes, the research supports both induction and waiting and certain circumstances, but there’s a lot of details and limitations to the research and things like that that people don’t always share, because they’re trying to simplify it, right? They’re trying to make it sound simple and easy to disperse this information, but it’s not that simple, this whole area of research. So let’s talk about the risks of PROM. Some of you have may have wondered when I said chorioamnionitis. That sounded like a big scary word. So that is defined as inflammation of the membranes.
So the sac surrounding, that’s the bag that makes up the bag of waters, the rates of that, if your water broke before the start of labor, you used to have about a 4 to 8% chance of developing, we’ll call it chorio, because that’s easier to listen to before the GBS testing era. So this can be diagnosed if your temperature is greater than 100.4 Fahrenheit, plus you have at least one or two other signs of infection. Another risk of PROM is infection in the baby. Before we used to test for GBS, that risk was about 2 to 3% if you had PROM. In research, this is defined as signs and symptoms of infection plus at least one positive diagnostic test. For example, blood cultures or an x-ray showing that there’s pneumonia or a spinal tap showing that there’s meningitis.
So I have a poll I’m going to put up for you all and I want to quiz you and find out what do you think increases the risk of the newborn having an infection after PROM. You can select more than one option if you’d like to or you could just pick one. So go ahead and look at the options. More cervical exams, being a GBS carrier, or having a labor that takes 48 hours or longer to start. Okay, I’m going to end the poll and we’ll see what you all…
Okay, looks like most of you picked more cervical exams puts the baby at having a higher risk of infection after PROM, and that is absolutely correct. In fact, there’s a lot of research showing that there’s almost what they call a dose response relationship where the more cervical exams you have during labor after PROM, the baby’s risk of infection keeps going up, because with those exams, you’re pushing the bacteria up the birth canal closer to the baby. Testing positive for GBS is also a correct answer. Having chorio is another correct answer. Labor taking a long time to start 48 hours or more is also correct. So all four of those options increase the risk of the baby having an infection after PROM. So now let’s go to the most important study ever done on this topic.
This was a study called the Term PROM Study published by a group of researchers led by Hannah. This very high quality study was published in the New England Journal of Medicine in 1996. Because it was so large with more than 5,000 participants in the study, the results from this Term PROM Study drive the results of any review on this topic. So whenever there’s a meta-analysis where they combine data, it’s going to contain a lot of the people from this study. So this study really drives the findings of most papers on this subject. So there were six different countries, including Canada, the United Kingdom, Australia, Israel, Sweden, and Denmark, enrolled people between the years 1992 and 1995. This was before they were screening people for GBS.
So GBS was untreated in these studies. Participants were assigned to one of four groups. So randomly assigned to either being immediately induced with Pitocin or immediately induced with a prostaglandin gel at the cervix or waiting for labor to start on its own for up to three days followed by Pitocin if needed for whatever reason or waiting for up to three days for labor to start on its own, followed by the prostaglandin gel if needed. Everyone in the study was swabbed for GBS when they got to the hospital, but they didn’t know the results during the study. Also, you had to have a non-stress test at the hospital before you could be enrolled and you were not included if you had any meconium staining of the waters or any signs of infection.
They’re really only looking at people who were low risk, whose waters broke, and there were clear waters and no signs of complications. So the people who were assigned to wait weren’t just waiting. They had something that we call expectant management. So after they had their assessment, they could either go home or they could stay in the hospital. They were instructed to check their temperature twice a day and to report any fever, change in color or smell of the waters, or any other problems. People in the waiting group could be induced if they developed complications, if they changed their mind and said, “I don’t want to wait, I want to be induced,” they could have an induction, or if labor did not start by the fourth day.
Some people in the study received antibiotics. It just depended on the healthcare provider’s preference. So the results when we compared the two Pitocin groups, the expectant management Pitocin group and the induction Pitocin group, because the Pitocin ended up being a better way of inducing than the prostaglandin gel. So there was no difference in cesarean rates, but as you can see, the C-section rates were very low in the study, about 13.7 to 15.2%, no difference in rates of vacuum or forceps delivery, no difference in newborn infections, no difference in the rate of stillbirths or newborn deaths, no differences in the baby’s Apgar scores at birth. However, the Pitocin induction group did have some benefits.
There were fewer cases of chorioamnionitis, 4% in the immediately induced group versus 8.6% in the waiting group. They had fewer cervical exams, which could have also influenced some of the other results, probably because they had a shorter time to birth. So they didn’t have to have as many cervical exams. They also had fewer cases of postpartum fever, 1.9% versus 3.6%, as shorter time until active labor began, median of 5 hours versus 17.3 hours. They were in the hospital a shorter time before birth and they had higher satisfaction rates, 95% versus 87% in the waiting group. Also, babies were less likely to receive antibiotics in the induction group after birth. So there were some limitations of this study that are really important to point out.
One, the researchers did not use the correct definition of chorioamnionitis. It was too easy to be diagnosed with chorioamnionitis. Many of you who are birth workers may be familiar with the fact that an epidural can cause a fever. So having a temperature of 99.5 or at least twice or a single temperature of 100.4 Fahrenheit would give you an automatic definition of chorio even if you didn’t have chorio. Also, the study was not large enough to detect true differences in mortality, and it thought that the findings that either could be new to chance or could not. We don’t know. There were four stillbirths or newborn deaths all in the waiting groups. The causes were low oxygen during the birth, GBS infection in the baby, and two cases of birth trauma.
So what happened next is we have several meta-analysis that were published where they combine a whole bunch of randomized trials into one large data analysis. The most famous of these is a Cochrane Review by Middleton at all published in 2017. They looked at 23 randomized trials with more than 8,600 participants. Ten of these studies were comparing expectant management to Pitocin while 12 compared expectant management to misoprostol, also known as Cytotec or a different prostaglandin. Only 2 of these 23 studies screened and treated participants for GBS. That’s about 320 people out of 8,615 were screened and treated for GBS.
Overall, it looked like the quality of evidence was low, is what the reviewers judged, and about half of the participants were from the Term PROM Study. Knowing that, what they’ve found was that immediate induction did lead to shorter durations until birth, which makes perfect intuitive sense, and people were less likely to experience maternal infection. That was low quality evidence. No increase in the risk of cesarean. Again, low quality evidence. Infants were less likely to need antibiotics after birth and there were fewer NICU admissions. On the other hand, one drawback is there was a higher rate of uterine tachysystole in four studies. That means the uterus was overstimulated and contracting too frequently, which can lead to potentially fetal distress.
Now, you notice I didn’t give you any actual statistics in this. That’s because often when they combine these studies, you don’t get the absolute risk, you just get relative risk. They did find no differences between groups with the risk of serious maternal infection. That was very low quality data. Definite newborn infection, also very low quality data, or perinatal mortality, which was moderate quality data. So if you look back and think, “Okay, what was the doctor saying in that YouTube video?”, some of it lines up with this, but you’re missing the nuance in terms of this data almost all coming from the era before we screened and treated for GBS. Because of that, other researchers have written repeatedly that it’s difficult to generalize the results.
When I say generalize, that’s a research team. That means we can’t necessarily apply these results to today’s population. So if you’re giving birth in a hospital with a high C-section rate or you’re giving birth in a country where most people are screened and treated for Group B Strep, these statistics might not apply to you. So this researcher is saying we have to interpret them cautiously due to the low rates of GBS colonization detection and prophylactic antibiotic use, as well as the inconsistency of the definitions of newborn infection. I put some guidelines in here about PROM. There are a couple position statements that have different opinions, but the American College of Nurse Midwives says that expectant management can be a safe option.
So we’re being told by the medical community that induction is the safest option, but the midwifery community believes that you can choose expectant management as a safe option if there are certain criteria, there’s no complications, there’s clear amniotic fluid, there’s no sign of infection, your GBS is negative, there’s no fever. The fetal heart rate is reassuring and there’s no vaginal exam at baseline and you keep the vaginal exams to a minimum. So you don’t want to do that at first vaginal exam right when somebody gets there because that starts to clock a little bit, because now you’ve introduced bacteria up close to the cervix.
On the other hand, the American College of Obstetricians and Gynecologists have a little note here saying that their recommendations have swung back and forth, even though the evidence hasn’t really changed in 20 years. So currently, they recommend labor induction with term PROM, although expectant management for 12 to 24 hours can be offered and they recommend immediate GBS prophylaxis. The Association of Ontario Midwives, I know we have a lot of Canadian attendees here today. The AOM has really incredible guidelines on a lot of subjects. I really like their papers because they’re very well researched and they’re easy to read and they have lots of great handouts and graphics.
So they have a whole section on term PROM and they recommend discussing the risks and benefits of both options. Both options can be appropriate depending on the situation. They want to avoid what we call digital vaginal exams. That means using the care provider’s hands. Even with sterile gloves, what you’re doing is you’re moving the bacteria up higher. You can use a metal speculum. They don’t talk about this necessarily, but we’ve looked at the research on this before. It’s really interesting. If you’re just using a metal speculum, that actually repels the bacteria. As long as you’re not sticking any fingers or gloved hands up there, you should be okay. Then they recommend induction at 18 hours if you haven’t gone into labor and you’re GBS positive. So that’s the research on PROM.
Go ahead if you have any questions on that to put your questions in the Q&A box and we’ll see which ones we can get to at the end. So the last myth we’re going to be debunking has to do with waterbirth. So what are the main barriers to waterbirth in most hospitals? I know some of you said it’s available in one or two hospitals near you. Go ahead and put in the comments, what do you think is holding us back from accessing waterbirth? Because it’s really just water in a tub. Okay, doctors are not trained, no training, liability, lack of control in part of the provider, nurses aren’t comfortable, fear, NICU docs, pediatricians, provider, lack of comfort, not supported by ACOG. If there’s one bad outcome, then all waterbirths are stopped.
So one of the things I’ve found in writing about the subject and speaking about it for more than a decade is that one of the main barriers to waterbirth on a system level in the hospital is the pediatric or neonatology department. Because even if the obstetrician is supportive and the nurses are supportive, the last holdout is usually the pediatrician or the neonatology department and that is because of their professional association. So the American Academy of Pediatrics has a long history of opposing waterbirth.
In their most recent statement on this from their Committee on Infectious Diseases and the Committee on the Fetus and Newborn, this was just 2022, they stated, “Families should be cautioned against waterbirth during and past the second stage of labor in the absence of any current evidence to support maternal or neonatal benefit and with reports of serious and fatal infectious outcomes in infants. Midwives and obstetricians offering this option must ensure that appropriate infection control strategies, including rigorous cleaning and disinfection, are in place to reduce the risk of infection.” So it boiled this down to the myth is that waterbirth has no benefits, it only poses risks for newborns.
So thinking back to my tips for evaluating information, what jumped out at you about this quote from the American Academy of Pediatrics that is a little bit of a red flag for you. Anything from this statement if you had to critically evaluate this statement using the tips for information? So they said, “The absence of any current evidence.” That is a really big claim. You’re saying there’s absolutely no current evidence to support any maternal or neonatal benefits. So it’s a broad sweeping claim without evidence to support it. Anything else? Reports of serious or fatal infection sounds very scary. So it’s like a fear-based statement and no statistics. Yeah, obviously, this is just two sentences in the paper, but they’re not really offering statistics and I don’t think they did later in the paper either.
Somebody said they ignore that water reduces the use of epidurals and all the risks that could come with epidural. That’s a good point. So the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists have been opposing waterbirth for a long time, and I’ve been breaking down and critiquing their statements for the past 10 years. In 2006, the AAP released a statement saying that waterbirth is very dangerous and does not have benefits. In 2014, ACOG and the AAP released a joint opinion again, denouncing waterbirth. This led to the few hospitals that were practicing waterbirth in the United States to shut it down unless they were doing it as part of a research study.
For a while, the main places where you could get waterbirth were at home births and free-standing birth centers because it’s still supported by those professional guidelines. Unfortunately, this had a chilling impact on the availability of waterbirth around the world. Countries like Spain and Portugal and other areas around the world, people were reaching out to me saying they’ve shut down waterbirth because of the American Academy of Pediatrics.
In contrast, the American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynecologists in the UK, and the Royal College of Midwives all endorse waterbirth as a safe option. It’s interesting to note that in the screenshot that I showed you on the last slide from 2022, it says there’s an absence of maternal or neonatal benefits, but in the 2016 paper, ACOG and APP acknowledged that there are maternal benefits. So this just goes to show you that these opinions are just opinions and they are choosing to include or neglect research depending on what they want to argue at the time. So what is the newest research on waterbirth? I’m really excited to share this information with you. So it’s very difficult to do randomized trials on waterbirth.
There are a couple of small, randomized trials, but in general, it’s really hard to say you give birth to your baby underwater and you don’t, because you have to allow for clinical judgment and preferences to change. Somebody may feel like getting out of the tub or the midwife may say, “Look, I don’t like how your baby is looking when I listen to them. I think you need to get out of the tub.” So you have to allow for those changes to happen during immersion in labor. So what we have now is a really large and high quality study on waterbirth. It’s the largest study to date. It was published by Bovbjerg, et al. in 2022. They examined 17,530 waterbirths.
What they did that was really unique is they included a matched cohort of 17,530 land births. This is important because they matched the two groups on dozens of factors. So for every one person who had a waterbirth, they found a comparable person who had a land birth who matched them on dozens of characteristics, because one of the problems is actually waterbirth groups tend to… The research have the best outcomes because only the healthiest, lowest risk people end up birthing in the water. Anybody with the slightest hint of complications is asked to get out of the water. So this is why this study is so important.
They were able to compare apples to apples by having comparably healthy, low-risk people who were having uncomplicated births to compare them. They also looked at many, many different health outcomes. Now, these were all low-risk births happening at homes or freestanding birth centers and being cared for by midwives. So what did they find? Well, when they looked at the results comparing waterbirths and land births, these are the results, the health outcomes that were significantly different between groups that favored waterbirth. So there are fewer postpartum hemorrhages, 2.38% in the waterbirth group versus 2.99% in the land birth group. There are fewer postpartum transfers to the hospital, 2.05% versus 2.5%.
There are fewer severe perineal tears of the third or fourth degree, 0.75% versus 0.84%. Fewer newborn transfers to the hospital, 1.39% versus 1.65%. Fewer cases of newborn respiratory distress syndrome, 1.49% versus 1.61%. Fewer cases of newborns needing to be hospitalized, 3.39% versus 3.58%. Most interestingly, fewer cases of newborn death, 0.28 deaths per 1,000 deliveries versus 0.51 deaths per 1,000 deliveries on land. So that in a nutshell is what the largest study on waterbirth has found to date. They have not only found benefits that favor waterbirth for birthing people, but also for newborns, which directly contradicts what the AAP was saying in their 2022 statement.
Out of the many, many health outcomes they looked at, in fact, they could only find two risks of waterbirth where land birth was favored. That was a uterine infection postpartum, happened in 0.31% of waterbirths versus 0.25% of land births and something called umbilical cord avulsion, which happened in 0.57% of waterbirths and 0.37% of land births. So umbilical cord avulsion is when the umbilical cord tears or rips as the baby is coming out. I’m not going to go into depth in that because I just released a podcast on this topic. This is EBB Podcast 258, where we talk about the risk of umbilical cord avulsion or tearing and how midwives and nurses and doctors and parents can help prevent that rare complication from happening.
So in terms of infections, because they mentioned the serious or fatal infections, meta-analysis of observational studies have found no increased risk of newborn infection with waterbirth and the Bovbjerg study also found no increased risk. However, there are published case reports of rare waterborne infections. So pseudomonas is a bacteria that can be present in the water, and it’s recommended that hospitals take frequent cultures from the birthing pool system and to heat disinfect hoses or use new hoses each time. This is because some pseudomonas strains have become resistant to disinfectants. So that’s why they recommend culturing the water regularly and using heat to disinfect things.
Legionella is another waterborne bacteria that has caused some rare cases of infections, but this is mainly a problem in spa-like pools, where the hot water is constantly circulating and being reheated like a hot tub. Those are extremely difficult to disinfect. So they recommend using a rigid or inflatable tub that’s filled with fresh water and not using those recirculating pipes. So we’ve debunked myths on three different subjects. We’re going to get into a few more things, the announcement and the Q&A. But in the meantime, go ahead and let me know what’s your number one takeaway and put it in the chat box.
So you can see out of the three subjects we’ve covered, GBS, PROM, waterbirth, as well as information or misinformation, what’s something that you’re going to walk away and put into action? Okay, you like the new studies on waterbirth, how the opinions of professional organizations are sometimes just opinions, not necessarily looking at the research, surprising benefits to waterbirth, evidence on induction for PROM. Fewer cervical exams are important. Evidence on waterbirth safety from the recent study needs to be communicated. Okay, a lot of takeaways.
The discrepancies, how the recommendations can have such global impacts, and that is something we’ve seen with VBAC as another example of when there’s one negative opinion on vaginal birth after cesarean, it has ripple effects around the world. That’s why I really wish there was more accountability for making sure that these kinds of important guidelines are evidence-based and include all stakeholders. So today, we talked about Group B Strep and the microbiome, management of PROM, and the benefits and risks of waterbirth. So we have signature articles on each of these topics. Signature articles are our free peer-reviewed blog articles that you can read from anywhere online, and we created short links for these.
This might be a good thing to take a screenshot of, because it’s really helpful to be able to just know off the top of your head, go to ebbirth.com/groupestrep to get the Evidence Based Birth® article on Group B Strep. There’s one-page handouts for each of those topics. We recently updated the GBS article this year. The PROM article is currently undergoing edits and those will be posted in the next few months. Then we are also updating the waterbirth article this year with the Bovbjerg study, but it’s not on the waterbirth article yet. So what you’re getting in this webinar is the latest information. So are you ready for the big announcement?
We have some exciting news, the Evidence Based Birth® that we’ve been working on for a while, and that is that we’ve recently launched a brand new doula mentorship program. This is inside our EBB Pro Membership. It’s provided at no extra fee to our current members and any new members who join. So inside this doula mentorship, we’re using a group mentorship model, doing a lot of networking, having monthly calls on different business topics, hosting breakout rooms, so that you can get to know other doulas. We created a specialized learning guide on the evidence.
Our hope is that newer doulas who maybe aren’t quite ready to join the EBB Instructor Program could do the doula mentorship over the next year and be ready to apply for the instructor program the next time it opens. So we have calls scheduled each month with different topics of discussion, and all of this is hosted inside the EBB Pro Membership program. This program makes the work that we do at EBB sustainable by supporting our team’s salaries and supporting the resources we provide to the public on our website and podcast. So you can learn more about the EBB Pro Membership and how to join by going to ebbirth.com/membership.
If you feel like you’re already qualified to apply for the EBB Instructor Program, you can check out those eligibility criteria at ebbirth.com/instructor and sign up for one of the Q&A’s about applying for the instructor program, which is separate from the Pro Membership. If you have any questions at all, feel free to email us at email@example.com anytime. Our lovely team members will respond to you if you have questions about the pro membership, the doula mentorship as part of the pro membership, or the instructor program. So now let’s do a quick question and answer. So I think we have time for about five minutes of questions.
All right. If I’m allergic to penicillin and have Group B Strep, what other antibiotic would they give me? That is a great question. We cover this in depth in our podcast on this subject, and I highly recommend going to ebbirth.com/groupestrep. Then doing a search, if you’re on a computer, search for the word allergy. This is a quick tip. When you’re searching EBB articles, I love to use either Ctrl + F if you’re on a PC or Command-F on a Mac. Type in the word you’re interested in and it takes you straight to wherever that word is in the paper. But there is a whole section all about allergies to penicillin and it’s too in depth. I can’t go into all the answers, but there’s pros and cons about the different options and we cover that in depth there.
So cefazolin is often an antibiotics that’s used that’s highly effective against GBS. There is a possibility if you’re at high risk for anaphylaxis, they probably won’t recommend cefazolin, but there’s also the recommendation now to do allergy testing because most people will outgrow their penicillin allergy at some point. So that is another option is to get skin testing for penicillin allergy. Then the other options are stronger antibiotics. Those have some drawbacks because they’re not as effective against GBS. So I recommend going to the article to learning more about allergies. Here’s a good question. I love this question. As a doula, I’ll be tending my first waterbirth soon. I would love some insight as to what I can do to help my client. She has a midwife who has attended waterbirths previously.
So any doulas in the room, want to give some advice in the chat box for how you help with waterbirths? I think one of the most amazing things about the use of hydrotherapy and water immersion in labor is that it makes the job easier in some ways for the doula. I would imagine harder for the midwife because the midwife has to do more positioning to be able to listen to fetal heart tones and do exams. But I think because the water helps so much with relaxation, it can really help. There’s some research that self-hypnosis is more effective when it’s combined with water immersion. So learning some deep relaxation techniques that you can use in the water could be helpful.
Then I know at my births, I was able to use waterbirths in the second and third, and my support team mainly just had to worry about keeping the water at the correct temperature. So our doula was helping heat water to add to the tub. But any other advice, please put it in there for our doula listener who had the question about the first waterbirth they’re going to. Somebody says, “I see PROM at rates higher than 10%, although I know that’s what textbooks say.” This is a great comment. Like I said, we’re in the midst of updating all the research on PROM right now, and I actually assigned one of our researchers to find a more current number.
We’re still seeing the 10% listed that there’s not been new research done on this, but we are looking in depth at the risk factors for PROM. What are some things that can increase the risk that you’ve experienced PROM? We’re adding a new section to the paper about extreme weather events and how extreme cold or extreme heat, especially if you don’t have access to air conditioning or green spaces, that that can increase the risk of both preterm PROM and term PROM. So looking forward to having all that information laid out there. Then there’s also sections that are currently in our PROM paper about different supplements and other risk factors that you can modify. If you want to avoid PROM, it’s important to avoid regular cervical exams leading up to labor.
So those weekly checks starting at 36 weeks can increase the risk of PROM. There’s a few other things you can look at in our article that’s at ebbirth.com/prom, where we talk about the risk of your water breaking. In general, your water breaking before labor starts, it could be physiological or normal. For some people, it’s just normal for your membranes to get a little bit weaker right before you go into labor. They could give way, but some people want to avoid it if they’re GBS positive or if they just don’t want to have that uncertainty of not knowing when labor is going to start. It can mess with your birth plans a little bit to have your membranes rupture before labor starts. So that’s something to keep in mind.
About waterbirth, is the water washing off the good bacteria from the vagina? So we have a podcast on that. It’s one of the first podcasts I ever recorded. It’s a little older. It’s episode number four, so it’s called Waterbirth and the Newborn Microbiome. So just Google Evidence Based Birth® waterbirth newborn microbiome. That should take you to that page where we have the old podcast there archived. There was a little bit of research. I was able to answer that question for you. There’s so many good questions here. So I’ve heard that if PROM is not checked, there’s a risk for cord prolapse. So the patient must come in to be evaluated with a cervical exam. Is this true?
We do address that in our PROM article at ebbirth.com/prom, I believe, because this was something I experienced. I don’t know if any of you have had this, but when I had PROM in my first birth, they told me I was not allowed to get out of bed because they said because my waters had broken, there was a chance that the cord would come out before the baby’s head and that’s called a cord prolapse, which is a potentially life-threatening event for the baby. They said, you’re not allowed out of bed. They wouldn’t even let me walk to the bathroom because of the nurses were so afraid of this happening. So I actually looked it up and found the research. There’s no increased risk of prolapse cord with PROM.
So, it’s still extremely rare, regardless if you have PROM or not. There might be other reasons you want to be evaluated when you have PROM. You might want to talk with your provider, make sure the baby’s heart rate sounds good, but doing a vaginal exam to check for a cord is not evidence-based as far as I know. Okay, maybe we have one more question. Can someone with PROM or GBS have a waterbirth? This is a great question because I love how all three of these topics are connected because GBS can be related to if you have PROM, then you’re a little bit more worried about newborn infection. Also, people worry if I have PROM or GBS, can I get in the tub? The answer is those safety statistics I showed you on waterbirth, they included people with PROM and people with GBS.
So, those safety statistics apply to people with PROM and people without. So yeah, you can have a waterbirth with PROM. Now, if there’s complications, if there’s a lot of meconium in the waters, if the baby’s heart rate is not reassuring, there might be other reasons they ask you to not birth in the tub. I got this question last week, I don’t think anybody’s asked it today, but people have asked, “Why doesn’t the baby breathe underwater?” Barbara Harper of Waterbirth International talks a lot about this. We cover this in our article on waterbirth at ebbirth.com/waterbirth.
But the animal research, the animal studies that we have on newborn animals being born underwater is that scientists believe that there are sensors on the face that can sense air and that’s what triggers the first breath. So it would make sense, because as a fetus, they’re floating inside of water for the whole pregnancy. They may be swallowing the water and it’s filling their bodies, but they’re not going to choke on water while they’re in the womb. So they can come out, their head can come out underwater, and then it’s when they’re surfaced to the water and their face feels the air that they take their breath unless they’re experiencing a complication that caused low oxygen. So it is possible that a baby could gasp with their head underwater if the baby is under a lot of stress.
That’s why midwives are so careful. If they think there’s any sign of stress in the baby or any warning of any complication, they’ll ask you to get out of the water. It’s important that you listen to them because that’s why midwives can have such good outcomes with waterbirth is because they can help identify who’s a good candidate for waterbirth and who is not. So I hope that answers your question in terms of GBS and PROM. So people in the waterbirth safety studies had GBS and PROM as well as not. I would love it if you have any kind words for our team and all the work that goes into putting on these free webinars, now’s your chance to thank all the hardworking EBB team members. Thank you all for coming and for valuing your education and for looking for good information.
I hope that you find this helpful, especially the tips that you can carry with you on red flags to look for when you’re evaluating information online or on social media. It looks like we have so many people who learned a lot today. It was really a pleasure and honor sharing this research with you. I hope to see you again at another EBB event someday. Till then, have a great rest of your day. Bye, everyone. Today’s podcast was brought to you by the Evidence Based Birth® Professional Membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community.
Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.
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