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Appreciate the Woman’s Guide to VBAC? Vote for us!

September 30th, 2010 by avatar

Many Science & Sensibility readers expressed their gratitude and excitement about A Woman’s Guide to VBAC, a project launched earlier this month on our sister blog Giving Birth with Confidence.  If you used, shared, or otherwise appreciated this resource, or if you enjoy any of the other amazing features of Giving Birth with Confidence, please take a moment to vote for us in Fit Pregnancy’s Best of the Web contest.  It just takes a few seconds.  We’re in the “Advice” category.

***VOTE NOW!***

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From Childbirth Educator to Doula and Back Again: Trends in the History of Birth Advocacy and Education

September 27th, 2010 by avatar

The ever-evolving history of the childbirth reform movement has new developments, which need to be incorporated into the older story which documents the shift from home to hospital birth; and the paradigm clash of midwifery and medical models of birth reflecting holistic and technocratic values, respectively.  We need to incorporate the story of the doula, which I argue, is one of many efforts to bridge the divide – to provide, as Robbie Davis-Floyd has called it, humanistic care in birth, which is what most women desire.

History is happening now.  In addition to the emergence of the doula in the past thirty years, more recently, we see efforts underway in maternal health policy (Childbirth Connections’ Transforming Maternity Care), among physician and nursing professionals (most especially around maternal quality measures, and maternity quality improvement) and resurgence among, for lack of a better word, ‘consumers’ or childbearing women, who seek greater access to vaginal birth after cesarean (VBAC). What are the goals of each stakeholder; how do they intersect and overlap, and come into conflict with one another?  This is a big story, and we need to tell it!

I take a small slice of this larger historical backdrop to consider the interconnected history of childbirth educators and doulas, which will be the subject of my research presentation at the Lamaze-ICEA Mega Conference in Milwaukee.

To back up a bit, when I embarked on my sociological investigation of the doula role, I was interested in many aspects of this innovative approach to childbirth advocacy and support.  What strategies and mechanisms enabled women with no medical training to insert themselves at the site where medical care is delivered to a patient in a hospital, and enact their self-defined role?  Why did women become doulas and what did the work mean for those who were able to sustain a regular practice over time?  How were doulas utilizing and leveraging the corpus of evidence based research which suggested their impact was as great, if not greater, than that of the physician, the culture of the obstetric unit, or the labor and delivery nurse?   Where did doulas come from?  What, in the history of childbirth reform, or childbirth education, or labor/delivery nursing, could help me understand how doulas emerged at this point in time in U.S. history?

Later, after learning that there were limited histories of childbirth education (by non-childbirth educators), and little research on the history of obstetric nursing, I had to take a step back and consider these factors as well.  Why was the work and perspectives of women who support other women during childbirth an overlooked piece of historical research? Why did histories of women’s health reform efforts largely exclude childbirth reform?  Why had there been no history of the women who were involved in childbirth education; in labor and delivery nursing; in the mainstream arena of birth care in the US?  So as not to be accused of ignoring the scholarship that does exist in this area, I acknowledge my debt to Margot Edwards and Mary Waldorf; to Judith Walzer Leavitt, to Barbara Katz Rothman, Robbie Davis-Floyd, Margarete Sandelowski, Deborah Sullivan and Rose Weitz, Judith Rooks and Richard and Dorothy Wertz (I can make my full bibliography available to those interested).  I have been inspired by these histories but they focused less on the women (childbirth educators) who were making history, and more on the larger cultural shifts in beliefs about medicine, technology, women’s bodies and reproduction.

When childbirth education per se was a topic of inquiry, the research focus tended to be on the primary sources of the male physician champions – Grantly Dick-Read, whose work informed the natural birth movement, and Ferdinand Lamaze (and his US counterparts – Thank you Dr. Lamaze author Marjorie Karmel, Elisabeth Bing) who formulated a method for accomplishing unmedicated, awake and aware childbirth.  However, most of this scholarship makes unsubstantiated generalizations about what particular childbirth educators (of various philosophies /organizations) believed, and how they taught.  There is surprisingly little in the way of empirical research – few scholars interviewed childbirth educators or conducted systematic observation of their classes over time.

So after completing my dissertation on the emergence of the doula role, I had the great opportunity to continue with my research interest through a research grant from Lamaze International to conduct an ethnographic investigation of childbirth education, with my colleague, medical anthropologist Clarissa Hsu.  We talked to educators, observed their classes and analyzed our data.

We found that educators who were actively practicing doulas drew heavily on their direct labor support experiences as authoritative resources for stories and examples that supplemented the material they taught. Actively practicing doulas also included more curricular content on early labor than educators without such experience. Having real births to draw upon provided doula-educators a different type of credibility and authority than educators without such current labor support experience. These educators relied on other mechanisms to establish their authority, such as knowledge of the latest research on birth and use of more authoritarian teaching styles.

We found that the intersection of doula practice and childbirth education has significantly affected how childbirth preparation classes are taught, and this new infusion of practice and ideology is worth exploring. I encourage you to explore this with us, and welcome your thoughts.

Christine H. Morton, PhD, is a research sociologist at the California Maternal Quality Care Collaborative an organization working to improve maternal quality care and reduce preventable maternal death and injury. Her research and publications have focused on women’s reproductive experiences and maternity care advocacy roles, including the doula and childbirth educator. She is the founder of an online listserv for social scientists studying reproduction, ReproNetwork.org. She lives with her husband, two school age children, and two dogs in the San Francisco Bay Area.

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Rigging the Election: When it comes to elective induction, are women asking for it?

September 24th, 2010 by avatar

There is a growing movement, backed up by evidence, practice guidelines, and efforts by agencies including the March of Dimes, the Institute for Healthcare Improvement and the Joint Commission, to reduce elective inductions, especially those occurring before 39 completed weeks of gestation.

Media coverage of these efforts tends to frame the problem as too many women asking for early delivery with no medical reason and the solution as hospitals “saying no” to these women.  But this woman-blaming paradigm is simplistic and flawed. New research shows that, not only have maternity care providers failed to convey the risks of early delivery to women, they may be offering or recommending elective deliveries despite the risks, and telling women they have a medical reason for induction but documenting the inductions as “elective”.

First, the evidence that educating women does help.

As reported in the July/August issue of the American Journal of Maternal/Child Nursing, researchers at St. John’s Mercy Medical Center in St. Louis, MO, studied the effect of a 40-minute educational intervention given in the context of hospital-based Lamaze classes. The intervention was an educational module about elective induction incorporating evidence and professional practice guidelines, taught along with the otherwise-unchanged Lamaze class curriculum. Researchers compared the elective induction rates between attendees and nonattendees in the 7-month period following the introduction of the new module. The content of the educational model was straightforward:

Specific risks of elective induction presented during the class included cesarean birth with longer postpartum recovery, pain, and potential complications as well as other associated risks such as longer labor, use of pharmacologic agents and their effects on the mother and fetus, and neonatal morbidity. Benefits included advance planning and timing with personal schedules. (p. 190)

Women were also given “talking points” to discuss with their provider if induction was recommended.

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The intervention appeared to be very effective. The elective induction rate was about 37% in both attendees and nonattendees before the intervention and in nonattendees after the intervention. But 28% of women who attended the classes that included the educational content had elective inductions, a significant reduction indicating that the hospital would only need to educate about 11 first-time mothers to prevent one elective induction.

But, you might say, that still leaves more than 1 in 4 first-time mothers having elective inductions. What else might be driving this besides lack of education? Well, it might be this: the researchers also discovered that nearly 70% of women were offered elective induction by their doctors. And, not surprisingly, women whose doctors offered them elective induction were far more likely to choose elective induction, whether or not they were exposed to the educational intervention. In fact, the magnitude of the difference was much greater than with educational content. Roughly speaking, doctors would have to refrain from offering elective induction to just three first-time mothers to prevent one elective induction.

Prior to the educational intervention, when the hospital leadership were considering how to decrease the use of elective induction, most doctors believed that the problem was that uninformed women were asking for it, an assumption turned on its head by the research findings.  In postpartum surveys, three-quarters of women who had “elective” inductions indicated that the physician suggested the option compared with only 25% of women who indicated that they initiated the request themselves.  Class attendance had an influence on whether women chose to act on the option of elective induction, but the difference wasn’t huge. About 38% of women who attended the class and whose doctors offered elective induction chose the option, compared with 50% of those who were offered elective induction but didn’t attend the class.

The researchers conclude:

Although education provided in prepared childbirth classes can be helpful for women in making the choice of whether or not to have their labor electively induced, the physician is a powerful influence…It is possible that patients perceive the offer of the option for elective induction as a recommendation that they actually have the procedure, particularly if they are told they are due now, overdue, or their baby is getting too big. (p. 193)

And therein lies the problem: it turns out many women having “elective” inductions think they’re having medically indicated inductions. In a follow-up study by the same research team, published in the current issue of the Journal of Perinatal Education (full-text available to Lamaze members), the researchers report more of their findings from postpartum surveys as well as data gleaned from reviewing the medical records of each woman after delivery.  They write:

The most significant discrepancy between the medical record and patient perception was related to macrosomia as an indication. For example, based on the medical record, macrosomia was the indication for 26.7% of inductions; however, 39.9 of patients noted that their physician told them they needed to be induced because “my baby was too big.” The next most common reason women believed they had an induction was that they were “due now or overdue” (20.3%), yet only 35 women (6.4%) who had an elective induction were 41 completed weeks of gestation and none were more than 41 3/7 weeks. The majority of women who indicated they were induced for being “overdue” were only 1 to 4 days past their estimated due date. (p. 28)

So what’s the take-home of all of this?  How do we rein in the overuse of elective induction? Clearly, childbirth education that specifically addresses the risks, benefits, and evidence-based indications for induction helps.  As we have seen, fewer women exposed to this educational content will choose induction. Researchers also found that women who had inductions were more likely to have reported feeling prepared and having the reality match up with their expectations if they had taken the classes. They were also less likely to report not knowing why they were induced compared with women who were induced but didn’t take the class. In other words, the class helped women have more fruitful conversations with their care providers.

But it is clear from this research – the first to explore these issues in depth with a combination of qualitative and quantitative approaches – that we have to change provider beliefs and practices to have a meaningful impact on induction rates. It’s time for more research on what happens behind the closed doors of prenatal visits, and for clear standards that tell doctors it is not okay to offer a major medical (often turned surgical) procedure to women as if it was benign or beneficial.

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Call for Applicants: Community Manager, Science & Sensibility

September 22nd, 2010 by avatar

Yes, folks, I am giving up the helm of Science & Sensibility.  It’s for very exciting reasons which I will share with readers soon, and I will continue to contribute to this blog (albeit less frequently and with a different focus).  We’ll also be adding new contributors who bring different, interdisciplinary perspectives on maternity care research, policy, and advocacy. But we need new capable hands to carry the vision and do the work of keeping Science & Sensibility moving in great directions. Applications are due October 15th!

About Science & Sensibility

Science & Sensibility is a multi-disciplinary blog launched in April 2009 by Lamaze International to improve knowledge of evidence-base maternity care among Lamaze Certified Childbirth Educators and other birth professionals and advocates.  It is one of the leading online resources for up-to-date news and analysis of research and policy issues affecting childbearing women. Currently the blog features articles from the following contributors:

  • Amy Romano, CNM, who provides critical analysis of research relevant to the Lamaze Six Healthy Birth Practices.
  • Henci Goer, who provides critical analysis of research related to cesarean surgery and induction of labor.
  • Andrea Lythgoe, LCCE, who contributes the “Understanding Research” series, teaching readers basic skills for understanding and communicating about maternity care evidence.
  • Tricia Pil, MD, who covers the science of patient safety.
  • Kimmelin Hull, LCCE, who covers postpartum and breastfeeding issues.
  • Kathleen Kendall-Tackett, PhD, IBCLC, who covers mood disorders, breastfeeding, and the link between pregnancy and chronic disease.

Eligibility Criteria

The eligibility criteria for appointment shall include, but not be limited to, the following:

  • Demonstrated commitment to advancing safe and healthy birth and to the Lamaze approach to pregnancy, birth, breastfeeding and parenting.
  • Knowledge of the fields of maternity care and perinatal education and their current trends and advances.
  • Knowledge of evidence-based maternity care and the limitations of evidence.
  • Reputation as an online presence advocating for safe and healthy birth preferred.
  • Progressive vision for the role Science & Sensibility can play in disseminating knowledge and shaping conversations.
  • Experience writing for a blog. (Experience writing for peer-reviewed publication(s) preferred.)
  • Knowledge of WordPress or other blogging platform.
  • Demonstrated ability to plan, coordinate, and manage tasks associated with a multi-contributor blog.
  • Lamaze-Certified Childbirth Educator preferred.

Term

After the successful completion of a two (2) month probation period, the Community Manager will be appointed for a two (2) year term and may be renewed for additional two (2) year terms.

Remuneration

Lamaze International will provide the Editor with a quarterly honorarium of $2,500 ($10,000 annually) and provides marketing and IT support as needed.

General Responsibilities

The Community Manager of Science & Sensibility is directly accountable to the Lamaze International Executive Director. The Community Manager is responsible for all aspects of preparing the content of Science & Sensibility for publication, and is responsible for engaging with other bloggers on collaborative efforts. The specific responsibilities include:

  • Prepare or solicit from contributors at least 8-10 blog posts per month and coordinate publication schedule.
  • Edit and prepare all content for publication in WordPress
  • Work with new contributors to provide supportive and constructive feedback on blog submissions, and identify and appoint new contributors as needed.
  • Monitor and engage with other blogs covering issues that impact maternity care research and policy.
  • Participate in or coordinate online community events including collaborative writing projects and blog carnivals.
  • Manage Science & Sensibility Facebook page and participate in Twitter communication.
  • Moderate blog comments, and establish and enforce Community policies (e.g., commenting policy, editorial policies, etc.).
  • Participate in biweekly phone calls with the Lamaze social media team.
  • Provide a bi-annual report to the Lamaze International Board of Directors on Science & Sensibility matters.

Interested applicants should submit a letter describing qualifications and vision, along with a current resume to Linda Harmon, Executive Director by October 15, 2010 at lharmon@lamaze.org.

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Breast Pumps, Nipple Shields, Hooter Hiders…Oh, My!

September 19th, 2010 by avatar

As a childbirth educator, I frequently receive letters, pamphlets, postcards and, yes, the occasional free sample of products targeted toward the expectant and new mother.  One particularly popular category of said products includes those revolving around breastfeeding.

As breastfeeding (thankfully) continues to re-gain momentum in our culture, so do the products which are developed for and marketed to breastfeeding mothers.

But what about these products?  Which ones are necessary?  Which ones are helpful?  A luxury?  Superfluous?  Unnecessary?  Ultimately unhelpful to the breastfeeding process?

As is with life in general, the answers to the above questions represent a slippery slope–the grade of that slope largely dependent upon the dynamics going on between each mother-baby duo.

Here is a non-exhaustive list of the types of breastfeeding-related products out there:

clothing:
-nursing bras, shirts, tank tops, gowns, pajamas, etc.

over-clothing accouterments meant to cover up the nursing mom and baby:
– Hooter Hiders, Baby Bond drapes, screens, slings, wraps, cloths, blankets, etc.

sore nipple treatment products:
– ointments, creams, gel pads, nipple shields and shells

leaking breasts:
– breast pads, nipple shells/covers

breastfeeding aids:
– nipple shields, nipple shells, tube feeding systems, syringes, cups,

breast pumps:
-one- and two-flanged, manual, automatic, hospital grade, hands-free pumps…

With all this equipment out there, how does a woman choose which of these items is important to have on hand upon baby’s arrival, and which products represent little more than a marketing ploy aimed at capturing the dollars of vulnerable, new parents? Which items ultimately have an influence on how we collectively view breastfeeding in our culture, which ones truly support the breastfeeding process, and which ones complicate it?

As documented and/or suggested in several recent studies (one being Kathleen Buckley’s A Double-Edged Sword:  Lactation Consultants’ Perceptions of the Impact of Breast Pumps on the Practice of Breastfeeding, as appeared in the Spring 2009 issue of The Journal of Perinatal Education and covered on this blog) a large percentage of American women view breast pumps as a necessary item on the to-get list prior to baby’s arrival.  The implicated assumption being: in order to achieve breastfeeding success, one must employ the use of a mechanical pump at some point, rather than encouraging the baby to perform the job of drawing milk from the breast on his or her own.

Of course, complicating this issue is the higher and higher percentage of women returning to work within a month or two of their baby’s births.  Whether by choice or by lack of adequate maternity leave, more women are trying to keep up with the practice of breastfeeding they so desire, all the while tending to their uncompromising duties at work (“work,” in this case, meaning financially reimbursed duties outside the home).

But here’s a seemingly little known secret:  in most cases, whether returning to work or not, long-term breastfeeding success usually depends on less accouterments than more.  And early introduction of tools like breast pumps (before, say, three weeks postpartum) and nipple shields?  They actually decrease a woman’s likelihood of achieving long term breast feeding.  (By long term, I mean, say, longer than a few months.)

Breast pumps, specifically, have some potential drawbacks: Unless a woman has an extraordinarily abundant milk letdown reflex, it is difficult to express a whole heck of a lot of milk via a breast pump.  Believe me.  I know.  I struggled for months at trying to get a breast pump to work for me, just to build up that little reserve of breast milk in the freezer for the occasional date night out or, way back when, a shift at work that kept me away from the baby beyond nursing time.

And because breastfeeding is a supply and demand system, the more you rely on the pump to generate milk for your baby, the less milk is being drawn from the breast.  Less milk “demand” equals less milk production.  Within a relatively short period of time (the body responds to a change in the supply-demand system within 24-48 hours) the woman begins to notice a decline in her milk supply.  Add to that, the visual image of how much milk is showing up in the bottle after any one pumping session (again, much less milk will come out into the bottle via the pump than would otherwise end up in the baby’s tummy via baby-to-breast feeding) and the woman starts to doubt her ability to feed her child.

Can breast pumps save the nursing trajectory for some moms and babies?  Sure.  There are a variety of scenarios in which breast pumps can undoubtedly be useful and helpful.  But that degree of assistance only goes as far as the knowledge of how to keep a woman’s milk supply up while also relying on the breast pump (basically, by adding in some extra stimulation of the breasts–a couple extra nursing sessions with the baby, or extra pumping sessions beyond the frequency of the baby’s normal nursing pattern).

And how about other items like nipple shields, an increasingly popular tool distributed by more and more lactation consultants?

nipple_shield

Are these tools the magic bullet they are so often made out to be?  Or is this a case of mistaken identity or, worse yet, blind acceptance of half truths fed to us by medical supply company salespeople working on commission?  In many cases, are products like nipple shields a divergence away from addressing, and treating, whatever the true problem is in a challenged breastfeeding situation?  Here is an excellent article that addresses these questions.

Whether it be in the realm of pregnancy, labor and delivery or breastfeeding, I see us as a general population more and more often taking the band-aid approach versus addressing underlying issues, problems and concerns head-on and dealing with them proactively and efficiently.  Going back to the nipple shield example:  if a baby and mother are having difficulty with breastfeeding due to a poor latch (the most common cause of breastfeeding woes) it’s easy to hand over a nipple shield which, when used carelessly, encourages the baby to latch on to the teat of the shield only and draw milk via isolated suction rather than suction plus significant jaw and tongue motion.  (watch this video clip and this for the proper manner in which a baby ought to latch on to the breast)

While nipple shields can temporarily help women with the most severe cases of inverted nipples:

invertednipple

or flat nipples:

flatnipple

there is not a strong indication for the frequent or regular use of nipple shields in most other situations.  The risks, however, are plentiful, as described in the article referenced above.

Of less severity are some of the other products mentioned:  special nursing clothes, drapes, etc. meant to hide mom and baby as much as possible from public view while breastfeeding.  Here, I realize, I’m opening up an enormous can of worms but…what the heck, the can is already open, right?

How many folks, when preparing to purchase one of the dozen different nursing cover-ups, stops to think about why they feel compelled to add one of these things to their collection of baby stuff?  If it’s purely a matter of mother’s modesty than, have at it.  But if it’s a concern over what other people think about the act of a woman feeding her child, well…couldn’t one argue that the mass production and marketing of breastfeeding cover-ups only furthers our culture’s still often distorted and prudish views of breastfeeding?

So, if you’ve made it to the end of this post, you’re likely looking for a conclusion.  My conclusion would be this:  think carefully about the products you buy in regards to feeding your child.  Think even more carefully about the products you recommend to an expectant, new and/or nursing mother.  Consider who will ultimately win at the end of that purchase:  The mother?  The baby?  The company who has happily sold another well-marketed product?

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