Archive for December, 2010

Safe, Healthy, Happy Birth Practice Advocacy in the New Year

December 30th, 2010 by avatar

As 2010 winds down with The New Year on the horizon, let us take a moment to contemplate what we have accomplished here at Science & Sensibility over the past twelve months.  Largely commandeered by Amy Romano in the past year, S&S has seen a 78% increase in world-wide traffic with over 113,000 visitors dropping by from 20 different countries and every state in the U.S.  Over the course of nearly one hundred posts by eighteen contributing writers, our words were heavily contemplated–garnering over 1,500 comments by our interested and impassioned readers.

Science & Sensibility’s momentum has been fueled by the vibrant interaction between writers and readers, covering topics such as:  home vs. hospital birth,  evidence-based maternity care and sometimes the lack-there-of and miraculous birth stories. We have gone forth to discuss the potential dangers of Misoprostol and the potential side effects of cesarean sections.  We learned more about the role of the doula and shared thoughts on what constitutes “beauty” in terms of childbirth.  In fact, we have just landed on Babble’s Top Ten List of the Best Pregnancy/Birth Blogs of 2010. (Kudos to Giving Birth With Confidence for landing the number one spot!)

So, coming on the tail of a fabulous year of writing, idea sharing and highlighting the latest research pertaining to pregnancy, birth and the postpartum period, what can we look forward to in the New Year?

I can assure you our writing will continue to be strong, our coverage of research and evidence-based guidelines extensive.  You will hear from many of the Science & Sensibility writers you have come to appreciate, and meet many new contributors as well.  My hope, too, is that we continue to reach those who can benefit from our work the most:  maternity, labor and postpartum care providers as well as the new and expectant parents with whom they interact.  I commend each member of this community to continually seek new ways to push the boundaries between commonly accepted maternity care practices and better, safer, evidence-based care.  And I encourage those practicing the safest levels of evidence-based care to speak up and share your success stories.  I hope that, no matter what side of the philosophical  fence you find yourself on, that you can earnestly contemplate the stance of another’s point of view and be open to the potential educational opportunities contained therein.  Challenge yourself to neither romanticize one extreme version of maternity care nor demonize the other but, instead, seek the safety in truth that lies somewhere in between.

To those of you who regularly follow this blog site, I offer my heart-felt thanks–particularly to those who take the next step and share the information contained herein through your own on-line networks.  The ultimate power of social media is born of the expansive dissemination of information.  I urge each of you reading this post to play your part:  share links of interest to those in your own private (and professional) networks.  Use your voice.  The pen is, in fact, mightier than the sword.

For those of you dropping by on occasion: please feel invited to come back on a more regular basis.  If you have not done so already, click on the RSS Feed button on the upper right hand side of your screen to ensure your receipt of each new blog post.  Great things are surging ahead…make sure you’re a part of the wave.

Let us all, ultimately, remember that each of us finds our way here through our germane devotion to investigating and employing safe, healthy and happy pregnancy, birth and postpartum experiences. In a perfect world, all three aspects would conjoin to become one reality.  I invite you to join me on the road in pursuit of that perfection.

Science & Sensibility, Uncategorized , , , , , , , , , , ,

Healthy Birth Practice #1: Let Labor Begin on Its Own

Each month, the Science & Sensibility community will review one of Lamaze’s Six Healthy Birth Practices in sequential order.  Today, new S&S contributor Joni Nichols will discuss Healthy Birth Practice #1:  Let Labor Begin on Its Own.

Reviewing the very first recommendation of the Lamaze Six Healthy Birth Practices immediately brings to mind a popular refrain we use in Mexico,

“Del dicho al hecho hay mucho trecho!”

Literally this expression means that there is a pretty big space between “said” and “done” and is akin to the English expression “easier said than done.”

According to Dr. Wagner ( Born in the USA. 2006, p.39), “Federal studies that analyze birth certificates tell us that the percentage of U.S. births that happen Monday to Friday, nine to five, is rapidly increasing; even emergency c-sections are more common Monday to Friday, nine to five…”  This isn’t caused by global warming or the effects of the moon…we are looking at a procedure called Induction.

Rindfuss, Ladinsky, Coppock, Marshall, and  Macpherson’s Convenience and the Occurrence of Births: Induction of Labor in the United States and Canada used data for the United States and Canada on number of births by day of the week, for their paper in the International Journal of Health Service that pointed to indirect evidence for the widespread incidence of the practice of elective induction. For both the United States and Canada, it found that substantially fewer births occurred on Saturdays, Sundays, and holidays than on weekdays. Controlling for such factors as prenatal care, race, education, legitimacy, birth weight and time, trends strongly suggested that the induction of labor was responsible for the patterns found.

The National US Survey of Women’s Childbearing Experiences, Listening to Mothers I, reports that “almost half of all mothers reported that their caregiver tried to induce labor.” Even more telling:

“One-third of those mothers cited a non-medical factor as at least partially the reason for the attempted induction.”

As Gail Hart points out in her review of current research booklet, Research Updates for Midwives (2005), “If women are being induced for legitimate reasons of health and safety, then mortality and morbidity statistics should be improving.  Yet the statistics are quite flat. An induction and augmentation rate of over 35% has not seemed to improve the health of mothers or babies.”

So if a medical reason isn’t the rationale for this interference in the normal process of labor and birth what is?

NOW you know why this article is being written amidst the hectic activities of the holidays, because major holidays are prime time for inductions!!! Perhaps the caregiver is eager to have assurance that s/he will be able to enjoy the holiday without a call to come to the hospital or birth center.  Perhaps the birth facility is enthusiastic about scheduling fewer personnel for Thanksgiving, Christmas and Easter.  Perhaps the mother is eager to have the baby’s birthday before the holiday, thinking she can enjoy the day with a baby in arms or be assured of spending the holiday with her older children or extended family.  Perhaps she has a family member or friend only available to assist her in the days before the holiday but not during the holiday. Oftentimes she fears that her preferred healthcare provider won’t be available and will agree to a scheduled early delivery to guarantee that the desired provider will be available for the birth (a common concern of women utilizing group maternity health care practices—regardless of holiday proximity).

Considering that induction of labor brings with it some important risk factors, perhaps induction isn’t quite so seductive after all. Five of the documented risks include:

1)    abnormal fetal heart rate[1]

2)    baby being admitted to the neonatal intensive care unit (NICU)[2]

3)    use of forceps or vacuum extraction[3]

4)    prematurity, jaundice and breastfeeding difficulties[4]

5)    cesarean[1] [5],[6],[7]

Given these risks, the gauzy image of hearth and family and newborn at holiday time can look quite different.  Perhaps mother will be scuttling between home and hospital to care for her physiologically premature baby, or struggling with breastfeeding, or recovering from major surgery!

Many women whose experiences I read about in online forums for cesarean support, relay that they signed up for their inductions fully believing they were only hastening a fully developed baby’s arrival and report surprise, sadness,  regret and often guilt when their births ended in the OR.  Not surprisingly, their experiences are corroborated by research findings.

A retrospective study, conducted by 12 institutions participating in the Consortium on Safe Labor, examined electronic medical records associated with 228,668 births between 2002 and 2008 at 19 US hospitals. The overall purpose of the study was to assess contemporary labor and delivery practices.  This study offers some observations about why nearly one-third of all US births involve a cesarean delivery and suggests that induction plays a prominent role. Zhang and colleagues found evidence that physicians may be intervening too much and too soon. For example, the researchers found that 44% of women in the study population had their labor induced and that the cesarean delivery rate was twice as high for such women compared with those who had spontaneous labor (21.1% vs. 11.8%).  Additionally, when labor did not progress normally after induction, physicians were quick to perform a cesarean delivery, half the time initiating the procedure before a woman had dilated to 6 cm. “Our study does provide some clues that induction might play some role,” Zhang said. Coauthor S. Katherine Laughon, MD, a postdoctoral fellow at the National Institute of Child Health and Development suggested “more study is needed to determine when induction is clinically necessary and when it might be safe to wait and see if spontaneous labor occurs.”

Roger Freeman, MD, professor of obstetrics and gynecology at the University of California, Irvine, said the results of the Zhang study are consistent with previous studies which have suggested that the way labor is managed is contributing to the upward trend in number of cesarean deliveries performed. Freeman said that induction is clearly a contributor, and suggested that physicians avoid elective induction, which can elevate the rate of cesarean delivery and prolong labor without offering the potential benefits of clinically indicated induction.

“The single most positive thing you can do to prevent primary cesareans is to avoid elective induction of labor.”

On his blog for Frisco Women’s Health Care Jonathan R. Weinstein, MD, FACOG states “Induction has to be the biggest reason for the rise in [cesarean] rate in the United States, likely only second to your doctor’s fear of being sued despite trying to do the best thing for you and your family.  Elective induction can be convenient for both the mom and the doctor but buyer beware.  If your cervix is not ripe (dilated and thinned out) prior to an attempted induction of labor you have up to a 90% failure rate for your induction which usually translates to you getting a [cesarean section].”

Gail Hart succinctly chronicles the way even a “simple” uncomplicated induction can begin an avalanche of interventions.  “Beginning with the cervical stretching and sweep to “ripen” the cervix, then to IV Pitocin, electronic fetal monitoring and amniotomy, then perhaps an intrauterine pressure catheter, amnio-infusion for unusual fetal heart tones, an epidural for the pain of Pitocin-induced contractions, mal-rotation or poor descent for fetal distress. It goes on and on. The mother ends up with a lifelong injury to her uterus. Her baby may be stressed and separated from the family. A normal birth turns into a nightmare and that’s only if all goes well!”

Her conclusion is quite chilling: “If we start a labor with chemicals, we may very well have to finish it with the surgeon’s scalpel.”  This is hardly the scenario a mother imagines when she requests or concedes to the suggestion of nudging her baby out from the uterus to beat the holiday rush!

The chapter on Induction in the 3rd edition of A Guide to Effective Care in Pregnancy and Childbirth by Keirse, Neilson, Crowther,  Duley, Hodnett and Hofmeyr reminds us that,

“there is very little methodologically sound research on the indications for elective delivery.  Irrespective of whether the induction is for social/ elective purposes or is medically indicated, current and recent research focuses instead on HOW to achieve the induction rather than what constitutes the need for induction vs. cost-benefit analysis.”

If, given all these concerns over induction for both mother and baby, a woman still wishes to continue a dialogue about elective induction with her caregiver, then a comprehensive explanation of different induction methods ought to ensue.  These methods were nicely reviewed in a May 2003 American Family Physician journal article: Methods for Cervical Ripening and Induction of Labor” by Josie L Tenore, M.D., S.M.  Likewise, a similar fact sheet written from a midwife’s perspective provides similar content— found at Nicole Deelah’s Sage Beginnings.

Both resources mentioned above review the non-pharmacologic approaches to cervical ripening and labor induction such as herbal compounds, castor oil, hot baths, enemas, sexual intercourse, breast stimulation, acupuncture, acupressure, transcutaneous nerve stimulation, as well as mechanical and surgical modalities such as stripping of the membranes and amniotomy. Pharmacologic agents utilized for cervical ripening and labor induction include prostaglandins, misoprostol, mifepristone, relaxin and oxytocin (Pitocin).  Ms. Deelah’s information provides the “realities” of what each entails for the mother and its attendant risk for both her and her baby.

Both authors concur that in the absence of a ripe or “favorable” cervix, a successful vaginal birth is less likely. Therefore, cervical ripening or preparedness for induction needs to be assessed before any induction regimen is selected. Assessment is accomplished by calculating a Bishop score. In 1964, Bishop systematically evaluated a group of multiparous women for elective induction and developed a standardized cervical scoring system. The Bishop score helps delineate patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth.

No discussion of elective induction is complete without considering the impact on the baby. “Although we certainly understand that at 37 weeks many women are exhausted from pregnancy and feel they are ready to give birth, their baby is physically not ready,” says Cindy Fahey, MSN, RN, PHN, Executive Director, PAC/LAC. (Perinatal Advisory Council: Leadership, Advocacy and Consultation) “Inducing labor before 39 weeks, with no medical indication, is dangerous for the newborn, and has been clearly shown to lead to increased complications at birth and beyond. We strongly urge pregnant women who plan to be induced to wait until at least 39 [completed] weeks of pregnancy.”

The last few weeks of pregnancy are critical to both lung and brain development. Complications of elective deliveries between 37 and 39 weeks include:

  • Increased NICU admissions
  • Increased respiratory distress and TNN (transient tachypnea of the newborn)
  • Increased need for ventilator support
  • Increased rate of sepsis
  • Increased feeding problems

“We can’t state strongly enough that early induction without clear medical cause is not only unnecessary; it can be damaging to the baby’s health,” says Fahey. “We encourage women who are planning to be induced to discuss early induction and its associated risks with their physicians to ensure that they make the best choice for their baby.”

Cara Terreri recently shared some astute observations on Giving Birth With Confidence about how to avoid a trip down the road to avoidable prematurity and describes the “red flags” a woman may encounter that tip her off to her caregiver’s interest in proposing a medically unsubstantiated induction.

Yes, awaiting spontaneous labor can be inconvenient–but it also has many health advantages!   A Cochrane Pocketbook: Pregnancy and Childbirth which focuses on the effectiveness of interventions on the health and well-being of pregnant women and their babies derived from the Cochrane systematic reviews reminds us that “labor induction is considered when the benefits of earlier labor outweigh the risks of labor induction.”  Those of us who read the evidence behind the Lamaze Six Healthy Birth Practices perceive the benefits of waiting and the risks in inducing.  Those who have only perceived the purported benefits of induction while bemoaning the “risks” of staying pregnant a few days or weeks longer may discover that one of the best holiday gifts they can offer their baby, themselves and their family is permitting the baby to choose his or her own birthday.

Post by:  Joni Nichols BS MS CCE CD(DONA) (CBI)

[1] http://www.ajog.org/article/0002-9378(95)91415-3/abstract


[3] http://aje.oxfordjournals.org/content/153/2/103.full

[4] http://www.marchofdimes.com/pregnancy/vaginalbirth_inducing.html

[5] http://www.ncbi.nlm.nih.gov/pubmed/20027037

[6] http://www.aafp.org/afp/20000215/tips/39.html

[7] http://www.ncbi.nlm.nih.gov/pubmed/10511367

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Postpartum Support International: A Sensible Resource for Birth Professionals

December 23rd, 2010 by avatar

“Honesty is disarming.  It should set the stage for dialogue.” — Jane Honikman, M.S., founder, Postpartum Support International

One of the first written accounts of postpartum mood disorders was in 1436. Margery Kempe, mother of 14, wrote:

“Wherefore after that her child was born she, not trusting her life, sent for her ghostly father, as said before, in full will to be shriven of all her lifetime as near as she could. And, when she came to the point for to say that thing which she had so long concealed, her confessor was a little too hasty …and so she would no more say for nought he might do. And anon for dread she had of damnation on that one side and his sharp reproving on that other side, this creature went out of her mind and was wonderly vexed and labored with spirits half year eight weeks and odd daysi.”

Background to Postpartum Mood and Anxiety Disorders
In the quote above, from Out of her mind: Women Writing on Madness, Margery’s honesty is indeed disarming, and provides historical context to set the stage for future dialogue: perinatal mood disorders have been around a long time, and based on current evidence, they aren’t going away.

  • Suicide is the leading cause of death for women during the first year after childbirth.1
  • Depression is the second most common cause of hospitalization for women in the U.S.; the first being childbirth.2,3
  • Major and minor postpartum depression/anxiety estimates range from 5% to 25% for new mothers in US.4,5,6,7,8
  • There is a seven-fold increase in the risk of psychiatric hospitalization for women following childbirth.9,10,11
  • Reports show that PPMAD affects up to 48% of women living in poverty.12,13,14,15


The Role Stigma Plays
Statistically, over 500 years later, Margery would still be at risk largely due to the powerful social mechanism of stigma regarding motherhood and mental illness.  Just as stigma about mental health disorders silences women today, Margery was similarly silenced in 1436.16,17,18 It is the silent fear of stigma that likely causes nearly 50% of present-day, affected women to go untreated for perinatal mood disorders.19,20

In her 2010 book Within Our Reach: Ending the Mental Health Crisis21, former first lady (and life-long mental health advocate), Rosalynn Carter noted:


Stigma is the most damaging factor in the life of anyone who has a mental illness. It humiliates and embarrasses; it is painful; it generates stereotypes, fear and rejection; it leads to terrible discrimination. Perhaps the greatest tragedy is that stigma keeps people from seeking help for fear of being labeled, “mentally ill” (p. 1).

Raising Awareness

One of the ways to end stigma is to increase awareness. In my recent interview [KMH1] with Jane Honikman, M.S., founder of Postpartum Support International (PSI), she offered:

The causes of stigma include ignorance and denial about the importance of emotional wellbeing of childbearing women.  On the community, national and international levels this ignorance is being eliminated through educational awareness campaigns.   There is no excuse not to be educated about the range of emotional reactions during the perinatal period.  Denial is a personal issue and more difficult to confront.  It is impossible to know how one’s expectations of motherhood will be met.  The mythology that surrounds parenthood is another huge barrier.  Taboos need to be openly discussed.  Often there are conflicts between the woman and her partner. These need to be discussed.  It is difficult to parent alone. Family members should participate in supporting the new family.  It is important to have frank and honest conversations about opinions and expectations within the extended family unit during pregnancy and following the arrival of the baby.

Increased awareness regarding prevalence, risk factors, and the need to screen has occurred at many levels. There has definitely been progress.  Jane further offered:

Awareness has increased tremendously since I first got involved nearly forty years ago.  The availability of accurate information, resources and referral networks is responsible for these changes.  The media has been our movement’s best friend.  For example, there are now free materials from the federal government, healthy start programs include maternal mental health curriculums, and states have active coalitions.  Insurance companies have eliminated barriers to receiving mental health coverage.  All of the major medical organizations have stepped forward offering educational seminars to their members.  The courts now consider mental health history when they encounter a crime. The internet has played an enormous role.  Postpartum Support International’s website www.postpartum.net has been a leader in this progress.

Further evidence of progress can be found in the published position papers related to maternal mental health of the following organizations:

Centers for Disease Control and Prevention (CDC)
The American Congress of Obstetricians and Gynecologists (ACOG)
The World Health Organization (WHO)
American College of Nurse-Midwives (ACNM)
Planned Parenthood
National Organization for Women (NOW)
The American Academy of Pediatrics (AAP)
National Alliance on Mental Illnesses (NAMI)
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
Children’s Defense Fund (CDF)
National Women’s Law Center
National Partnership for Women and Families (NPWF)
The U.S. Preventive Services Task Force
American Psychological Associatio(APA)
US Dept of Health and Human Services
March of Dimes
National Institute of Mental  Health(NIMH)
Healthy Mothers Healthy Babies
International Childbirth Educators Association (ICEA)

Postpartum Support International (PSI) has had a tremendous influence on raising awareness about postpartum mood and anxiety disorders. Given their successful leadership in advocating for maternal mental health using evidence-based research, it serves to look more closely at the organization’s structure and become familiar with the resources they provide all childbirth professionals.

Postpartum Support International Background
PSI was founded in 1987 by Jane Honikman in Santa Barbara, California. The purpose of the organization is to increase awareness among public and professional communities about the emotional changes that women experience during pregnancy and postpartum.  The non-profit organization’s greater mission is to promote awareness, prevention and treatment of childbearing-related mental health issues in every country worldwide. It is the vision of PSI that every woman and family will have access to information, social support, and informed professional care when needed.  PSI promotes this vision through advocacy and collaboration, and by educating and training the professional community and the public.  

How PSI Works
PSI is run and maintained by volunteers. According to Wendy Davis, Ph.D., PSI Program Director, there are currently 479 active members and of that number, approximately 50 of those are childbirth professionals (birth or postpartum doulas, childbirth educators, lactation consultants).  There are 145 PSI Support Coordinators in the United States, and 48 in other countries. Support coordinators provide support, information, and resources to anywhere from 2 to 20 families every month, and many of them lead free support groups. We also have specialized PSI Coordinators for military families, Dads, Spanish-speaking moms, and legal resources.

PSI maintains a warm line (1.800.944-4PPD) which is managed by 9 English speaking volunteers, and 8 Spanish speaking volunteers. On average, the English warm-line receives 90 calls a month, and the Spanish warm-line, 70 calls per month. The toll free number connects the caller with informed and caring PSI telephone support volunteers 7 days a week. What happens when an individual calls in? Dr. Davis explained:

The caller hears a greeting and then can leave a voicemail message in English or Spanish. The calls are usually returned within several hours; volunteers make every effort to connect with the caller within 24 hours at the most. The warm-line is answered live in English on Tuesdays and Wednesdays, during regular business hours, Pacific time. Warm-line volunteers offer non-judgmental support, information, and local resources. They will connect the caller with their area PSI Support Coordinator so they can find support or providers as close to home as possible.

The PSI website
provides consumers and professionals with current research, and resources.  According to Dr. Davis:

The hallmark of our website is our Support Map Page that lists PSI support coordinators, free support groups, and events in every U.S. state and 35 other countries. Childbirth professionals can be assured that they can find volunteers in their own area who are available to help them and the families they serve. Our Coordinators are trained to provide support, information, and local resources as well as phone or email support to families as needed. The website also includes current evidence-based information on the range of pregnancy and postpartum mood disorders, tips for coping, resources for moms, partners, and professionals, educational materials like brochures and posters in English and Spanish, new research articles, and a bookstore. There is one page that just lists information and links in non-English languages, and one section of the website has been translated to Spanish. We update the website constantly to keep it current, adding new research and resources daily.

One of the additional resources she described is the PSI Free Chat with an Expert:

PSI hosts free, live phone sessions every week facilitated by licensed professional experts in perinatal mental health. There is a session for moms and their helpers every Wednesday and for Dads on the first Monday of each month. These sessions provide a forum to share, listen to others, and talk with a PSI expert about resources, symptoms, options and general information about perinatal mood and anxiety disorders. You can learn more about the facilitators and call schedules [here].  

Sensible Resource: How to use PSI in Practice
How can childbirth professionals best utilize PSI for their clients? Dr. Davis suggested:

  • Find your local PSI Coordinator on the Support Map so that you can connect clients with them.
  • Create links to PSI website in the resource section of your websites, provide basic facts about perinatal mental health in educational materials, include information about pregnancy and postpartum mental health in prenatal education.
  • Have PSI brochures or posters available.
  • Use the 13-minute PSI educational DVD with clients. You can see a preview of the DVD, and one for fathers on the PSI website here.

How could childbirth organizations best utilize PSI for their professionals?  Again, Dr. Davis shared great ideas:

Come to PSI trainings, use the PSI website, join PSI and be part of our listserve for PSI members who are doulas, contact local coordinators or the PSI office with questions, provide educational materials and training for their students and members. The PSI Professional trainings, offered in several places around the country and at the PSI annual conference every year, are designed to include childbirth professionals. PSI 2011 trainings are scheduled for Los Angeles in January, Michigan and Kentucky in March, Indianapolis in May, and in Sept 2011 the 25th annual PSI conference will be held in Seattle in conjunction with PSI-Washington, which has a long history of involvement with childbirth professionals. You can keep track of trainings on the website here. http://postpartum.net/Professionals-and-Community/Trainings-Events/Trainings-and-Conferences.aspx

My heartfelt hope is that the information shared here will provide childbirth professionals evidence-based resources for their practice and clients.

Thank you for reading the article.

Still, I keep thinking about Margery Kempe: over 500 years later, why are depression and childbirth the two top reasons for a woman to be hospitalized2,3?

I extend an invitation to all childbirth professionals to honestly examine current positions, or lack thereof, regarding maternal mental health. What are current positions regarding perinatal mood disorders?  Are we, as childbirth industry professionals, comfortable discussing mental health issues with our clients?  Do we  know how to screen?  Do we know how to refer to local resources in our local communities?

Ask yourself this:  What help do you need in becoming comfortable discussing mental health issues with your clients? Let your organizations hear from you.

Professionally, let’s examine if our organizations have mental health resources on their websites, blogs, training materials, and fact sheets. Given that suicide is the leading cause of death in the first year following childbirth1, I would offer that having suicide prevention information on websites might be a place to start.

USA National Suicide Hotlines
Toll-Free / 24 hours / 7 days a week

**View Walker’s complimentary post over at Giving Birth With Confidence where she expands further on her interview with Jane Honikman**

I would like to extend my gratitude to Jane Honikman, M.S., for her contribution to this article, and for her steadfast commitment to women everywhere. Jane…I will pass my heart to you any day.  And thanks, as always, to Wendy Davis, Ph.D., for working until 3AM to help me with this article. Also, thank you to both Cara Terreri, and Kimmelin Hull for giving me the opportunity to write for their sites, and to Lamaze International for their support. The full content of my interview with Jane Honikman can be found at www.fullydilated.net

Posted by:  Walker Karraa, MFA, MA, CD (DONA)

iKempe, M. (1436). The book of Margery Kempe. In Shannonhouse, R. (Ed.) (2003). Out of her mind: women writing on madness. New York: Modern Library. pp. 3-7.

1 Oates, M. (2003). Suicide:  The leading cause of maternal death.  The British Journal of Psychiatry, 183, 279-281.

2 Gold , K., Marcus, S., (2008). Effect of maternal mental illness on pregnancy. Expert Review of       Obstetrics & Gynecology, 3 (3), 391-401.

3 Blenning, C., Paladine, H. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496.

4 Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., et al. (2005).   Perinatal depression prevalence, screening accuracy, and screening outcomes: Summary, evidence report and technology assessment, No. 119. AHRQ Publication No. 05-E006-1.

5 Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

6 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

7 Yonkers, K., Chantilis, S. (1995). Recognition of depression in obstetric and gynecology practices. American Journal of Obstetrics and Gynecology, 173(2), 632-638.

8 Gavin, N.I., Gaynes, B.N., Lohr, K.N., Meltzer-Brody, S., Garlehner, G., Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. American Journal of Obstetrics and Gynecology, 106(5 Pt 1), 1071-1083.

9 Harlow, B.L., Vitonis, A.F., Sparen, P., Cnattingius, S., Joffe, H.,  Hultman, C. M. (2007). Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Archives of General Psychiatry, 64(1), 42-48.

10 Manisha, S. (2005). The role of state public health in perinatal depression. Fact sheet. Association of State and Territorial State Officials.

11 Postpartum Mood Disorders. The Jennifer Mudd Houghtaling Postpartum Depression Foundation Website. Retrieved May 1, 2009 from http://www.ppdchicago.org/.

12 Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

13  Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

14 Position statement: Screening for  prenatal and postpartum depression. (n.d.). Perinatal Foundation and Wisconsin Association for perinatal Care. Retrieved April 9, 2009 from http://www.perinatalweb.org.

15 Isaacs, M. (2004). Community care networks for depression in low-income communities and communities of color: A review of the literature. Submitted to Annie E. Casey Foundation and the Howard University School of Social Work and the National Alliance of Multiethnic Behavioral Health Associations (NAMBHA).

16 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

17 Ibid.

18 Abrams, L.S., Dorning, K. (2007). Bridging the gap: Barriers to service use among low-income women with postpartum depression. Funded by the Center for Vulnerable Populations Research at the UCLA School of Nursing and the UCLA Faculty Senate in cooperation with the Public Health foundation Enterprises WIC program.

19 Maternal Depression Making a Difference Through Community Action: A Planning Guide (n.d.). Mental Health America, Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved March 4, 2009 from: http://www.mentalhealthamerica.net/go/maternal-depression.

20 Ramsay, R. (1993). Postnatal Depression. Lancet, 314, 1358.

21 Carter, R. (2010). Within our reach: Ending the mental health crisis. New York, NY: Rodale, Inc.

Doula Care, Healthy Care Practices, Patient Advocacy, Practice Guidelines, Prenatal Illness, Research, Science & Sensibility, Uncategorized , , , , , , ,

When Conflict of Interest Threatens the Quality of Education

December 21st, 2010 by avatar

A few weeks ago, I was invited to teach a one-time, free, community education class on breastfeeding basics.   As an independent, Lamaze Certified Childbirth Educator in my community, I was happy to oblige—recognizing that low-cost or no-cost community health education classes play an important role in any and all communities.  Being passionate about the dissemination of accessible, evidence-based lactation information, I was more than happy to volunteer the information normally apart of my eight-week childbirth preparation series.

But there was a catch.

My invitation to teach came from a neighbor of mine who owns the local baby supply store in town.  While her secondary reason for offering occasional classes on location, in her store was to further her hard-earned reputation as a one-stop-shopping depot for all things baby—even to the point of providing monthly free classes on varying topics of interest to pregnant, nursing and new mothers during which new and expectant women can mingle and make social connections—her primary purpose was to increase store traffic and, therefore, sales.

A sub-section of Lamaze International’s Code of Ethics for Childbirth Educators speaks to the issue of Conflict of Interest:

1.06 Conflicts of Interest

(a)    Childbirth educators should be alert to and strive to avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. When a real or potential conflict of interest arises, childbirth educators should first disclose the conflict to clients and then take reasonable steps to resolve the issue in a manner that prioritizes the clients’ interests and protects clients’ interests to the greatest extent possible.

How did this invitation to teach (on a volunteer basis) a single class challenge the code of ethics I, as an LCCE, have promised to abide by?  The possibility that my instruction would include subversive or overt recommendations of in-store products the store owner hoped I would incorporate into the two-hour class.

“Feel free to stop on by the store a day or two before the class to see what all we have in stock—that way you’ll know which products to mention when talking about breastfeeding,” my neighbor suggested.  “We’ll probably offer some sort of discount the night of the class for anything purchased that evening.”

Should I have been concerned with the amount of sales generated by my overview on the anatomy, physiology, practice and benefits of breastfeeding?  Of course not.  Would I have been in breach of my promise to uphold Lamaze’s Code of Ethics in regards to Conflict of Interest, had I accepted the invitation to teach this class?  Well, let’s see:

Disclaiming a conflict of interest entails confessing any sort of financial reimbursement given to a conference speaker, health care provider, instructor or administrator (or to his/her family member) that might influence his/her decision to use, recommend or employ a certain product, service or practice of care.  So, by definition, because I was not being paid to teach this class, I would not have technically been in breach of my Lamaze Code of Ethics commitment.

The slippery slope, however, became evident in this business owner’s expectation that the content of my presentation would directly entice class participants to buy certain products, based on my recommendations under the guise of authoritative knowledge.  If, for example, I swore by the functionality of the most expensive breast pump in the store—raving about its ability to support the continuation of breastfeeding over long periods, including mother’s-return-to-work-scenarios, and its status as a “must have” product for all moms with infants, despite the previous ten-minute mini-lecture I’d provided on the supply and demand system of lactation—that could have been perceived by my students as advice on a product they “should” have at home in order to succeed at breastfeeding.

If, however, I mentioned and even showed examples of breastfeeding-related products in conjunction with curriculum content—for example, providing a visual demonstration of how to determine a “good” versus “bad” nursing bra in terms of support, proper fit, lack of underwire structure and easy release of cup latch—would this be considered entering the dangerous waters of Conflict of Interest?  I would argue the answer here is, “No.”

Obviously, receiving a monetary kick-back for each sale made of a particular item, or a percentage of total sales on the night of my class would be a brazen breach of ethics on my part and I’m happy to say such an arrangement was never discussed by business owner nor educator.

I did, in fact, go on to teach the one-time class in question—Conflict of Interest and guilt free, and in the presence of a lovely, invested, intelligent, un-coerced audience!

Ethics can be a tricky thing and, I for one, am thankful for Lamaze International’s clear delineation of the Ethical Standards by which it expects its certified educators, employees and agents to abide.  Wouldn’t it be fantastic to see all professional organizations follow suit?

Posted By:  Kimmelin Hull, PA, LCCE

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Webinar Round Up: Education Across the Wire

December 17th, 2010 by avatar

This week, I had the benefit of sitting in on three webinars related to maternity and/or overall patient care.  For those of us looking for additional ways to stay current on the latest and greatest happenings in our industry, webinars are a fantastic tool.  Often occurring sometime around noon(EST), these 1 hour audio/visual sessions feature experts and leaders in their respective fields and are sometimes associated with continuing education credits.

On Tuesday, Childbirth Connection’s Amy Romano, CNM and Harold Miller, President and CEO of the Network for Regional Healthcare Improvement, and Executive Director of the Center for Healthcare Quality and Payment Reform discussed healthcare payment reform in terms of maternity care—ways in which the improvement of care quality can be linked to financial incentives.  To download the webinar, go here.  Childbirth Connection’s next webinar is scheduled for Tuesday, January 18: Disparities in Access and Outcomes of Maternity Care.  To register, go here.

On Wednesday, I listened to the Lamaze International-hosted webinar, Becoming Baby Friendly—Strategies Creating a Culture That Promotes Breastfeeding, presented by Eileen M. DiFrisco, MA RN IBCLC and Karen Goodman, MA RN IBCLC LCCE.  The speakers did a tremendous job outlining the ways in which they have worked toward earning Baby Friendly status at their hospital, NYU-Langone Medical Center, over the past few years.  To access this and other previous Lamaze webinars (and obtain CME credits!) go here.  (Webinars become available on line two weeks after the event.)

Yesterday, our very own contributor Tricia Pil, MD participated in a webinar, The Patient Activist, through the Institute for Healthcare Improvement. This event was a follow-up to the Institute’s 22nd annual Forum on Quality Improvement in Healthcare.  To access previous (free) audio programs from the IHI, including yesterday’s enlightening conversation on the momentum to improve healthcare through the work of patient advocates/activists, go here. For a schedule of up-coming webinar events, go here.

**With all of these websites/webinar services, don’t forget to register for up-coming events.  In doing so, you will receive reminder emails as well as log-in information to gain you access to up-coming, live events.  The benefit of attending webinars live-time?  There is almost always a Q&A session at the end during which attendees can submit questions to the speakers–furthering the educational experience.**

Let us go forth and keep the conversation about improving maternity care, and health care in general, long, strong and effective!

Continuing Education, Healthcare Reform, Patient Advocacy , , , , , , , , , ,

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