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The Best Practice Guidelines: Transfer from Home Birth to Hospital – Collaboration Can Improve Outcomes

April 17th, 2014 by avatar

 By Lawrence Leeman, MD, MPH and Diane Holzer, LM, CPM, PA-C

© http://www.mybirth.com.au/

© http://www.mybirth.com.au/

On Tuesday, readers learned about the history and objectives of the Home Birth Consensus Summit, a collective of stakeholders, whose goal is to improve maternal infant health outcomes and increase collaboration between all those involved in serving women who are planning home births.  The interdisciplinary collaboration that occurs during the Summits brings representatives from many different perspectives to the table in order to improve the birth process for women and babies. You may want to start with the post “Finding Common Ground: The Home Birth Consensus Summit“ and then enjoy today’s post on the Home Birth Consensus Summit’s just released “The Best Practice Guidelines: Transfer from Home Birth to Hospital.”  Today’s post was written by Dr. Lawrence Leeman and Midwife Diane Holzer, two of the members on the HBCS Collaboration Task Force, a subgroup tasked with developing these transfer guidelines.  Share your thoughts on these new guidelines and your opinion on if you feel that they will improve safety and outcomes for mothers and babies. – Sharon Muza, Community Manager, Science & Sensibility

Leea Brady was a second-time mother whose first baby was born at home. One day past her due date, an ultrasound revealed high levels of amniotic fluid, which can pose a risk during delivery. Although she planned to have her baby at home, on the advice of her midwife, Leea transferred to her local hospital.

“I knew that we needed to be in the hospital in case anything went wrong,” said Brady. “I was really surprised when I arrived and the hospital staff told me they had read my birth plan, and they would do everything they could to honor our intentions for the birth. My midwife was able to stay throughout the birth, which meant a lot, because I had a trusting relationship with her. She clearly had good relationships with the hospital staff, and they worked together as a team.”

A recent descriptive study (Cheyney, 2014) reports that about ten percent of women who plan home births transfer to the hospital after the onset of labor. The reason for the overwhelming majority of transfers are the need for labor augmentation and other non-emergent issues. Brady’s transfer from a planned home birth to the hospital represents the ideal: good communication and coordination between providers in different settings, minimizing the potential for negative outcomes.

However, in some communities, lack of trust and poor communication between clinicians during the transfer have jeopardized the physical and emotional well being of the family, and been frustrating for both transferring and receiving providers. Lack of role clarity and poor communication across disciplines have been linked to preventable adverse neonatal and maternal outcomes, including death.(Guise, 2013,Cornthwaite, 2008) With optimal communication and cooperation among health care providers, though, families often report high satisfaction, despite not being in the location of their choice.

Recent national initiatives have been directed at improving interprofessional collaboration in maternity care.(Vedam, 2014) This is why a multi-disciplinary working group of leaders from obstetrics, family medicine, pediatrics, midwifery, and consumer groups came together to form a set of guidelines for transfer from home to hospital. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital are being officially launched today by the Home Birth Consensus Summit and will be highlighted at a series of upcoming presentations at conferences and health care facilities.

The authors of the guidelines, known as the Home Birth Summit Collaboration Task Force, formed as a result of their work together at the Home Birth Summits.

© http://flic.kr/p/3mcESR

© http://flic.kr/p/3mcESR

“Some hospital based providers are fearful of liability concerns, or they are unfamiliar with the credentials and the training of home birth providers,” said Dr. Timothy Fisher, MD, MS, at the Hubbard Center for Women’s Health in Keene, NH and an Adjunct Assistant Professor of Obstetrics and Gynecology, Dartmouth Medical School. “But families are going to choose home birth, for a variety of cultural and personal beliefs. These guidelines are the first of their kind to provide a template for hospitals and home birth providers to come together with clearly defined expectations.”

The guidelines provide a roadmap for maternity care organizations developing policies around the transfer from home to hospital. They are also appropriate for transfer from a free-standing birth center to hospital.

The guidelines include model practices for the midwife and the hospital staff. Some guidelines include the efficient transfer of records and information, a shared-decision making process among hospital staff and the transferring family, and ongoing involvement of the transferring midwife as appropriate.

“When the family sees that their midwife trusts and respects the doctor receiving care, that trust is transferred to the new provider,” said Dr. Ali Lewis, a member of the HBCS Collaboration Task Force. She became involved with the work of the committee in part because of her experiences with a transfer that was not handled optimally. “It is rare that transfers come in as true emergency. But when they do, if the midwife can tell the family she trusts my decisions, then I can get consent much more quickly, which results in better care and higher patient satisfaction.”

The guidelines also encourage hospital providers and staff to be sensitive to the psychosocial needs of the woman that result from the change of birth setting.

“When families enter into the hospital and feel as if things are being done to them as opposed to with them, they feel like a victim in the process,” said Diane Holzer, LM, CPM, PA-C, and the chair of the HBCS Collaboration Task Force. “When families are incorporated in the decision-making process, and feel as if their baby and their body is being respected, they leave the hospital describing a positive experience, even though it wasn’t what they had planned.”

The guidelines are open source, meaning that hospitals and practices can use or adapt any part of the guidelines. The Home Birth Summit delegates welcome endorsements of the guidelines from organizations, institutions, health care providers, and other stakeholders.

References

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(4), 571-581.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health.

Guise, J. M., & Segel, S. (2008). Teamwork in obstetric critical care. Best Practice & Research Clinical Obstetrics & Gynaecology, 22(5), 937-951.

Vedam S, Leeman L, Cheyney M, Fisher T, Myers S, Low L, Ruhl C. Transfer from planned home birth to hospital: inter-professional collaboration leads to quality improvement . Journal of Midwifery and Women’s Health, November 2014, In Press.

About the Authors:

leeman larry headshotDr. Lawrence Leeman, MD, MPH/Medical Director, Maternal Child Health, received his degree from University of California, San Francisco in 1988 and completed residency training in Family Medicine at UNM. He practiced rural Family Medicine at the Zuni/Ramah Indian Health Service Hospital for six years. He subsequently earned a fellowship in Obstetrics. He is board certified in Family Medicine. He directs the Family Medicine Maternal and Child Health service and fellowship and co-medical director of the UNM Hospital Mother-Baby Unit. Dr. Leeman practices the family medicine with a special interest in the care of pregnant women and newborns. He is Medical Director of the Milagro Program that provides prenatal care and maternity care services to women with substance abuse problems. Dr. Leeman is a Professor in the Departments of Family & Community Medicine, and Obstetrics and Gynecology. He is currently the Managing Editor for the nationwide Advanced Life Support in Obstetrics (ALSO) program. Areas of research include rural maternity care, pelvic floor outcomes after childbirth, family planning, and vaginal birth after cesarean (VBAC). Clinic: Family Medicine Center

Diane Holzer head shotDiane Holzer, LM, CPM, PA-C, has been a practicing midwife for over 30 years with experience in both home and birth center. She was one of the founding women who passionately created an infrastructure for the integration of home birth midwifery into the system. She sat on the Certification Task Force which led to the CPM credential and also was a board member of the Midwifery Education and Accreditation council for 13 years. She served the Midwives Alliance of North America on the board for 20 years and is the chair of the International Section being the liaison to the International Confederation of Midwives. Diane is the Chair of the Collaboration Task Force of the Home Birth Summit and currently has a home birth practice and works as a Physician Assistant doing primary health care in a rural Family Practice clinic.

Babies, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Practice Guidelines, Transforming Maternity Care , , , , , , , ,

Finding Common Ground: The Home Birth Consensus Summit

April 15th, 2014 by avatar
© HBCS

© HBCS

While home birth has a proven safety record in countries outside the U.S., some attribute that to the fact that, in other countries, home birth takes place in the context of an integrated health care system. It is critical that all of the stakeholders in the maternal health care system are working together to ensure safe birth options in the U.S. as well.

The Home Birth Consensus Summit (HBCS) is a unique collaboration of all of the stakeholders currently involved in home birth in the United States. First held in 2011, the Home Birth Consensus Summit offers physicians, midwives, consumers, administrators and policy makers; (a varied group of representatives who do not often share common ground,) a chance to take a 360 degree look at the current maternal health care system and tease out the areas of conflict and common ground in order to increase safety in all birth settings.

Today on Science & Sensibility, our readers learn about the Home Birth Consensus Summit; its participants, purpose and process. Thursday, we will have the opportunity to review one of the groundbreaking products from the past two summits, when the HBCS releases the “Best Practice Guidelines: Transfer from Home Birth to Hospital” for consideration and adoption by maternal health organizations. Learn more about the HBCS from Summit Delegate Jeanette McCulloch as she interviews Saraswathi Vedam, RM FACNM MSN Sci D(hc), Home Birth Consensus Summit convener and chair. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: What was the motivation behind launching the Home Birth Consensus Summit?

Saraswathi Vedam: Women want – and deserve – respectful, high quality maternity care regardless of their planned place of birth. Women and their families are not served by the interprofessional conflict and confusion that occurs in many regions in the US around place of birth.

While there may be points of disagreement, I know from numerous conversations with consumers, midwives, physicians, administrators, and policy makers that there are many more areas in maternity care where we all share a common set of principles and goals. Everyone is committed to working towards improved quality and safety for women and infants.

In 2011, a very intentionally selected group of stakeholders came together for the first Summit at the Airlie Center, in Warrenton, VA. These individuals represented all key leaders of the maternity care team, researchers, policy makers, payors, consumers, and consumer advocates. They came to the Summit with a wide variety of perspectives – including those for and against planned home birth. At the Summit, these delegates engaged in a unique process designed to help those with opposing viewpoints untangle complex issues. This process, called Future Search, guided the group through a complete exploration of every aspect of the maternal health care system. There were frank, challenging, and productive conversations, often among stakeholders who rarely, if ever, had been at the same table before. Once we were able to discover common ground, we were able to create a realistic and achievable strategic action plan together.

JM: Tell us about what common ground the Home Birth Consensus Summit has found so far.

SV:  As the delegates discussed their shared responsibilities and vision for providing the best possible care, we realized that the vision applied to all birth settings. The nine common ground statements describe a maternity care environment that respects the woman’s autonomy, ensuring she has safe access to qualified providers in all settings, and that the whole team that may care for her are well prepared with the clinical skills and knowledge that best applies to her specific situation. This will require attention to equity, cross-professional education, and research that includes the woman in defining the elements of “safety” and accurately describes the effects of birth place, or different models of care, on outcomes. The delegates shared a goal of increasing knowledge and access to physiologic birth, access to professional education and systems for quality monitoring for all types of midwives, from all communities; and reduction in barriers like cost and liability. Coming to this place of understanding and agreement, though, was only the beginning. Each of those action statements had to be turned into a concrete action plan that all of the stakeholders collaborated on developing.

© HBCS

© HBCS

JM: What is happening with the common ground statements now?

SV: Multi-disciplinary work groups have formed around each common ground statement. In 2013, the work groups came together for the second summit, again at the Airlie Center, to discuss progress made so far and tackle challenges.

Coming to this place of understanding and agreement, though, was only the beginning. The common ground statements are also encouraging a dialogue outside of our action groups that we could have never predicted. For example, the statements were read into the congressional record by Congresswoman Roybal-Allard, who said that the publication of the Home Birth Consensus document was “of critical importance to all current and future childbearing families in this country.” In the following year, several of the Summit delegates were invited panelists and presenters at an Institute of Medicine Workshop on Research Issues in the Assessment of Birth Settings.

JM: What are some of the top outcomes of the work groups?

SV: One exciting outcome – a set of Best Practice Guidelines to provide optimal care for mothers and families transferring from home to hospital – will be released by the Home Birth Consensus Summit later this week. This project represents what the Summits are all about: bringing together stakeholders to look at every facet of an issue, and work together on concrete initiatives to improve outcomes. These guidelines are based on the best available research on effective interprofessional collaboration. Delegates who are leading midwives, physicians, nurses, policy makers and consumers from across the U.S. formed the Collaboration Task Force. They met regularly over eight months on weekends and after hours to research and carefully design a concrete evidence-based tool to improve quality and safety for women and increase respectful communication among providers. Easing the friction that can sometimes occur when families arrive at the hospital can not only increase safety for families, but also build trust and collaboration between providers.

© HBCS

© HBCS

Another group is collaborating to develop a Best Practice Regulation and Licensure Toolkit – a resource for state policy makers that will provide a best practice model of midwifery regulation to be used as a template to enact or improve licensure in a particular state.

Another important outcome is a study of midwives and mothers of color to better understand social and health care inequities that lead to higher incidence of prematurity and low birth weight.

JM: What comes next for the Summit?

SV: The action groups are continuing their work on initiatives in each of the common ground areas. At Summit III, scheduled for Fall 2014 in Seattle, WA, each action work group will share the products of their collaborations, and address some remaining priorities. These include research and data collection, ethics, and access to equitable care during pregnancy. We plan to expand the participants to include more leaders from policy and practice to disseminate the documents and engage more in this exciting work.

I have been working towards ensuring equitable birth options for women and their families for nearly 30 years. My goal for the Summits is to increase the probability that my four daughters – and everyone’s daughters, wives, and sisters – will experience high quality, respectful maternity care.

What are your thoughts on the Home Birth Consensus Summits and this collaborative model?  How do you see this further maternal infant health and safety.  What would you like to see discussed by the stakeholders at Summit III in Seattle this fall?  Let us know in the comments and join us on Thursday to learn more about the details of the soon to be released “Best Practice Guidelines: Transfer from Home Birth to Hospital.”

Bios:

© Saraswathi Vedam

© Saraswathi Vedam

Saraswathi Vedam, RM FACNM MSN Sci D(hc), is the convener and chair of the Home Birth Consensus Summit. She has been active in setting national and international policy on home birth and midwifery education and regulation, providing expert consultations in Mexico, Hungary, Chile, China, Canada, and the United States. She serves as Senior Advisor to the MANA Division of Research, Chair of the ACNM Transfer Task Force, and Executive Board Member, Canadian Association of Midwifery Educators. Over the past 28 years she has cared for families in all birth settings. Professor Vedam’s scholarly work includes critical appraisal of the literature on planned home birth, and development of the first US registry of home birth perinatal data. Contact Saraswathi Vedam.

© Jeanette McCulloch

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, is the co-founder of BirthSwell an organization improving infant and maternal health by changing the way we talk about birth and breastfeeding. She has been using strategic communications and messaging to change policy, spread new ideas, and build thriving businesses for more than 20 years. Jeanette is honored to be working with local, national, and international birth and breastfeeding organizations (including the Home Birth Consensus Summit) and advocates ensuring that women have access to high-quality care and information.

Babies, Healthcare Reform, Home Birth, Legal Issues, Maternal Quality Improvement, Maternity Care, Newborns, Practice Guidelines, Uncategorized , , , , ,

Home Birth After Hospital Birth: Women’s Choices and Reflections – A Research Review by Jessica English

April 3rd, 2014 by avatar

By Jessica English, LCCE, FACCE, CD(DONA), BDT(DONA)

Today’s research examines the factors that influenced women who chose home birth for the subsequent child, after their previous child was born in a hospital.  Lamaze Certified Childbirth Educator Jessica English, along with midwifery colleagues just published “Home Birth After Hospital Birth: Women’s Choices and Reflections” in the Journal of Midwifery and Women’s Health.  Jessica shares about the research, some of the findings and wraps up speaking about the role that childbirth educators can play in helping women to find satisfaction in their chosen birth location. Are you an LCCE and have published research?  Consider writing a review for S&S.  I would love to highlight our LCCEs.  - Sharon Muza, Science & Sensibility Community Manager.

As a childbirth educator and doula, I have been listening to women’s birth stories for many years. I’m honored that they trust me again and again with the details of their triumphs, frustrations, joys and sometimes outright trauma. When my agency, Birth Kalamazoo, organized a meeting in 2011 to discuss the midwifery model of care, I didn’t think much of it when the attendees introduced themselves and shared a few details about their births. After all, I knew most of them very well (having taught them or in some cases even attended their births), and I knew their stories.

But one of the midwives we’d invited to speak that day took special note of those stories. Ruth Zielinski, PhD, is a hospital-based nurse-midwife, university professor and researcher in my community. She noticed that a handful of the women who spoke mentioned that they had given birth to their first baby in the hospital, then chose home birth for later babies. She approached me after the meeting, curious about why the women might have chosen home birth after their hospital experiences. I shared my perceptions based on my experience listening to women. Intrigued, Ruth wondered if this was something we could research? Neither of us had ever seen academic research on the topic of women who chose home birth after a hospital experience. Soon enough, we had a four-woman research team in place: Ruth; myself; Kelly Ackerson, an academic colleague from Ruth’s department of nursing; and one of Ruth’s undergraduate students, an honors nursing student who was planning a career in midwifery.

Our first task was to identify the structure of the research process. How would we get the information we needed? We settled quickly on focus groups, and wrote a series of open-ended questions that we expected to elicit the participating women’s honest assessments of both their home and hospital experiences, as well as the reasons behind their decision to choose home birth. The next step was to recruit the participants. Through Birth Kalamazoo’s Facebook page, our e-newsletter and via local midwives, we invited women who fit our criteria to participate in a focus group. The primary requirement was that they needed to have had at least one hospital birth followed by at least one home birth within the past 10 years.

Five focus groups followed, each with four participants and two researchers (one who asked the questions and one who took field notes). The focus groups were transcribed verbatim by members of the research team. After each focus group, team members conferred to make sure that we were in agreement about the themes that were starting to emerge. After the fifth focus group, we agreed that no new themes were emerging and we had reached “saturation of the data.” Led by Ruth and her student Casey Bernhard, the research team identified five themes that summarized what the mothers had shared. A sixth focus group of women (one from each prior focus group) provided “member checking” – we shared the themes we’d identified and asked them to verify whether or not they were in keeping with what they had heard during the focus groups.

The resulting research, “Home Birth After Hospital Birth: Women’s Choices and Reflections,” is published in the current issue of the Journal of Midwifery & Women’s Health.

Some Key Findings: Women’s Choices and Reflections

To summarize, five recurring themes were identified from the women’s reflections on both their hospital and home births: choices and empowerment; intervention and interruptions; disrespect and dismissal; birth space; and connection.

Choices and empowerment. The women in our groups reported that with their hospital births they felt they did not actually have much choice in the direction of their care. Although a few women in the study had generally positive hospital experiences, most reported feelings of disempowerment and limited choices associated with their hospital birth and more meaningful choices and feelings of empowerment with their home births.

Interventions and interruptions. During their hospital births, women experienced significantly more interventions compared to their home births. Many of the women in our study perceived these interventions as unnecessary. They commented on timetables, hospital “agendas” and interruptions both during the birth and postpartum period for their hospital births.

Disrespect and dismissal. Many of the women in our study said they felt that their hospital-based providers tended to focus more on anatomical parts and the medical process of birth, rather than on them as whole people. With their home births, they reported a much more holistic model with great respect for their decisions.

Some women who wanted to continue care with both a home birth provider and a hospital-based provider (known as “dual” or “concurrent” care) were dismissed from their hospital-based practice when they revealed that they were planning a home birth.

Birth space. Universally, women reported feeling more comfortable laboring in their own homes, surrounded by only the people they chose to invite into that space. Several women mentioned the appeal of having their older children with them for the birth, or at least having that option.

Connection. When women in our study reported positive hospital births, they also spoke of their positive connections to their providers. For both home and hospital settings, women said that feeling a sense of trust and connection to their doctor or midwife was important and even helped them to feel more comfortable with the process of birth. That theme of connection extended to women’s reflections that during their home births they also generally felt more connected to their bodies, to their babies and to other family members.

Reflections and Implications for Childbirth Educators

As an experienced Lamaze Certified Childbirth Educator and doula, I wasn’t surprised by the findings of our research. The reflections of the women participating were very much in keeping with the stories I have heard for almost a decade from my students, clients and even random women (and men!) who want to share their experiences. It does help me, however, to see the themes identified so clearly. I can envision sharing this research with women who are choosing a home birth for a second, third or fourth baby after a prior hospital birth. It may be validating to them to see many of their own feelings and reflections mirrored in other women’s experiences.

When I think about limitations of this study, I think about the natural differences between first and subsequent births. First births are often longer and more complex, with second and later births often shorter and more straightforward. Could that have influenced women’s feelings of empowerment? As an educator and doula, I also have observed that, after their first baby, many women in general feel more assertive and empowered to take control of their choices for their later birth experiences, whatever the birth setting.

In fairness to the hospital environment, it’s also important to remember that our study was limited to women who felt compelled to make a change for subsequent births. Women who have had very positive, respectful, low-intervention hospital births often choose that same setting for future babies, and their voices were not represented in our focus groups.

Our research may also have been influenced by the specific birth culture in Southwest Michigan. For example, women in our area sometimes want to receive care from both a hospital-based provider and a home birth midwife, but they are typically discharged from their hospital-based practice if they reveal they are planning a home birth. I know this isn’t the case in all areas of the country, and I can’t help but wonder if it’s due in part to the lack of licensing for Certified Professional Midwives (CPMs) in our state. Fellow LCCEs and doulas in states where CPMs are licensed have shared that women in their communities may have easier access to this kind of dual care. I think this issue merits further exploration, with research comparing the home birth experiences of women in various states where CPMs are licensed, unlicensed and specifically outlawed.

As I analyze our results with my childbirth educator hat on, I keep mulling the impact of feelings of safety and comfort on oxytocin. When women feel safe, nurtured, supported and comfortable, we know that the hormones of labor work more efficiently. Did the women in our study have more straightforward births at home in part because the environment allows their bodies to work optimally? I have given talks to labor and delivery nurses on ways they can boost oxytocin in the hospital environment, and as a doula trainer I also address this issue with new doulas. For many women, the home birth setting is inherently designed to maximize oxytocin.

The connection theme that arose in our study is also closely tied to oxytocin. In attending hospital births as a doula, I try to facilitate moments of connection between a woman and her care providers. Penny Simkin’s landmark research on women’s lasting birth memories also points to the importance of such relationships. (Simkin, 1991) Connection comes very naturally between a doula and her client, and often between a home birth midwife and a laboring woman as well. Those connections can be more difficult in a busy hospital environment where a woman is working with a nurse she has likely never met, and often with a provider who is one of many in a busy practice, and who may have several other patients in labor. Can we make more space within our medical system for nurture, if not for the emotional benefits then for the biological effect on the chemical balance in women’s bodies?

In addition to the connection challenges, the themes identified in our research also point to other weaknesses inherent in the medical model of birth. As an educator, I’m already thinking about how I can use these findings to help prepare families for more positive hospital-based experiences. How can they navigate the system to help prevent some of the pitfalls many of these women experienced during their hospital births? I believe so strongly that meaningful change in our system begins with families who speak up for what they need and want for their births. Childbirth educators are on the front lines to help educate families about what a positive, healthy birth experience can look like, and to prepare our students to advocate within the system they’ve chosen to support them.

As leaders in our birth communities, educators can also directly work for change by talking with nurses, midwives and physicians about what women are looking for in their births. Respectfully discussing both the points of dissatisfaction and satisfaction mentioned in this study can help reinforce positive behaviors and change those that may be detrimental to women and to birth. Many of the things women say they want for their births are strongly supported by quality scientific evidence. Take kangaroo care as an example. Ten years ago, a woman in our community might have said in this focus group that she wanted a home birth in part because her hospital providers refused to allow uninterrupted skin-to-skin contact for a few hours after the birth. Today, we have a hospital in our community that is a national leader in kangaroo care for all families and another that is trying to reach that benchmark.

Change is slow, but childbirth educators can help make it happen! Better birth is not just an issue of physical health and emotional well being, it is also financially beneficial to hospitals to flex to provide the compassionate, evidence-based care that will keep families within their system, coming back for subsequent births.

However, the intention of our research was not to dissuade women from home birth. For those who continue to choose that setting for later babies, it may be helpful for educators, doulas, midwives, physicians and others within the maternity care system to understand the factors that motivate them to make that informed choice for their families.

Would you share this research with your childbirth education students and expecting families?  How would you use it?  Do you think that the conclusions are valid?  Do you see things differently? Discuss with us in the comments section. – SM

References

Bernhard, C., Zielinski, R., Ackerson, K. and English, J. (2014), Home Birth After Hospital Birth: Women’s Choices and Reflections. Journal of Midwifery & Women’s Health. doi: 10.1111/jmwh.12113

Simkin, P. (1991). Just Another Day in a Woman’s Life? Women’s Long‐Term Perceptions of Their First Birth Experience. Part I. Birth, 18(4), 203-210.

About Jessica English

jessica english-bw head shotJessica English, LCCE, FACCE, CD(DONA), BDT(DONA) is a Lamaze Certified Childbirth Educator, birth doula and DONA-approved birth doula trainer. She is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, birth photography, in-home lactation consulting and renewal groups for mothers. She is currently producing a short film about birth, due out in the fall.

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Midwifery, New Research, Research, Transforming Maternity Care , , , , , ,

Childbirth Connection Joins with the National Partnership for Women & Families – Everyone Benefits

March 20th, 2014 by avatar

national partnership women family logoA favorite resource for both myself as a childbirth educator and one that I share frequently with families in my classes has long been Childbirth Connection. Since 1918, when this organization was founded and known as the Maternity Center Association, they have been a “national voice for safe, effective and satisfying evidence based maternity care.”  Childbirth Connection accomplishes this by highlighting current issues and obstacles in maternity care, sharing evidence based information in easy to read and understand downloadable handouts and partnering with other organizations, including Lamaze International to lobby for and promote evidence based care for women and their families in the childbearing year.

You may be familiar with Childbirth Connection as the organization that has been conducting and publishing the landmark Listening to Mothers Surveys and Reports since the first of the LTM reports was published in 2002.  These comprehensive reports questioned mothers about their experiences from preconception through the postpartum period and shed light on many issues – including how much of the care women are receiving is not based on evidence and how limited many of the choices women are given for options while receiving care.  Information discovered through the surveys and published in the LTM reports has been enlightening and sometime shocking, as it highlighted the “real life” experiences of women around the country – who are experiencing maternity care currently in the USA.

Earlier this year, Childbirth Connection announced that they are becoming a core program of the National Partnership for Women & Families, a Washington DC based organization founded in 1971, whose mission is to improve health for women and families, and make the nation’s workplaces more fair and family friendly.  Each organization brings different strengths to the collaboration. Childbirth Connection has a long history of clinical and research focus programs based on evidence based care, while the National Partnership has long established relationships with policy makers.  The fit is a natural one that will benefit American women and mothers and improve maternity care in the USA.

One of the first publications released by Childbirth Connection, under the umbrella of the National Partnership for Women & Families, was a report; “Listening to Mothers: The Experiences of Expecting and New Mothers in the Workplace.” This report was prepared from information gathered during the most recent LTM III survey.

Some key findings from this report include:

  • Holding a job during pregnancy is the new normal.  In fact, women are the primary or sole breadwinner in over 40% of families with children.
  • Women often need minor adjustments on the job to protect their health during pregnancy. 71% of women needed more frequent bathroom break and 61% of women needed some schedule modification or time off in order to attend crticial prenatal health care appointments.
  • Pregnant women’s need for accommodation often goes unspoken and may be unmet, or are often denied.  Many women do not speak up out of fear of repercussions, refusal or uncertainty about how their request will be viewed.
  • Less economically advantaged women are in greater need of accommodation than more advantaged women. Women of color, lower educated women and women who held part time jobs needed more accomodation.
  • Upon returning to work, new mothers experience bias, lost pay, loss of responsibilities and other actions, including losing their job altogether. More than one in four women reported experiencing bias from their employers due to perceptions of their “desire, ability, or commitment” to doing their jobs.
  • Breastfeeding remains a challenge for employed new mothers.  58% of women reported that breastfeeding while employed presented obstacles, including employers not providing an appropriate clean and private location or adequate breaks in which to express milk.

childbirth connectionAs childbirth educators, the women in our classes most likely are working outside the home and many will return to work after having their children.  These are issues that they will face no matter where they are located in the USA, and as educators we can sympathize with their situation and provide concrete resources to help them problem solve solutions.  The National Partnership for Women & Families/Childbirth Connection should be on the short list as a great resource for these women.  We can also share our own tips, encourage discussion amongst the families and help prepare them for some of the above challenges that they may face.

Congratulations to Childbirth Connection on this new opportunity!  I am looking forward to reading and sharing future work done by your organization and in cooperation with the National Partnership for Women & Families.  Educators and others – what information do you feel is important to share with your families about working while pregnant, returning to work after birth and maintaining the breastfeeding relationship once your students are working again.  Comment with your suggestions, advice and resources, so that we can all offer the best information to all families.

References

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: New Mothers Speak Out. New York, NY: Childbirth Connection.

 

 

 

 

 

 

 

Babies, Childbirth Education, Maternal Quality Improvement, Maternity Care, Transforming Maternity Care , , , ,

Series: Welcoming All Families; Working with Women of Color

February 25th, 2014 by avatar

By Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE

In honor of Black History Month, and as part of Science & Sensibility’s occasional series on welcoming all families to our classrooms and practices, Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE writes a two part post for the series speaking to meeting the needs of families of color.  Today, Tamara shares some insights into the experiences of women of color and their families in childbirth classes and on Thursday, Tamara will discuss how educators can make their classes friendly to women of color and their partners, with information and resources for the educator as well as other birth professionals. – Sharon Muza, Community Manager, Science & Sensibility

© Williams Family

© Williams Family

In my second year of nursing school, I gave birth to my daughter. When pregnant with her, I faced the choice of taking a Lamaze class or completing my Biochemistry course. Both classes were on the same night.  I wanted to become a midwife and knew the benefits of birthing with the least amount of interventions. I also knew the stigma I would face as a single young Black mother so I prioritized and choose Biochemistry. I had to complete my semester before giving birth. I did not even think of taking a class other than what was offered at the hospital. I was not offered any alternatives either.  I thought to myself, “How difficult could labor be? It all seemed so simple.” In preparation, I read the book, Preparation for Birth: The Complete Guide to the Lamaze Method by Beverly Savage and Diana Simkin.  I was ready with the electric massager and my birth plan.

I never second thought the benefits of Lamaze class or thought it wasn’t something Black women did, however I clearly remembered people saying, “Why do you want to take that class?” “You don’t need that,” or just laughing because somehow I should’ve just known what to do and didn’t. Women in my neighborhood started having babies as teenagers.  In the prenatal clinic, there was limited information about birthing options and childbirth education other than the public education programs that played endlessly on a loop in the waiting room. Grandmothers, who were mostly the primary caretakers, would expect the girls to tough it out without pain relief as this could be seen as punishment for getting pregnant so early. Some mothers hoped it would serve as a deterrent to getting pregnant again. Childbirth education was not an expectation as past generations just knew to go to the hospital when the pain got too bad. I was just expected to know to move and breath and squat and groan with the contractions and to just deal with the pain. The baby would eventually come out.

A few months after the birth, I wished I had taken a class. I had a horrible birth and breastfeeding experience.  The book and “barely there” labor support was not enough to get me through the emotional challenges of labor. I needed more. I needed practice. I needed discussion. I needed to know the real deal and how to navigate the system. From my birth experience, I knew childbirth education was an essential path to have a beautiful normal birth experience.  I felt so passionate about this that I became a Lamaze certified childbirth educator.

The women I get to mentor in my childbirth classes come from different cultures and backgrounds than I do. They have different fears and concerns. What troubles me is the low attendance of women of color (WOC) in childbirth classes. Lamaze class is about learning healthy habits, building confidence and facing fears. Techniques shared in class help women create solutions for potential labor scenarios and manage labor pain while partners learn skills to comfort and protect moms in labor and to communicate effectively with care providers. This is especially important for African American (AA) women.

The Office of Minority Health reports AA women have 2.3 times the infant mortality rate as non-Hispanic whites.  AA women have twice the rate of sudden infant death syndrome and are 2.3 times more likely to begin prenatal care in the 3rd trimester than non-Hispanic white women. (Mathews, et al, 2013)  The cesarean birth rate amongst AA women is no better.  The rate of cesarean delivery declined among non-Hispanic white women for the third straight year to 32.3% in 2012. The 2012 cesarean rates rose, however, among non-Hispanic black (35.8%) and Hispanic (32.2%) women.  (Hamilton, et al, 2013)  Amnesty International 2010 report, Deadly Delivery: The Maternal Health Care Crisis in the USA revealed AA women are nearly four times more likely to die of pregnancy-related complications than white women. These rates and disparities have not improved in more than 20 years. (Amnesty International, 2010)

Attending childbirth class is a path, and some people may say, a Rite of Passage to achieve better health, better birth outcomes and better breastfeeding for African American Women.  For the past two years, R.O.S.E., Women E-News and MomsRising have hosted a twitter chat (#blkbfing) encouraging women of color to breastfeed. These organizations also have to emphasize breastfeeding success starts with a normal birth, minimal interventions and a healthy mother.  Skills and techniques learned in Lamaze classes support these outcomes.

So, if we know the health disparities that affect WOC during pregnancy and birth and the government knows, how can I and other educators reach and encourage more attendance in Lamaze class. Does the instructor need to look a certain way? Are childbirth classes just for white women?  I sat down with Domineque and her husband Davon who delivered in New York City, NY and Reese McGillie, who birthed in Seattle, WA to talk about their experience attending a childbirth classes as women of color.

Tamara: Tell me about your experience in childbirth class? Were you the only African American in class?

Domineque: Well to start off as a new mom and WOC, I was really unsure what to expect at a Lamaze class.  However, after discussing things with my husband and talking to others, we decided to give it a try.  I wanted to know what others thought of Lamaze class. No one I knew ever attended one. As a school teacher, I am always into learning new things. I was nervous and afraid as this was a surprised pregnancy. I wanted everything to go right. I searched websites constantly and read tons of books. I must say I had a great experience. I felt a warm welcome and was very comfortable there. I don’t remember now if we were the only AA couple. (chuckles) I think we were, but I wasn’t bothered by that.

© McGillie Family

© McGillie Family

Reese: I had a familiar feeling of being the only AA woman in the class. It did not bother me during class. I might call it being complacent. Typically, I expect to be the only AA woman in classes, conferences and trainings. I had a great learning experience in my childbirth class. In hindsight, it would have been nice to have other AA women in attendance to not feel alone even though I was in a class full of people. You know, sort of having the ability to meet and join up with some Sista friends. Perhaps it was a combination of my security as a AA woman but sitting in that room, I knew no matter what, my experience would be different. I’m sure the other mothers did not worry about arriving at the hospital and having someone question them about their level of education, adequate prenatal care, whether they were married or even had a partner or even their competency level to parent their child.

TH: Do you feel the class touched upon topics specific to African American women such as higher rates of preterm labor, pre-eclampsia and lower rates of breastfeeding?

Reese: No. I wish it did. Twice I faced pre-term labor.  My first baby was born at 34 weeks. I was sad and afraid especially because I could not get a clear answer as to why I was having pre-term labor. It would have been nice to know sometimes preterm births happen more in AA women and that the exact reasons why are unknown in most cases.

TH: Do you think learning about the risks associated with birthing and being AA would make a mother more or less anxious about the process?

Domineque: I believe it would make anyone more anxious when the topic is introduced.  Giving strategies to reduce preterm birth such as recognizing labor contractions, how to time contractions, how to rest and hydrate oneself was discussed in class but not in the context of this only happens or happens more to AA women. We discussed pre-eclampsia in class but again not geared towards AA women. If it was just discussed as something that AA women experience more than other ethnicities, I might have felt singled out and self conscious. I did not know AA women experienced higher rates of pre-term births and pre-eclampsia. I am not sure if learning that specifically in class would have changed my learning experience.

TH: Did friends or family try to talk you out of the class? If so, what were their reasons for suggesting you not to take a class?

Domineque:  I didn’t get persuaded or dissuaded from others. No one in my circle attended a childbirth class and really had no input into the decision. My husband and I talked about our fears of being young parents, newlyweds and my desire to have an unmedicated birth. We agreed to do it. Thank goodness no one tried to dissuade us.

Reese: I was encouraged to attend childbirth classes by my midwife. It was an expectation. I was excited to take a class with Penny Simkin.

TH: Did it make a difference to you whether your instructor  was African American?

Domineque: No. I wanted someone who was experienced and fun. My biggest concern about attending a Lamaze class is  whether or not it was going to be boring and just filled with breathing exercises.

Reese: No. I was already reading a book Penny Simkin authored and was excited to attend her class

TH: What were two skills you learned in class that you were able to apply in labor and/or after giving birth?

Domineque:  Lamaze classes prepared me for a safe, healthy birth. I also learned about breathing and relaxation. Most importantly, I learned coping strategies and movement techniques. The class also gave me practical advice on how to start breastfeeding such as holding the baby skin to skin. I was able to breastfeed Dyllan for a long time. I was even surprised how easy it was to nurse in public. During our childbirth class there was a video clip of an AA woman breastfeeding her baby immediately after birth and I thought “Wow, I want to do that.”

TH: Did seeing images of AA women in birth and breastfeeding change your feelings or make you more confident about what you would be able to do in your birth?

© McGillie Family

© McGillie Family

Reese: Yes. Absolutely. I remember clearly the AA couple’s birth story in class. She seemed powerful. She was not in a hospital and it influenced my belief that even AA women could have beautiful experiences. That having great births were not just reserved for Caucasian women or those with money.

TH: What would you tell another African American mother about taking a childbirth class?

Domineque: I would tell them that after leaving the Lamaze class, I felt comfortable with breathing strategies and more at ease and confident. It was definitely worth it. The class prepared me to have conservations with my care providers.  One of the best parts of class was practicing the use of the acronym B.R.A.I.N. I was learning how to assert myself in situations where I was taught the doctors knew everything and I shouldn’t question what was happening.

TH: Davon, what would you tell AA men about taking a childbirth class?

Davon: As a husband, I would tell all partners, not just AA men, to weigh out options on pain medication vs. no pain medication and be there to support your spouse every step of the way. I believe a lot couples choose not to attend a Lamaze class because they think all that’s needed is an epidural. I learned there is so much more to birth than just the physical pain of the contractions. A woman needs the most support during vulnerable times like deciding when to go to the hospital and help her to advocate for walking and changing positions in labor.  My wife and I worked hard together to get through labor.  Support is key.  My wife was able to have an unmedicated birth using the techniques we learned and practiced in class.

TH: I have a few questions for the readers:

Is the Millennial generation of AA woman easier to reach and educate through social media instead of traditional classes?  Are you an AA mother who attended a childbirth class? What was your experience? Were your needs met in class? If you did not take a class, how did you prepare for birth? Did friends and family support your decision or turn their nose up at you?

I am grateful these two women shared their experiences with me. They even gave me insight as an AA woman and instructor to become more sensitive to how I run my classes. I find myself wanting to be more inclusive and not make race an issue, at least not in birth. Is there any situation in life that race does not play a role? Stay tuned for my post on Thursday that will include resources on how to make classes culturally sensitive and welcoming to AA families.

References

Amnesty International. (2010). Deadly Delivery: The Maternal Health Care Crisis in the USA.

Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2012. National vital statistics reports; vol 62, no 3. Hyattsville, MD: National Center for Health Statistics. 2013.

Mathews TJ, MacDorman MF. Infant mortality statistics from the 2009 period linked birth/infant death data set. National vital statistics reports; vol 61 no 8. Hyattsville, MD: National Centers for Health Statistics. 2013.

About Tamara Hawkins

tamara hawkins head shotTamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE is the director of Stork and Cradle, Inc offering Prenatal Education and Breastfeeding Support. She graduated with a BSN from New York University and a MSN from SUNY Downstate Medical Center. She is a Family Nurse Practitioner and has worked with mothers and babies for the past 16 years at various NYC medical centers and the Elizabeth Seton Childbearing Center. Tamara has been certified to teach childbirth classes since 1999 and in 2004 became a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant.  Follow Tamara on Twitter: @TamaraFNP_IBCLC

Childbirth Education, Guest Posts, Maternity Care, Series: Welcoming All Families , , , , , ,