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Series: Welcoming All Families – The Need for LGBTQ- Specific Childbirth Classes

June 24th, 2014 by avatar

By Kristin Kali, LM, CPM

© Kendra Quinn

© Kendra Quinn

Today on Science & Sensibility, as part of the occasional series, Welcoming All Families, midwife and educator Kristin Kali, LM, CPM shares information on holding a childbirth class that is designed specifically for LGBTQ families.  Kristin discusses the benefits of holding an LGBTQ class, provides some resources and offers additional information on content designed to meet the specific needs of LGBTQ families.  - Sharon Muza, Community Manager, Science & Sensibility

Take off your childbirth educator hat for a moment, and consider your own personal experience. If you are a member of a culturally marginalized group, (and if you do not identify as a member of a marginalized group – imagine) you know the difference between being in a space where you are welcomed and respected, versus being in a space with others who share a similar cultural experience, who speak a common language, and who have aspects of everyday life in common. In a space that is welcoming yet mixed, you may only discuss things you hold in common with those around you, unless you are willing to teach others around you in order for them to understand you and your experience. But if you are in a position of vulnerability, such as being pregnant, or in a class to prepare you for giving birth, you are not likely to discuss things that the people around you simply do not understand or do not have a context for.

Imagine being a lesbian, gay, bisexual, transgender or queer person who is going through pregnancy, with many of the same physiological concerns as any pregnant person, and with many of the same needs and desires, including the desire for a healthy baby, a positive birth experience, and a childbirth class to help assist in attaining that goal. Yet, although you have much in common, if you are in a class of primarily heterosexual couples, or even a class with many different types of families, some of the primary aspects of your experience of bringing this baby into the world and becoming a parent will not be shared.

© Firestone-Kahn 2013

© Firestone-Kahn 2013

Now put your childbirth educator hat back on again. As a childbirth educator, you might be thinking, “Well, there are many unique circumstances that people have when they come to a childbirth class – people may be coming from having dealt with infertility, military wives whose husbands are away at war, women who are giving birth as single moms. We are together to learn about giving birth, so that’s mostly what we talk about when the group comes together.” I invite childbirth educators to imagine any one of those unique scenarios, and envision if the class was full of people who had that scenario in common. How powerful would that be? What might be discussed in the safety of others who truly understand this experience? How might that affect the empowerment, strength and resolve of someone who is preparing for the prospect of giving birth and becoming a parent?

I can tell you, after 9 years of teaching specialized childbirth classes for LGBTQ families, that it is very powerful. When people live in a culture where their relationship may not be honored with the right to marry, when a child is born and a parent is not legally recognized as a parent and they have to prove themselves worthy to a social worker just to gain legal parentage (or perhaps legal parentage is not allowed in their state at all), when they didn’t simply have sex with their partner, rather they used all of their savings and maxed their credit cards just to get the funds for sperm so that they could conceive, it is such a relief to be in a group that has the same common denominator. More than that, it allows for camaraderie, and issues that are unique to families like theirs to be discussed.

In my childbirth classes, the families introduce themselves to each other with the “usual” information, such as name, due date and place of birth. However, before we get started with introductions, I briefly talk about the transformation of self that happens when a person becomes a parent, and as a person’s gender is so central to who they are, of course gender is central to that experience. I invite the introductions to include stating the pronoun that they prefer people to use in reference to them, and also what they plan for their baby to call them – maybe Mom or Dad, but perhaps a different word that more closely matches their gender such as Baba or Dadmom or anything else.

The second thing we do is share conception stories – I’ll bet this is not something discussed in heterosexual or mixed groups! But for the LGBTQ families in my class, the pregnancy experience started way before that little one was growing inside, and sharing these stories candidly establishes normalcy when the situation is not viewed as “the usual way” by society. Furthermore, families may be still be carrying emotional aspects of their conception process in a way that can impact the birth itself, or the partnership during the transition to new parenthood. Sharing conception stories brings me, as the instructor, up to date. It lets me know what happened for each family in the process of getting to this class, and anything important that I need to watch out for or hold space for with each parent-to-be.

Throughout the class, after setting the stage for open discussion and creating such a sense of safety, participants are likely to ask the important questions that they may not otherwise have asked. People feel free to be exactly who they are, not a guarded sense of “how much can I share about myself and not have the other parents look at me weird or be a spectacle”. We cover all the aspects of labor and birth that would be covered in any childbirth class. In fact, my class is based on a popular curriculum. I just bring together LGBTQ families and specifically discuss topics that are unique to this group within the context of the curriculum.

What makes an LGBTQ childbirth ed class so special? I will let the parents speak for themselves by sharing some of the feedback and comments I have received after class:

“There is something wonderfully supportive about being surrounded by other queer families. It created a truly safe and inclusive space where our LGBT experience was at the center, and not just touched on as an aside or an exception to the norm.”

“I am so grateful for this class. Going in as a queer family, not having to translate from everyone else’s ‘normal,’ not needing to explain our family was great.”

“As a gender variant pregnant woman, this class provided support and community that is often lacking in society at large.”

“I needed to voice fears and have time to ask questions in a non-judgmental space.”

“It’s not just about using neutral pronouns and terms (like “birth parent” instead of “mom”). It’s  great to be in a room full of queer folks who understand my experience, so I feel like my queer specific questions are adding to the group’s experience rather than distracting or pulling the class off on a tangent.”

As an educator, it is important to be able to inform people about what to expect, and to be able to hold people as they explore their thoughts and feelings in relation to the class material. While LGBTQ families may have a lot in common, each family is unique. There is a broad range of family structures, conception histories, gender issues, co-parenting strategies, and interpersonal dynamics to explore, all in relation to giving birth and caring for a newborn.

For those who are interested in teaching childbirth classes for LGBTQ families, there are a number of considerations. Are there enough families in your community to support an exclusive class? Even if you are an LGBTQ person, do you have experience working with a variety of LGBTQ people in the process of becoming parents? Are you able to name common birth and postpartum dynamics that come up in lesbian partnerships, for transgender parents, and extended co-parent families?

You can educate yourself by reading books about LGBTQ family- building:

The New Essential Guide to Lesbian Conception, Pregnancy and Birth
And Baby Makes More
Confessions of the Other Mother

Attend an LGBTQ cultural sensitivity training that is specific to birth and family-building:

MAIA Midwifery LGBTQ Cultural Sensitivity Trainings

Check out websites and blogs about LGBTQ parenting:

http://www.mombian.com/
http://www.lesbiandad.net/
http://itsconceivablenow.com/
http://www.milkjunkies.net/

I do not recommend that non-LGBTQ allies teach this specialized class. Instead, enthusiastically refer LGBTQ families to a specialized class if there is one in your area, explaining the value that so many families have found in attending a childbirth class with other queer families. (Read about ways to make your mixed class supportive for LGBTQ families here and a lesbian couple’s CBE class experience  here.)  The sense of safety that is created when a marginalized group gathers exclusively allows something to happen that would not happen in a mixed group. Being in “safe space” provides a sense of common understanding that goes way beyond welcome and acceptance. It allows for dialogue regarding a common lived experience and a shared cultural identity. There is a sense of knowing – not needing to explain the things that to an outsider could be explained, but would not truly be understood without direct, lived experience. Kind of like becoming a parent.

If you are interested in teaching childbirth classes for LGBTQ families in your community, please don’t hesitate to contact me.

Are there educators in your community who teach LGBTQ childbirth classes?  Maybe you are one of those educators?  Do you see the need for such classes in your community?  Share your experiences and observations with our readers on specialized classes such as this. – SM

About Kristin Kali

© Kristin Kali

© Kristin Kali

Kristin Kali, LM CPM is the owner of MAIA Midwifery and Fertility Services, a fertility-focused midwifery practice that provides holistic, individualized care. MAIA serves all families, with specific expertise in serving LGBTQ families, single parents by choice, transgender parents and those conceiving over 40. Fertility consultations, classes and support groups are available in Seattle, Oakland, and online.

Kristin is a Certified Professional Midwife through the North American Registry of Midwives. She is a Licensed Midwife in California and Washington. Kristin is a graduate of Seattle Midwifery School and a member of the Midwives Association of North America, National Association of Certified Professional Midwives, American Society for Reproductive Medicine, Gay and Lesbian Medical Association, California Association of Midwives, and Midwives Association of Washington State.

Childbirth Education, Guest Posts, Parenting an Infant, Series: Welcoming All Families , , , ,

11 Ideas to Share with Families that Encourage Father-Baby Bonding

June 12th, 2014 by avatar
flickr.com/photos/44068064@N04/8587557448

flickr.com/photos/44068064@N04/8587557448

With Father’s Day right around the corner, now is a great time to check in with your curriculum and confirm that you share lots of information on how fathers can connect with their new babies.  In the early days and weeks after birth, mothers spend a lot of time with their newborns, getting breastfeeding well established and recovering from childbirth with their babies by their side.  And this is as it should be.  Fathers often can feel left out or excluded, simply because of frequent nursings and the comfort that babies get from being close to their mothers.

It is good to share with fathers that there are many ways to connect and bond with their newborns and young infants.  I like to cover many of these topics throughout my childbirth education classes, so that the fathers leave feeling excited and positive about connecting with their children in these very special ways.

1. Early interaction

Connecting fathers and their newborns early in the first hours can help cement the bond between a father and his child.  Dr. John Klaus and Phyllis Klaus, in their book, “Your Amazing Newborn” state that when a father is given the opportunity to play with his newborn in the first hours after birth, and make eye to eye contact, he spends considerably more time with his child in the first three months than fathers who did not have this intimate connection in the first hours.  When the mother gets up to take her first shower is a wonderful time for fathers to share this early bonding time with their newborns.

2. Skin to skin

The benefits of skin to skin with a newborn are well known; temperature regulation, stress reduction, stabilization of blood sugar, release of oxytocin (the love hormone), comfort and security.  Fathers can and should have skin to skin time with their newborns as soon as it makes sense to do so.  Getting a new father settled in a comfortable chair, with his shirt off, a naked baby on his chest and both of them covered by a cozy blanket is a wonderful opportunity for both of them to benefit from the oxytocin release that will occur.  And is there really anything better than the smell and touch of a just born baby?

3. Singing to baby

Penny Simkin has written here before on the benefits to singing to your baby in utero, and then using that familiar song once baby has been born to calm and sooth the newborn.  Fathers can choose a special song or two and sing it to the baby  frequently during pregnancy, and then that can become his special song to sing to the baby on the outside. A wonderful opportunity for connection and bonding between the two.

4. Bathing with baby

New babies love nothing more than taking a bath safely cradled in the arms of a parent.  While most newborns don’t require frequent bathing, having the father take a bath in body temperature water with the baby on their chest is a wonderful way to relax and bond.  The baby feels secure and comforted and the father can enjoy a relaxing bath while focusing on enjoying time with their newborn.  Remember, safety first!  Always have another adult available to hand the baby off to when entering and exiting the tub.  Babies are slippery when wet.

5. Paternity leave

While the United States is hardly known for its generous leave for parents after the birth of a baby, both mothers and fathers are entitled to take up to 12 weeks of unpaid time off in the first year after the birth (or adoption) of a child according to the Family and Medical Leave Act and still have job protection.  Fathers can plan to utilize this benefit and even consider using some of this leave when (and if) the mother returns to work, taking the opportunity to be the primary parent for a period of time. Planning ahead for this leave both from a financial and workload standpoint would be helpful.

6. Reading to baby

Fathers can make time everyday to read to their baby.  Certainly, when very young, the baby is not understanding the words, but nevertheless, newborns and young infants are fascinated with the sound of human voices and are very comforted by being held close and listening to the voice of their father, safe and familiar.  In the beginning, it is not even important what is being read, just that time is set aside to do so.  Read your favorite novel, magazine or newspaper if you like!  As the baby gets a bit older, you can start reading more age appropriate books with pictures that are attractive to infants.

flickr.com/photos/beccaplusmolly/2652566750

7. Babywearing

Babywearing offers a great opportunity for fathers and babies (even newborns) to connect and bond.  Most babies love to be worn, and when a father does so safely it is a chance to further strengthen the bond between a father and his child.  Additionally, wearing a baby makes it easy to be out in public or doing tasks and chores around the home, or even working, depending on what type of job the father may have.  There are many types of carriers on the market and families should always make sure they are using a carrier safely and responsibly, and that it fits both father and baby well.  In my classroom, I have several different types of baby carriers hung on a wall, for families to try and I provide a weighted doll so that folks can get an idea of what it really feels like.

8. Exercising

Fathers can find ways to get their much needed exercise in while also spending time with their baby.  When their baby is very young, talking the baby for a walk, in a baby carrier or a stroller, is a great way to get out and burn some calories while being with their child.  As the baby gets older, putting them in a child seat on a bike, using a jogging stroller, or a bike trailer, is another alternative allowing dad to pick up the pace.  Consideration should always be taken to follow the instructions and age/weight guidelines that come with the equipment to prevent injury to the child.

9. Establish returning home rituals

Returning home from work after a long day offers fathers a chance to connect with and bond with their baby.  Encourage fathers to have a clear transition from work to home and taking a deep breath before getting ready to be fully present with their baby when they walk in the door.  Have a special ritual of greeting, welcoming the child into your arms and taking a few minutes to reconnect after a day (or night) of separation can make for a lovely opportunity for bonding and easing back into being home with those you love.

10. Father-child traditions

Fathers may want to continue traditions and special activities that they did with their fathers when they were children or consider starting some new ones of their own.  Going to the donut shop for Sunday morning goodies, Friday night family movie night, attending certain community activities and sporting events all offer quality time for children to further connect with their fathers.  Encourage the fathers in your class to recall the special traditions they had with their fathers or male role model, and continue the activities with their own children, or create their own new ones.

11. Parenting – not babysitting

One of my pet peeves is when I hear parents (both mothers and fathers do this) talk about how the father is “babysitting” or “watching” their children.  In my mind, a father no more babysits their child than the mother does.  They parent their child and sometimes that means being alone with the child and sometimes that is jointly with the other parent.  I model this speech by using the term parenting vs the other alternatives that imply that spending time with their children is not something that fathers regularly do.

It can be easy to forget, especially in the sometimes chaotic first weeks and months of welcoming a baby, that fathers have a lot to offer to their new child and it benefits both the parents and the baby to establish this connection and enhance bonding early and often.  Do you take the opportunity to share ideas with the families in your classes on the importance of father baby time?  In honor of Father’s Day this upcoming Sunday, recommit to encouraging these and other appropriate activities to the families in your class.  Please share other suggestions that you have for helping fathers to bond with their new babies.

Please note: I recognize that not every family is made up of a mother and a father, and that families all look different.  Today we honor the father in celebration of Father’s Day.  But a hearty thanks goes out to all the parents who work hard everyday to love and protect their children.

References

Klaus, M. H., & Klaus, P. H. (1998). Your amazing newborn. Da Capo Press.

 

Childbirth Education, Infant Attachment, Newborns, Parenting an Infant , , , , , ,

“Break Time for Nursing Mothers” – It’s the Law!

May 8th, 2014 by avatar

By Kathleen Marinelli, M.D.

In honor of Mother’s Day, which is coming up this weekend, I thought it would be important to talk about a challenge that many mothers face after having a baby.  Returning to work and continuing to breastfeed their baby.  Many countries offer a generous leave for new mothers, but here in the USA, it is not uncommon for a new mother to find herself back at work 6 weeks after giving birth.  So many challenges face these women, and the added pressure of work environment that is unsupportive of the breastfeeding relationship and the mother’s need to have a private, appropriate place to pump and store her  milk while separated from her baby is not only critical, it’s the law.  Today on Science & Sensibility, Kathleen Marinelli, M.D, the Chairwoman of the United States Breastfeeding Committee updates us on the “Break Time for Nursing Mothers” law and shares resources for clients and students who are returning to work and breastfeeding.  While this day seems far away to families sitting in  a childbirth class, making space for this discussion and sharing resources can help women to continue to breastfeeding smoothly after returning to work. – Sharon Muza, Community Manager, Science & Sensibility.

With more than half of women with infants employed, simple workplace accommodations are critical for breastfeeding success. By helping moms understand their rights as a breastfeeding employee and plan for their return to work, childbirth educators, doulas, health care providers and lactation care providers can support a successful transition so that working moms are supported to reach their personal breastfeeding goals.

The federal “Break Time for Nursing Mothers” law requires employers to provide break time and a private place for hourly paid employees to pump breast milk during the work day. The United States Breastfeeding Committee’s Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law compiles key information to ensure every family and provider has access to accurate and understandable information on this law.

Key Facts about the “Break Time for Nursing Mothers” Law:

Who is covered: The law applies to nonexempt (hourly) employees covered by the Fair Labor Standards Act.

Space: Employers are required to provide a place that is not a bathroom. It must be completely private so that no one can see inside. Employers are not required to create a permanent dedicated space for breastfeeding employees. As long as the space is available each time the employee needs it, the employer is meeting the space requirements.

Time: The law requires employers to provide “reasonable” break time, recognizing that how often and how much time it takes to pump is different for every mother. Employees should consider all the steps necessary to pump, including the time it will take to gather pumping supplies, get to the space, pump, clean up, and return to their workspace. Employers must provide time and space each time the employee needs it throughout her work day.

Enforcement: The U.S. Department of Labor’s Wage and Hour Division (WHD) is responsible for enforcing the “Break Time for Nursing Mothers” law. If an employer refuses to comply, employees can file a complaint by calling the toll-free WHD number 1-800-487-9243.

Small Businesses: All employers, regardless of their size or number of employees, must comply with the “Break Time for Nursing Mothers” law. Following a complaint from a breastfeeding employee, businesses with fewer than 50 employees may be able to apply for an undue hardship exemption. To receive an exemption for that employee, the employer must prove that providing these accommodations would cause “significant difficulty or expense when considered in relation to the size, financial resources, nature, or structure of the employer’s business.” Until they are granted an exemption by the Department of Labor, they must comply with the law.

State laws: Employees who are not covered by the “Break Time” law may be covered by a state law. Contact your state breastfeeding coalition for help understanding the breastfeeding laws where you serve.

The “Break Time for Nursing Mothers” law was an important victory for families, but breastfeeding success shouldn’t depend on a mom’s job type. The Supporting Working Moms Act would expand the existing federal law to cover approximately 12 million additional salaried employees, including elementary and secondary school teachers. We can all help make this happen! Use USBC’s easy action tool to ask your legislators to cosponsor the Supporting Working Moms Act with just a few clicks. Twelve million employees are counting on us! As Surgeon General Regina Benjamin advised us, “Everyone can help make breastfeeding easier.”

We know that workplace lactation support is a “win-win”, benefiting families, employers, and the economy, yet one of the major causes for the drop-off in breastfeeding rates is the lack of effective, reasonable workplace accommodations when mothers return to work. Employers that provide lactation support experience an impressive return on investment, including lower healthcare costs, absenteeism, and turnover rates, with improved morale, job satisfaction, and productivity. The retention rate for employees of companies with lactation support programs is 94%, while the national average is only 59%!

Breastfeeding and working is not only possible, it’s good for business. Find additional information and resources in USBC’s Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law and help spread the word about this valuable new resource with your clients by sharing this link: www.usbreastfeeding.org/workplace-law.

Moms, babies and employers everywhere will be glad you did!!

Important links and information:

Online Guide: What You Need to Know About the “Break Time for Nursing Mothers” Law
Action Alert: Supporting Working Moms Act
Directory of State, Territorial, and Tribal Breastfeeding Coalitions
United States Department of Labor Employee Rights Card
Wage and Hour Division Break Time for Nursing Mothers Webpage
The Business Case for Breastfeeding

Do you talk to patients, students and clients about tips for successful re-entry into the workforce while still breastfeeding a baby?  What are your favorite resources to offer women so they know their rights and understand the responsibilities of their employer to assist them in continuing to express breastmilk for their baby. If you are not mentioning this to your families, maybe you will consider how important this information is after reading today’s blogpost and consider passing on these resources.  - SM

About Kathleen Marinelli, M.D.

Marinellii-head shotDr. Kathleen Marinelli is the Chair of the United States Breastfeeding Committee, an independent nonprofit coalition of almost 50 nationally influential professional, educational, and governmental organizations, that share a common mission to improve the Nation’s health by working collaboratively to protect, promote, and support breastfeeding, where she represents the Academy of Breastfeeding Medicine. She is also a Neonatologist and Breastfeeding Medicine Physician at Connecticut Children’s Medical Center, in the Connecticut Human Milk Research Center, and Associate Professor of Pediatrics at the University of Connecticut School of Medicine.

 

Babies, Breastfeeding, Childbirth Education, Guest Posts, Infant Attachment, Parenting an Infant , , , ,

Series: Welcoming All Families; Working with Women of Color – Educator Information

February 27th, 2014 by avatar

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

Today, contributor Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE finishes her two part post series “Welcoming All Families; Working With Families of Color” with a fantastic post on evaluating how well your classes are meeting the needs of Women of Color and tips and information to create a space that welcomes and celebrates WOC and their families.  While, February is Black History Month, educators have a responsibility to offer classes that are inviting and appropriate for WOC all year long. Find Tamara’s first post here. – Sharon Muza, Community Manager, Science & Sensibility. 

black mother and newborn

© David Blumenkrantz

Are your classes inviting and supportive for Women of Color? Or are WOC not your “target market”? I received a comment after sharing my post about Tuesday’s Welcoming All Families; Working with Women of Color blog post; “Sadly many of my (as you say) ‘women of color’ friends, associates and even just casual acquaintances have told me straight up ‘you don’t need to do all that!’,” referring to the belief that taking a childbirth class is not really a valuable or important part of preparing to have a baby for African American women. I believe that it will take more than a few focus groups to get to the bottom of why some WOC do not feel the need to take childbirth education. In today’s post, I would like to focus on childbirth educators! How can childbirth educators be sure their classes are appropriate and inviting to Women of Color?

Prior education experiences

The first thing childbirth educators have to be aware of is that people are more likely to connect with people of their own culture. An example of this; a vegan may be more likely to seek out health care from a provider who blogs about a vegan lifestyle. WOC and other ethnic communities will seek out education from a provider they can relate to culturally. At the least, the educator will have proven to be sensitive to their needs whether those needs are cultural, ethnic or economic. Vontress writes in the Journal of Multicultural Counseling and Development, “Members of minority groups bring an experience of consciously having to negotiate and even survive educational treatment of invisibility or negative ultra-visibility,[ultra-visibility; being singled out or made to be the “token” Black person], lower expectations, stereotyping, hostility and even abuse.” If an expectant mother or her partner has ever had this type of experience, why would they want to sit in yet another class and perhaps have those same feelings brought up all over again? What if they are presently feeling dismissed, their concerns ignored and rushed with their health care provider? Childbirth educators have the responsibility to understand this and make our classes welcoming by using language and images that subconsciously allude to our support and equal treatment and understanding of families of color.

I am guilty of saying “the baby’s mouth and lips should look pink to indicate great oxygenation.” A WOC in class raised her hand and said, “Even brown babies?” I responded “Well, yes, especially a newborn.” Be mindful that WOC have babies of all color hues. Some babies may be dark when born and others may be very light. Darker hued mothers who have not been around newborns may not know to expect their newborn to look light skinned.  A culturally sensitive childbirth educator should mention this fact, so that all families can be prepared. During early pregnancy class, talk about how WOC may experience expansion of the areola and that yes even though they may have dark areolas to start, the areolas can get darker. In discussions about nutrition, talk about soul food cooked in a healthy flair. Remember that the standard American diet is not a one size fit all solution. The Physician Committee for Responsible Medicine mentions 70 percent of African Americans are lactose intolerant (compared with only 25 percent of whites) and may suffer from cramping, diarrhea, and bloating after eating dairy products. Encouraging a WOC to have cheese and yogurt to get calcium and added protein may not be the best advice. Offer alternatives that are appropriate for everyone.

Marketing and teaching materials

Next, evaluate your marketing materials. Have you placed images of women of color on your website, brochures, and social media pages? Do you keep up with the health disparities and concerns for women of color? Do the images on your classroom walls or your teaching posters represent a wide variety of ethnicities?

Review your teaching materials. Do you show birth and breastfeeding images of WOC? Are there images of WOC exercising, eating well, and asking questions of their care providers? In order to effect behaviorial change, one has to be able to envision oneself doing something similar. A great example is a commercial from fatherhood.gov. This videos features an African American dad learning cheerleading moves with his daughter with the grandmother listening and approving of the interaction in the background. AA women love this commercial because we remember performing the same type of cheers when we were young. This type of imaging will promote interest in fatherhood and also plant a seed in the minds of some men that it’s okay to spend daddy-daughter time, maybe even doing something fun or a little silly. The commercial would not be as effective if it showed a Caucasian father doing the same thing. There would be no connection. And if there is no connection, there is no assimilation, and therefore no change in behavior. When expecting parents can see themselves in the “role models” then they can see themselves emulating this behavior with their own children, or their own birth or breastfeeding experience.

Be ready to make change

Once your evaluation is complete, make some changes. There are not many sources to purchase ready made childbirth class images of women and families of color. Don’t hesitate to create your own. Look for images of AA couples on sites such as Shutterstock, Corbis Images , iStockphoto, or Fotosearch. Then use some creativity to create posters and images you can use! Or better yet, have a contest in your classes, asking them to create a poster. Invest in videos that show women of color birthing and breastfeeding. I use Injoy’s products in my classes as I find their videos do a good job representing multicultural families.

In Injoy’s “Miracle of Birth 4″ video, Natasha’s birth shows a biracial couple experiencing a birth supported with analgesia. In “Understanding Labor 2″ and the “Miracle of Birth 3,” Chelsea’s birth follows a young African American couple as they have an epidural birth with augmentation. Daniela’s birth follows a bi-lingual Spanish speaking couple as they have a cesarean birth. Injoy offers an option to purchase these videos individually which is great for a limited budget. The Baby Center has a video of Samiyyah‘s birth center birth which can be imbedded in PowerPoint presentations or played on a monitor. Unlike the well edited and discreet videos Injoy offers, this Baby Center video feels raw and uncut. Be prepared with Kleenex. This birth is a great lead in into discussing orgasmic birth, normal birth emotions, vocalization for pain relief and the fetal ejection reflex during pushing.

Language used when addressing health concerns of African American women is important. As an instructor, you don’t want to talk about pre-eclampsia and preterm birth in a manner that assumes that AA women should already know they are at higher risk for these diseases, but rather frame it as health care workers and researchers are uncovering higher rates of pre-term birth, diabetes, cesareans and lower rates of breastfeeding in the AA community. Presenting these subjects in this fashion, as an awareness among health care providers, may remove any feelings of guilt or negative self-consciousness for those who may not know the information ahead of attending class. Sources to find information related to women of color include Office of Minority Health, March of Dimes, Womenshealth.gov and Women’s Health Guide to Breastfeeding.

Create an event

Consider bringing in guest speakers to your class. Is there a WOC birth advocate in your area that has a large following? Collaborate with her to spread the word. Can you host a Twitter chat or Facebook party discussing your intent to serve the needs of WOC and clarifying the wants and needs of your birth community. Have WHO code compliant corporations donate products for a baby shower or a baby fair. Ideas for a fair may include a pediatric dentist who discusses the important of infant oral care. Bring in a safety expert who will discuss and demonstrate car seat safety and installation. Have a prenatal fitness expert and/or nutritional counselor to discuss food and the connection to gestational diabetes. A community midwife or OB can discuss the impact of lifestyle choices on the risks of developing pre-eclampsia, diabetes related to induction and cesarean births and low birth weight babies. Conclude the event with a game show set up like Family Feud with topics covering medical options, comfort techniques and support strategies for breastfeeding families. Having a fun event always draw crowds.

Offer tiered pricing

Are your classes accessible on an economic level? Do you accept insurance or have a sliding scale for families. The National Health Service Corp has a great resource on how to set-up a discount fee schedule. Is your practice set up to accept social service coupons or Medicaid for childbirth class subsidies such as what Washington State offers? The Kaiser Family Foundation reports 27 states out of 44 that responded to their Medicaid Coverage of Prenatal Services Survey offer coverage for childbirth education. Independent instructors will have to research their own state Medicaid offices for specific information on provider eligibility and reimbursement rates. When receiving reduced fees or subsidies, it may be tempted to schedule classes during the day. Please remember even people on Medicaid or WIC have jobs. Let’s respect that and offer flexible schedules for classes in the evening and on weekends.

Can you set up scholarships? Human Resources and Services Administration has several large grants available to serve the maternal child health community. The March of Dimes has scholarships available for grants reducing disparities in birth outcomes. The What to Expect Foundation has a new program to teach practices that build a healthy pregnancy. The wonderful Kellogg Foundation is another resource to tap into for help building a program to be inclusive and inviting to women of color.

Community connections

Do you have local resources so you can connect AA women to WOC birth workers that share their ethnicity and culture? Sista Midwife Productions has a resource list by state of birth workers of color. If we have to refer out to help a mother feel more comfortable and get what she needs rather than what we have to offer, that’s a win-win situation.

Educators need to learn from the clients they serve. We have to ask the community what information is important to WOC. The Black Mothers Breastfeeding Association can serve as a template to build networks that educate and support pregnant WOC. Invite mothers and fathers of color to lead groups for expectant parents. Groups can cover topics such as how to have conversations about birth options, cultural expectations of birthing mothers and parenting styles and ethnic cooking with a healthy spin and specific topics related to controlling or preventing gestational diabetes and pre-eclampsia, reducing cesarean birth and increasing breastfeeding success.

In order to attract WOC to our classes, educators need to become culturally sensitive and appropriate. Evaluations of our marketing and teaching materials are in order to ensure inclusion of AA women. Educators have to be up to date on the statistics and health facts and challenges facing AA families. Our hospitals, birthing centers, birth support groups and networks should brainstorm ways to fund and provide scholarships and/or grants to make classes economically feasible. Lastly, if we are serious about supporting all mothers and helping them to have a safe and healthy birth, let’s build and support local birth support groups.

Change can be challenging. Start with small goals. The first step is self-evaluation. What had been working and what can be improved? Share your resources? Where do you find images and videos that are welcoming to women of color and all ethnicities? After you have evaluated your program, come back and let me know what worked and did not work. If you need some help, please contact me. I’m excited to try some of these resources myself. I’ll keep you posted on my Facebook page.

References

Vontress, C. “A Personal Retrospective on Cross Cultural Counseling.” Journal of Multicultural Counseling and Development, 1996, 24, 156-166

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

Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant, Series: Welcoming All Families , , , , ,

Research Review: Are There Any Benefits to Performing an Early Frenotomy on Newborns?

December 10th, 2013 by avatar

By Elias Kass, ND, LM, CPM

Breastfeeding is often considered the next big challenge after childbirth. New mothers and babies work together to establish a successful breastfeeding relationship. Sometimes, there are complications that can make things harder than they should be.  Tongue tie is one of the circumstances that can interfere with getting the breastfeeding relationship off to a good start. Please welcome Dr. Elias Kass, to Science & Sensibility as he reviews a recent study on early frenotomy (tongue tie clipping) in newborns and shares his thoughts on the study results. – Sharon Muza, Community Manager

With tongue tie seemingly on the rise, it’s always nice to see new literature approach the issue. “Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie” (Emond et al) compares releasing the tongue tie (frenotomy) immediately versus waiting and providing standard breastfeeding support.

What is tongue tie?

Tongue tie describes the presence of a frenulum that restricts the tongue’s ability to reach out and grasp the breast for successful breastfeeding.

Anterior tongue tie Image Source: Melissa Cole, IBCLC, RLC

Anterior tongue tie
Image Source: Melissa Cole, IBCLC, RLC

The most profound anterior tongue tie is one that connects the tip of the tongue to the edge of the gum. These babies have a V- or heart-shaped tongue when they cry, cannot extend their tongue at all, cannot follow a finger tracing along their bottom gum, and cannot generally latch well. Tongue ties can occur all along the spectrum of the tongue and the floor of the mouth, and some are hidden under the surface layer of skin, which we call “posterior tongue tie.”

The role of the tongue in breastfeeding

The tongue is incredibly important in breastfeeding. The baby must reach out with his tongue and grasp the breast. The tongue forms the primary seal, preventing milk loss and air intake. The movement is intrinsic to the tongue. Rather than sawing the tongue in and out, the muscular impulse starts at the tip of the tongue and moves inward, moving milk from the breast into the mouth. The middle of the tongue acts to form the milk into a ball, and the back of the tongue is responsible for coordinating swallowing, raising the larynx so that milk is directed down the esophagus and not down the trachea into the lungs.

What happens when a baby is tongue tied?

Tongue tie interferes with this intricate coordination in many ways. Some babies cannot extend their tongue. Those babies will have difficulty finding and attaching to the breast, but they may be able to nurse if the nipple is placed in their mouth just right. These babies come off the breast easily and become frustrated because they cannot adjust the position of the nipple in the mouth. The babies who are so tied they cannot extend their tongue over their bottom gum will reflexively clamp their gums. To the nursing parent, this pressure can feel like biting, and can damage nipples incredibly quickly, causing cracking, bleeding, pain, and because the skin is now broken, infection. 

Some babies can extend their tongue against the “rubber band” of the tongue tie, but their tongues “snap back” frequently. This can feel like a sawing against the underside of the nipple, and that friction can also damage nipples. These babies tire easily, because their feeding is made more difficult by the resistance of the rubber band. Snap back can sound like clicking. Clicking can also be caused by loss of suction from the underside of the breast. The tongue should stay mostly in the middle of the mouth when breastfeeding, with the jaw opening to create suction in the middle and back of the mouth. If, when baby opens her jaw, the tongue is tied to the bottom of the mouth, her tongue will snap away from the breast, losing suction.

Some babies can extend but not cup their tongues. These babies generally mash the nipple against the roof of the mouth, causing flattened, ridged nipples. Others thrust their tongue against the nipple instead of reaching under it, which leaves the nipple looking like a lipstick applicator.

What is a frenotomy?

Frenotomy refers to the procedure where this tongue tie is released (or in some places, “revised”). Though not all providers perform this procedure, providers from many different specialties have been known to offer it: pediatricians, family practice doctors, ear nose and throat specialists, dentists, and some midwives. For most, it is a simple, in-office procedure.

What did this study look at?

The researchers determined which babies were tongue tied based on the Hazelbaker Assessment Tool for Lingual Frenulum Function and the LATCH score (Latch, Audible swallowing, nipple Type, Comfort, Hold ). Those who had mild-moderate tongue tie according to the Hazelbaker score, as well as a LATCH score less than 8 out of 10 were eligible for the study. Those babies with severe tongue tie according to the Hazelbaker score were not randomized, and were instead offered immediate frenotomy; their outcomes were not considered as part of the study. Some parents of babies who otherwise qualified for the study refused to be randomized because they felt strongly about receiving frenotomy upon diagnosis.

When considering whether to intervene for tongue tie, it’s important to consider appearance as well as functionality. Some tongue ties are not readily visible but interfere greatly with functionality. Some tongue ties appear dramatic, but breastfeeding is not affected. (There are other long-term considerations, like speech and oral health, in deciding whether or not to release a tongue tie that is not affecting breastfeeding.) The Hazelbaker score is a good way to evaluate functionality because it takes into account whether baby can extend her tongue, cup it into the appropriate shape, moved it appropriately, and maintain suction, as well as the severity in appearance. The Hazelbaker score has good inter-scorer correlation, meaning that different professionals using the tool will arrive at the same conclusion (whether or not the baby should have a frenotomy) nearly 90% of the time. Using a consistent tool can help the individual provider get a better sense of who needs the procedure, but it can also help us as readers to know whether the study population was appropriate, and whether the study’s conclusions can inform our own practice.

V-shaped tongue Image Source: Osama Moshet, MD, FAAP

V-shaped tongue
Image Source: Osama Moshet, MD, FAAP

The LATCH score is a very broad evaluation of how breastfeeding is going, and despite its name, only barely addresses latch itself. Using such a general assessment in conjunction with the Hazelbaker score may have helped the researchers isolate the babies who were both tongue tied and having difficulties breastfeeding, as opposed to those who were tongue tied but doing okay.

In measuring outcomes, they used these two measures again, and added several more measures concerning breastfeeding behavior of newborns, breastfeeding self-efficacy (how confident mom felt in her ability to feed her baby, as well as an observer’s evaluation of breastfeeding effectiveness), and pain.

Conclusion

The primary outcome was LATCH score at 5 days. Secondary outcomes were LATCH score at 8 weeks, and the other measures listed above at 5 days and 8 weeks. The Hazelbaker score was another “outcome of interest” at 5 days, as was infant weight at 8 weeks. At 5 days, parents could choose to have frenotomy regardless of whether they had been randomized to the control arm or the intervention arm.

The researchers concluded “Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.”

Discussion

Though the study is structured fairly soundly, it doesn’t really answer its own question of whether frenotomy helps improve breastfeeding, largely because of the outcomes they chose to study. The LATCH score is not an indication of tongue functionality, success of frenotomy, or long-term breastfeeding success. Five days is also probably too soon to pass final judgement on whether the frenotomy helped; babies and nipples are still healing. The study also excluded those with severe tongue tie, and it’s safe to assume these babies would have significant improvement when their tongue ties were corrected.

Mothers did feel significantly more effective in their feeding when their babies had received frenotomy (which is correlated with duration of breastfeeding), and more of those who didn’t receive frenotomy were feeding by bottle. It’s unclear whether this bottle feeding was because of the pain associated with breastfeeding or because of inadequate milk transfer or nutrition, but it’s possible that some of those parents have been helped by immediate frenotomy. Indeed, some of the mothers who had been randomized to the control group requested early frenotomy because their feeding was so painful. There were statistically significant improvements in the Hazelbaker score, representing improvement in both appearance and functionality.

Very thick  submucosal/posterior tongue tie. {link url="http://www.bayareabreastfeeding.net"}Bay Area Breastfeeding & Education, LLC{/link} Image Source: Bay Area Breastfeeding & Education, LLC

Very thick submucosal/posterior tongue tie.
Image Source: Bay Area Breastfeeding & Education, LLC www.bayareabreastfeeding.net

Many features of this study mirror how I treat tongue tie in my practice. Almost all babies are referred by lactation consultants or their own pediatricians because they are having difficulty breastfeeding, or because their tongue ties are so profound that we can anticipate speech and oral health problems if it’s not corrected. I use both the Hazelbaker score and the scoring tool in the appendix of RL Martinelli’s “Lingual frenulum protocol with scores for infants” to capture the infant’s feeding history, anatomy, and functionality on both the gloved finger and at the breast. These scores help support a systematic approach to these infants, and helps communicate back to their referring provider what I’m looking for when I decide whether or not to recommend frenotomy. Though most babies referred do need frenotomy, some need other kinds of support instead, and some just need reassurance around normal feeding patterns.

The article didn’t go into much detail about the aftercare. Aftercare is a crucial variable in improving breastfeeding and maximizing success of the procedure. Seattle area practices who perform significant numbers of frenotomy have collaborated to create a list of exercises we ask parents to do with their babies 5 times daily for a week to keep the area open, reduce reattachment, and help baby learn to maximize their new freedom of movement. We also generally recommend craniosacral therapy to help release tight muscles and retrain movement patterns. Many families have incorporated other feeding tools or accessories into their regimens, whether that’s nipple shields, bottles, supplemental nursing systems, or formula. With frenotomy, most will be able to start to move away from those tools, and need continued support from a lactation consultant to relearn how to nurse at the breast. Though most mothers feel that baby nurses differently immediately, some babies take longer to change their approach, and some do not benefit at all.

Releasing tongue ties is a very satisfying part of my practice. I love when breastfeeding parents nurse immediately after the procedure and their faces light up because for the first time it doesn’t hurt to feed. These parents have been working very, very hard to breastfeed, and I feel strongly that this procedure removes a significant obstacle. The more I work with breastfeeding families, the more in awe I am of the complexity of breastfeeding, and importance of excellent breastfeeding support.

Childbirth  and breastfeeding educators should be sharing that painful breastfeeding sessions are not normal and should be evaluated by a lactation consultant.  Educators should provide resources for qualified LCs in their communities to families in need.  For those that work with breastfeeding dyads, what are you seeing in terms of tongue tie and treatment success? Please share your experiences.- SM

References

Ballard, J. L., Auer, C. E., & Khoury, J. C. (2002). Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.Pediatrics, 110(5), e63-e63.

Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., & Sutcliffe, A. (2013). Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Archives of Disease in Childhood-Fetal and Neonatal Edition, fetalneonatal-2013.

Martinelli RL de C, Marchesan IQ, Berretin-Felix G. Lingual frenulum protocol with scores for infants. Int J Orofacial Myology. 2012;38:104–112.

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, including prenatal, birth and pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

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