Science & Sensibility

Childbirth Connection’s Listening to Mothers Initiative just released the Listening to Mothers III (LTMIII) results late last week.  For the third time in the past 11 years, this organization has gone out and queried women on a variety of topics related to pregnancy, birth, postpartum and breastfeeding.  They have questioned thousands of women to accurately assess how the actual experiences hold up against what we know to be best practice and evidence based maternity care. I have relied on the past two survey results frequently during my professional career in maternal health and am thrilled to have the new survey results now available.

I thought it would be interesting to run some of the LTMIII results through the filter of Lamaze International’s Healthy Birth Practices.  The Healthy Birth Practices were most recently updated by Lamaze in 2009, and consist of six simple, evidence based practices that greatly contribute to keeping birth safe and healthy for mothers and babies. Each easy to remember practice has its own short video that parents can watch that talks about that specific care practice and safe alternatives.  Additionally, each Healthy Birth Practice has an accompanying Practice Paper with all the citations for the peer-reviewed, gold standard research that supports that particular practice.

Some useful links and information upfront

Listening to Mothers I

Listening to Mothers II

New!  Listening to Mothers III

Survey Questionnaire 

Major Study Findings

Interesting facts before we get started

While the LTMIII survey only looked at 2400 women,  please be aware that one percentage point change in results would represent approximately 40,000 mother/baby pairs, based on a US birth rate of around 4 million births a year.

35% of women had not intended to be pregnant at the time of this pregnancy, including 5% who stated that they had never intended to become pregnant at all.

52% of those planning to get pregnant did have a preconception meeting with a health care provider, (which could be viewed as a wonderful time to determine if this health care provider might be a good match for their maternity care needs.)

85% of women based their maternity care provider on insurance requirements or restrictions.

78% of women worked with an obstetrician (this has dropped over the course of the three studies.)

9% of women worked with a family practice doctor

8% of women worked with a midwife who practiced in a hospital, as one of the requirements of the study was that the mother was having a hospital birth.

The average length of time spent actually in a prenatal appointment, with health care provider or their nurse was 32 minutes.  (OB: 31 min, Family Practice/MW 35 min.) I was pleasantly surprised that it was this long, I expected less.

Over the course of the three studies, the cesarean rate of study participants went up, (24% to 31%), the VBAC rate went down and labor augmentation was cut in half from 53% to 26%.  More women used nitrous oxide for pain relief during their labor in the most recent study (6%, up from 2% in the first study)

30% of the women chose not to ask a question that they wanted answered at least once during their prenatal appointments.

Overall, women were unable to make choices in line with the Healthy Birth Practices, and did not know that deviating from these practices was not evidence based and resulted in increased interventions.

Let’s see how things stack up

Healthy Birth Practice 1: Let Labor Begin on Its Own

Research shows that in the absence of medical issues, mothers, babies and labors do best when labor starts spontaneously on its own. The final few weeks of pregnancy are vital for the putting the “finishing touches” on baby and helping to make the transition to life on the outside as smooth as possible.

41% of all women surveyed attempted a medical (involved a care provider) induction and of those induced, 74% were successful, (the woman went into labor) for an overall medically induced labor rate of 31%

Reasons why women were induced

• 44% were full term
• 19% wanted to get the pregnancy over
• 11% wanted to control the timing of birth
• 16% were induced for a large baby (note: the average weight of these babies induced for suspected macrosomia was 7 lbs 15 ounces.)
• 18% were induced for being “overdue” (note: the average gestational age of those babies induced for being overdue was 39.9 weeks)
• 18% were induced for a maternal health problem

Interestingly, 26% of women had their due date changed toward the end of their pregnancy; 66% of those were given an earlier due date and 34% were given a later one.

68% of women had a late third trimester ultrasound to estimate fetal weight

Healthy Birth Practice 2: Walk, Move Around and Change Positions in Labor

Women with the ability to move and change positions are able to use this movement to help cope with the pain of labor.  Access to water in the form of a shower or tub can be a valuable coping technique.  Having access to intermittent fetal monitoring or telemetry movements can facilitate movement and promote labor progress for many women.

Only 43% of women walked around after being admitted to the hospital in labor

40% of women used position changes and movement for non-pharmacological pain relief

Healthy Birth Practice 3: Bring a Loved One, Friend or Doula for Continuous Support

Many women will thrive in labor if surrounded by a caring, supportive birth team.  Adding a skilled birth doula to the team has been shown in many studies to improve the outcome of birth and reduce interventions and cesareans.  While more and more birthing women are aware of a doula, many are still not having one in attendance at their birth.

99% of mothers had at least one support person present, (most often this was a partner, then a family member or friend)

6% women used a doula

75% of mothers were aware of what a doula does and of those 75% who knew, 27% would have liked a doula supporting them at their birth.

Healthy Birth Practice 4: Avoid Interventions That are Not Medically Necessary 

Although research shows that routine and unnecessary interference in the natural process of labor and birth is not likely to be beneficial—and may indeed be harmful—most U.S. births today are intervention-intensive.

98% of the women had at least one ultrasound during pregnancy and 70% had three or more over the course of their pregnancy

68% of women had a late third trimester ultrasound to estimate fetal weight.

83% of women had some type of pain medication

67% had an epidural or spinal, and 92% of those who did reported this to be “very helpful” or “somewhat helpful.”

62% of women surveyed had an IV during labor

51% of women had one or more vaginal exams in labor. (I was surprised at this, I would have suspected higher)

47% had bladder (Foley) catheters

31% of women had a labor augmented with pitocin

50% of birthing women had their labor either induced or augmented with pitocin

20% had their membranes ruptured artificially (AROM)  after labor began

36% of women had their labor started or augmented by AROM

1% of women requested and had a maternal request cesarean for non-medical reasons

40% of women drank fluids during their labor

21% of the women ate during labor

85% of women birthing vaginally did so without forceps or vacuum

87% of women responding had at least one of the five big interventions (attempted labor induction, epidural, pitocin augmentation, assisted delivery with vacuum or forceps or cesarean.

60% of the women had at least two of the above five interventions listed above

Healthy Birth Practice 5: Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push

Women push most effectively when permitted to push in the positions that feel best for them.  Allowing the baby to “labor down” even after reaching full dilation until moms feel the urge to push can help women to push a baby out quicker and under their own steam.  Pushing in positions that allow the pelvis to open as much as possible and making space by getting the sacrum out of the way can help promote descent during pushing.

68% of women surveyed birthed on their backs

23% birthed in a semi-sitting position

8% gave birth in a position off their back, either side-lying, squat or hands & knees

Healthy Birth Practice 6: Keep Mother and Baby Together; Its Best for Mother, Baby and Breastfeeding

Experts now recommend that right after birth, a healthy newborn should be placed skin-to-skin on the mother’s abdomen or chest and should be dried and covered with warm blankets. Any care that needs to be done immediately after birth can be done with your baby skin-to-skin on your chest.  This early time together promotes breastfeeding, helps stabilize the newborn’s temperature and blood sugar and also offers a unique chance for high levels of natural oxytocin that promote bonding and help with immediate postpartum bleeding.

47% of mothers responding had their baby in their arms within the first hour

40% of mother-baby pairs were not skin to skin when they were first held

33% of all babies were with hospital staff the first hour

60% of mother-baby pairs roomed in together

18% of babies spent time in the NICU

25% of babies spent their days with mom and their nights in the nursery

49% of mothers who stated that they intended to exclusively breastfeed were given formula samples or offers.

29% of newborns were supplemented with water or formula during the hospital stay

Summary

After reading through the LTMIII report, I found myself discouraged by the current results.  It was clear that women were making choices and/or being informed by their care providers to choose practices that have long been known to create a cascade of interventions, do not improve outcomes for mothers or babies and are not evidence based.  For the majority of the women who responded to this survey, the Healthy Care Practices are still a pipe dream and not a reality in their hospitals and with their current providers.  I know change comes slowly, and it can take years for protocols to catch up with the evidence but frankly, after reading the summary of how things did or did not change over the course of the three studies I was still shocked.

Have you had a chance to go through the study yet?  What were your thoughts?  Anything surprise you?  Can you share a bright point that you noticed?

Join us later this week as I examine what the LTMIII survey had to say about childbirth education and how women are receiving pregnancy and birth information and from where.

 

 

 

 

Sharon Muza Breastfeeding, Cesarean Birth, Childbirth Education, Doula Care, Epidural Analgesia, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Newborns, News about Pregnancy, Research, Transforming Maternity Care, Uncategorized Childbirth Connection, Healthy Birth Practices, Lamaze International, Listening to Mothers III, Listening to Mothers surveys, research, Sharon Muza

by Christine H. Morton, PhD and Monica Basile, PhD, CPM, CD(DONA), CCE (BWI)

Last month there were great discussions after a study was published by the University of Minnesota, examining the potential cost savings to Medicaid if doulas worked with Medicaid clients, helping to reduce interventions and cesareans.  Today and next Tuesday, regular contributor, Christine Morton and her colleague Monica Basile, take a look at that study and another from Oregon, and share thoughtful insight about topics that might still need to be addressed if costs savings were to be effectively realized in a two part blog post. – Sharon Muza, Community Manager, Science & Sensibility

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How can doula supported births help reduce the cesarean rate and realize cost savings within Medicaid-funded births? Two studies published last month offer the opportunity to address this complex question.

We support the goal of increasing access to doula supported care to childbearing people of diverse racial/ethnic and class backgrounds, and we are pleased that discussions are taking place about how doulas may be able to help reduce racial disparities in maternal and infant health. We recognize that work toward these goals requires policy advocacy, which depends heavily on economic arguments for the benefits of doula care.

However, by limiting the discussion of benefits to the economic impacts of reduced cesareans, advocacy for Medicaid funding of doula supported births—without specifying the doula model of care and without according true value to the doula’s impact—may have unintended consequences for individual doulas, and the organizations that represent them.  One such consequence may be that the resulting system will continue to perpetuate a model of economic marginality and potential exploitation for the doulas who serve a low income population of childbearing people.

The AJPH study by Katy Kozhimannil and colleagues in Minnesota received a lot of media attention when it appeared last month, even live coverage in the Huffington Post.  This study compared 1,079 selected Medicaid doula patients in Minnesota to Medicaid patients nationwide for their total cesarean rates.  They found that doula clients of a community program in Minnesota had a rate of 22.3% while national Medicaid had 31.5%.  The authors reported three scenarios, all assuming that if states reduced cesarean rates, by offering doula services, there would be varying levels of cost savings, depending on the cesarean rate achieved, and by reimbursing doulas between $100-300 per birth.

In our view, the Minnesota study design raises several methodological questions, which are applicable to this study and to future research on doula-attended births. We outline those questions here, as well as raise several more substantive concerns about the implications of the study’s stated conclusions.

1. Why did the researchers not compare Minnesota Medicaid doula clients to Minnesota Medicaid women who gave birth?  Minnesota has a much lower rate of total cesarean that the US as a whole (27.4% during this time period), and this would have been a better matched comparison.  A better comparison would be doula attended births vs. non-doula attended births at the same facility.  It is not clear from the study whether the doula program whose data was utilized served women at one or multiple hospitals in Minneapolis. 
2. Why did the researchers not limit their investigation to primary cesareans?  Doulas typically support women in labor rather than women undergoing repeat cesareans.  The total cesarean rate includes repeat cesarean so it will be much higher than the primary cesarean rate, which is more applicable to doula clients.  Including total cesarean rates means that the researchers are comparing a limited universe (doula support of women in labor) to all births (thus including repeat and primary cesarean).   The data source for this study, (Nationwide Inpatient Sample), however, does not have this information.
3. Cesarean rates are very dependent on the parity distribution of the birthing population, so first time mothers need to be compared to first time mothers and multiparous women to multiparous women. This information is not available in the data source used by the researchers, but in future studies of this type, it is critical to verify that the proportion of each is the same in the intervention and control populations.
4. States are implementing a number of payment reform models to reduce cesareans among women covered by Medicaid, with limited success.  In part, that is because cesareans are influenced by a number of factors, with payment incentives only one.  (Many of these issues are covered in the CMQCC white paper on improvement opportunities to reduce cesareans, which argues that a multi-pronged strategy is necessary). 
5. Because hospital rates of cesarean have been shown to have high geographic variation in a number of studies (Baicker 2006; Main et al 2011; Caceres 2013; Kozhimannil 2013), it may be more feasible to have comparison groups of hospitals with similar primary cesarean rates.  Until we understand what accounts for variation in cesarean rates between institutions (unit culture; facility policies and protocols), it may be premature to assess the independent effect of labor support by a trained doula.

While doula support is associated with fewer cesareans across the board (Hodnett 2012), the methodological issues described above are likely to over estimate the benefits of doula-attended births in terms of reducing the cesarean rate for Medicaid covered births.  This, in turn, raises questions about the purported cost savings.  In the Minnesota study, the cost breakpoint is no more than $300 dollars for the doula per birth.  In most cities, doulas charge well above this amount for fee-for service care.

A cost-benefit analysis by Oregon Health & Science University researchers for the Oregon State Legislature was presented at the Society for Maternal Fetal Medicine in February 2013, which found that doula care in labor provides a cost benefit to payers only when doula costs are below $159.73 per case.  In that study, data sources are not entirely clear, but do seem to come from the OHSU facility where a hospital-based doula program is in place.  In that program, doulas are on call on weekends only and come to assist in a labor when requested by the woman during her prenatal care or when she arrives at the hospital.  A case-control study claiming the benefits of this doula model at OHSU was published as an abstract, and although it claims “women receiving doula care were statistically less likely to have an epidural during labor (p = 0.03), have an episiotomy (p = .03), or cesarean delivery (p = .006) and on average, doula attended women had a shorter hospital stay compared to the control group (p = .002),” nowhere does it show what the actual rates were.  This is important, because, they are likely to be relatively low overall, given that OSHU is a teaching hospital, with midwives and family practice physicians providing maternity care.

There are several types of doula models; not all have the same components.  The community-based doula model, as exemplified by the HealthConnectOne approach has a solid evidence base. This model employs doulas who are trusted community members, and provides extensive prenatal and postpartum support in addition to continuous labor support.  Doulas work collaboratively with community organizations, have extensive training in experiential learning and cultural sensitivity, and are paid a wage commensurate with their value and expertise, serving an important workforce development and grassroots empowerment function. Some so-called community doula programs do not incorporate all these components.

Hospital-based programs usually assign or utilize an on-call doula, who has not met the mother in advance and is not likely to follow up postpartum.  Some advocates of Medicaid doula programs utilize the community health worker (CHW) model, which seems to mirror the community-based doula (CBD) model but with important differences.  The American Public Health Association has defined CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve.”  Yet, despite their widespread utilization in public health over the past several years, the conditions of their training, job opportunities, and even job description are idiosyncratic, and highly varied, and this “lack of CHW identity and standards of practice has led employers to contribute to the confusion about who CHWs are and what they do.” While the CHW and CBD models offer important job opportunities to members of under-resourced communities, their wages are often on the low side, with full time work paying $35,000 to $42,000 annually.  According to a health careers website, “CHWs often are hired to support a specific health initiative, which may depend on short-term funding sources. As a result, CHWs may have to move from job to job to obtain steady income.  This short-term categorical funding of health services is a challenge to the stability and sustainability of the CHW practice.”

In cost-benefit or cost effectiveness studies, it is critical to clearly specify the doula model of care on which the economic model is based.  It seems the doula model in the Minnesota study incorporates extensive pre and post partum contact and that there is an attempt to match doulas and clients in terms of race/ethnicity and language, but this is not always possible.   The study does not indicate what the doulas in the Minnesota program were paid, however, and that information was unavailable on their website.

Before we move to the topic of reimbursement, we want to note that the type of doula model is critical for assessing the benefits of doula-attended births.  The research clearly shows different outcomes for doulas who are affiliated with hospitals compared to those who work independently (Hodnett, 2012).  If a cost benefit model shows little gain in terms of outcomes, or yields a price point in the low hundreds of dollars, it may be that findings are affected by the assumptions embedded in the calculations.

More fundamentally, however, we argue that doula benefits cannot be captured solely through an economic model.  Neither should doulas be promoted as a primary means to reduce cesarean rates.  Both strategies (economic benefits and cesarean reduction) for promoting doulas have significant barrier.  In part two of this topic, running on Tuesday, April 2nd,  we discuss our concerns about reimbursement and program sustainability alongside a caution against relying too heavily on arguments that position the doula as primarily a money saver and cesarean reducer.

References

Baicker, K, Kasey S. Buckles, and Amitabh Chandra. Geographic Variation In The Appropriate Use Of Cesarean Delivery: Do higher usage rates reflect medically inappropriate use of this procedure? Health Affairs 25 (2006): w355–w367; doi: 10.1377/hlthaff.25.w355

Caceres, Isabel A., Mariana Arcaya, et al., Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact, PLoS ONE 8(3): e57817. doi:10.1371/journal.pone.0057817

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues, Health Affairs 32, NO. 3 (2013): 527–535; doi: 10.1377/hlthaff.2012.1030

Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K and Gould JB. 2011.  Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality.  Palo Alto, CA: CMQCC.  (Available at http://www.cmqcc.org/white_paper)

About the authors

 

Monica Basile has been an active birth doula, childbirth educator, and midwifery advocate for 17 years, and holds a PhD in Gender, Women’s and Sexuality Studies. Her 2012 doctoral dissertation, Reproductive Justice and Childbirth Reform: Doulas as Agents of Social Change, is an examination of emerging trends in doula care through the lens of intersectional feminist theory and the reproductive justice movement.

 

Regular contributor Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth, which will be published by Praeclarus Press in Fall 2013. For more on Christine, please see Science & Sensibility’s Contributor page.

Christine Morton Cesarean Birth, Doula Care, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Research, Uncategorized cesareans, Christine Morton PhD, doulas, Medicaid and maternity care, Monica Basile, research

Regular contributor Penny Simkin shares her experiences with parents who sing to their baby in utero and then continue after birth and looks at what the research says about this practice in this two part blog piece.  Part two can be found here. Join me in reading about some unique situations that Penny shares as she explores this opportunity for parents to bond with their unborn child.  - Sharon Muza, Science & Sensibility Community Manager.

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People have sung to their babies forever. Every culture has lullabies and children’s songs that are passed down through the generations. New ones are written and shared and the custom goes on –a rich part of the fabric of human civilization. These songs are designed to relax babies, calm their fears, or entertain and amuse them throughout childhood. As we have learned more about the life and capabilities of the fetus, we have realized that the fetus can hear clearly for months before birth, and also can discriminate sounds and develop preferences for some sounds over others. Furthermore, at birth, newborns respond to familiar sounds by becoming calm and orienting toward the source of the sound, and even indicate their preferences for familiar voices and words over the unfamiliar.

Newborn babies prefer their parents’ and other familiar voices over those of strangers (1), and they prefer hearing a story that their mother had read frequently in utero rather than an unfamiliar story or the familiar one read by someone other than their mother (2).  Fetuses hear, remember, have preferences, respond to, and discriminate among differences — in sounds, music, voices.

These exciting findings have inspired educators to advocate prenatal learning through recordings played through a mother’s abdomen (of languages, music, and other things). They have inspired birth activists and baby advocates to provide a safe enriching environment for the fetus. Advocates of prenatal bonding emphasize communication between parent and unborn child as a powerful way to strengthen the bond.

I’d like to offer my take on this phenomenon and urge everyone who works with expectant parents to tell them about some unique and heart-warming benefits of singing or reciting rhymes to their unborn babies.

I think my interest in parents singing to their babies prenatally began in the 1980s when I first read Michel Odent’s book, “Birth Reborn”(3). Odent is a French physician who has always been ahead of his time. He had a unique and original maternity care program at his hospital in Pithiviers, France. His book had a great influence on my understanding of normal birth, and the book is still worth reading today, along with all his subsequent ones. One lovely aspect of his program is particularly relevant to the topic of this blog post. The program included a weekly singing group at the hospital, attended by pregnant women, their partners, families with young babies, the midwives, and Odent himself. The group was led by an opera singer who believed singing to be important for fetuses, babies and those who care for them. Odent’s account inspired me to invite Jamie Shilling, a folk singer who had recently taken my birth class, to bring her guitar and her baby to my classes a half hour early each week and sing with the expectant parents. That went on very successfully for several class series, then the groups decided to combine and carry on in a monthly sing- along for expectant parents and new families, in a private home –Although the groups  eventually disbanded, they provided many parents with opportunities to sing together and connect with their babies and each other in relaxing and peaceful surroundings. A high point during that time was when Michel Odent came to Seattle to give a conference and he agreed to come to one of our sing-alongs. See the photo of Jamie leading the group of expectant and new parents, with Michel Odent and myself participating. He taught us the song, “Little Black Cat” in French.

I couldn’t help but think during those times, how the unborn and new babies must love hearing their parents singing. Seeing the parents caressing the mother’s belly as they sang was heartwarming. That happened  in the mid- 1980s, when much research on the capabilities of the unborn and newborn baby was beginning to be published. Recalling those special gatherings, I have always suggested to my students in childbirth class that they sing to their unborn babies, or play their favorite recorded music, with the thought that the baby will remember it and be soothed by it after birth.

But it was one couple, whom I served as a birth doula, who took my suggestion to another level, and showed me much more about the value of singing to the unborn baby. They were having their second child, hoping for a VBAC. When they discovered that they were having a boy, they decided to give their baby the song, “Here Comes the Sun” and sang it to him often during pregnancy. The VBAC was not possible, and as the cesarean was underway, and the baby boy, crying lustily, was raised for the parents to see, the father began belting out the baby’s song. Though the mother didn’t have a strong voice under the circumstances, she also sang. The baby turned his head, turned his face right toward his father and calmed down while his father sang. Time stopped. As I looked around the operating room, I saw tears appear on the surgical masks.

It’s a moment I’ll never forget, and it was that event that taught me the value, not only of singing prenatally, but also, singing the same song every day. Not only does the baby hear his or her parents’ voices, not only does he or she hear music, but the baby also gets to know one song very well. Familiarity adds another feature to this concept, because we know that fetuses have memory and prefer the familiar. Think for a moment about what this might have meant to our cesarean-born baby –suddenly being removed from the warmth, wetness, and dimness of the womb with its mother’s reassuring heartbeat, into the cold bright noisy operating room. The baby’s transition to extrauterine life is hectic and full of new sensations. He cries reflexively, but perhaps also out of shock and discomfort. Then he hears something familiar – voices and music and the sounds of words that he has heard many times before – something he likes. He calms down, and seeks the source of this familiar song. Everyone present is moved by this gift to the baby from his parents.

I’ve become passionate about this idea as a way to enhance bonding between parents and babies, but also as a unique and very practical measure for soothing a fussing baby or a sick baby who can’t be held or breastfed. Please join me on Thursday, for Part Two on this topic when I will continue the discussion including research evidence that supports this concept: practical suggetions for childbirth professionals to share with expectant parents; and some very endearing film clips of families singing to their babies.

References:

1. Brazelton B. Cramer B. (1991)The Earliest Relationship: Parents, Infants, and The Drama Of Early Attachment . Da Capo Press Cambridge, MA.

2. De Casper A. 1974, as described in Klaus M, Klaus P, Kennell J. 2000. Your Amazing Newborn. Da Capo Press, Cambridge, MA.

3. Odent M. 1984, Birth Reborn. Pantheon Books: New York 

Penny Simkin Cesarean Birth, Childbirth Education, Doula Care, Guest Posts, Infant Attachment, Newborns, Parenting an Infant, Vaginal Birth After Cesarean (VBAC) Childbirth Education, Infant Attachment, Michel Odent, newborns, Penny Simkin, perinatal bonding, Singing to baby

By Cara Terreri, BA, Community Manager for Lamaze International’s Giving Birth With Confidence blog

Today is the second post in an occasional series on Science & Sensibility, “Journey to LCCE Certification.”   We are following Cara Terreri as she progresses on the path to become a Lamaze Certified Childbirth Educator.  Her journey started with her Childbirth Education Seminar and in this post we learn about her experience as an observer at a birth.  In the future, we will continue as she develops her own curriculum, teaches her first classes and sits for the exam.  I invite you to cheer her on and offer your support, suggestions and encouragement based on your own experiences on a similar journey. – Sharon Muza, Community Manager

Since my last post that talked about beginning my path toward LCCE certification and attending a Lamaze Childbirth Educator Seminar, I have not progressed very far. My day job and family life have taken precedence. That being said, I was lucky enough to be given the opportunity to attend a birth! A friend of a friend was due with her second baby and was open to the idea of an almost-complete stranger (me!) attending her birth. I treated the experience as if I were a doula-in-very-early-training and talked at length with the mom about her first birth, her expectations and feelings about her upcoming birth, and my proposed role during her labor and birth. I was upfront in letting her know that while I knew quite a bit about birth, I was not certified as either an educator or doula, and that I was very early in my stages of training for both.

While I was so excited about the upcoming experience, I was also very anxious. Would I know what to do? Would I be able to step up and help mom when she needed it and how she needed it? By nature, I tend to be more of an introvert – initiating conversation with someone new or speaking up in an unfamiliar situation can sometimes take me out of my comfort zone. I did my best to ready myself for the situation by talking often with mom and taking a crash self-study course in labor support. I re-read specific sections of all of my favorite birth books and rehearsed possible scenarios in my head.

When it came time for birth, I was able to arrive within minutes of mom and dad at the hospital. I helped support mom – who had asked immediately for an epidural – while waiting for the epidural by massage, touch, verbal encouragement, and having water ready after she vomited. In our conversations prior to birth, mom talked fondly about the epidural during her first birth, which she said rescued her from the pain of laboring with Pitocin. But she also talked about leaving it “up in the air” for her second birth.

The experience and environment came very naturally to me. I felt comfortable jumping in and doing what I could, suggesting positions, using touch, etc. Of course, there were moments when I wished I knew more – how to respond more with verbal encouragement, how to encourage more movement while keeping fetal monitors in place for the requisite 20 minutes, and how best to calm a very panicked mom, who was still waiting for an epidural when she entered transition and pushing (note: the epidural never came).

Attending a birth was an amazing teaching tool for me, both in preparation for a future career as a doula as well as a childbirth educator. Having never attended any births but my own, it was so enlightening to attend a birth as an observer/support person. One unexpected part of my role was the support I provided in helping to encourage communication/conversation between staff and the parents. I also learned the importance of not projecting my own feelings about birth onto others, as it doesn’t always apply. As baby was kept in the warmer for an extended period of time for suctioning (there was meconium and baby had significant amounts of fluid), I ached for mom to be able to have skin-to-skin with her baby. But, when we had a quiet moment, mom told me, “I wasn’t ready to hold him; I was still recovering from the shock of the fast birth – it was overwhelming.” It just goes to show that everyone deals with and feels differently about their birth experience.

In my unfamiliar role as birth observer, I also earned new respect for the experience of a loved one in the labor room. As mom panicked at the onset of transition, she cried out in fear and pain, “Help me, help me!” I of course, recognized what was happening and knew she would be ok and that this was just the next natural phase. Dad, however, did not necessarily share the same knowledge! I could only have imagined what it was like for him to witness his wife panicked, in pain, and very scared.

Preparing dad/partner is just one way that childbirth education can have a real impact on a birth experience. Another is preparing and knowing about pain relief options. Even if a mom knows she will get an epidural, there are MANY cases where it doesn’t come in time or does not “work.” Knowing about and preparing for natural pain relief can go a long way, especially for parents who do not have a doula.

Next steps in my journey include preparing to teach for observation early next year, attending more births, attending a local childbirth class for observation, and burning the midnight oil with the Study Guide to prep for the exam in April.

I would love to hear input from other educators and doulas – what kinds of things did you discover in the first few births you attended? How does attending births help you as an educator?  When you were starting out, did attending births change how how you had considered teaching certain topics or clarify information that you absolutely want to stress in your own childbirth classes?  Please share those first birth on your own personal journey to becoming a birth professional.

About Cara Terreri

Cara began working with Lamaze two years before she became a mother. Somewhere in the process of poring over marketing copy in a Lamaze brochure and birthing her first child, she became an advocate for childbirth education. Three kids later (and a whole lot more work for Lamaze), Cara is the Site Administrator for Giving Birth with Confidence, the Lamaze blog for and by women and expectant families. Cara continues to have a strong passion for the awesome power and beauty in pregnancy and birth, and for helping women to discover their own power and ability through birth. It is her hope that through the GBWC site, women will have a place to find and offer positive support to other women who are going through the amazing journey to motherhood.

 

Sharon Muza Childbirth Education, Doula Care, Giving Birth with Confidence, Guest Posts, Lamaze International, Series: Journey to LCCE Certification, Uncategorized Cara Terreri, Childbirth Education, childbirth educator training, guest post, Lamaze International, LCCE, Series: Journey to LCCE Certification

This post is part of a blog carnival in honor of World Breastfeeding Week.  Honored to participate- SM

As it is World Breastfeeding Week and National Breastfeeding Month, my Google alerts, Facebook feeds and favorite blogs have been swirling with statistics, information, celebratory tidbits and fascinating facts about breastfeeding, locally, nationally and internationally.

In recognition of those people who support women who breastfeed, organizations are offering free access to journals and other resources during International Breastfeeding Week, including the International Lactation Consultant Association’s free offer to download the quarterly, peer-reviewed Journal of Human Lactation,  the US Department of Health and Human Services Office of Women’s Health offering a free Breastfeeding Action Kit and the American College of Nurse Midwives’ Journal of Midwifery and Women’s Health offering free access to a past journal edition chock full of breastfeeding information.

I think back to the breastfeeding relationship with my own two children, recalling my personal difficulties, struggles, trials, pain and tribulations that I slogged through while establishing a positive breastfeeding relationship with my first born and proving my own personal theory that we should always have our second children first!  Remembering and appreciating the people who helped me to not give up, despite many setbacks, including many, many lactation consultants, my childbirth educator, my pediatrician, my local La Leche League support group, my partner, friends and family.

There has been a lot of press lately about expectations for women around breastfeeding.  Several months ago, Time Magazine had an article entitled “Mothers’ Milk” with a cover picture chosen specifically for its provocative nature.  Recently, the American Academy of Pediatrics passed a resolution advising pediatricians not to provide formula company gift bags, coupons, and industry-authored handouts to the parents of newborns and infants in office and clinic settings.  Nationwide, hospitals and two states (Rhode Island and just last month, Massachusetts) have banned the distribution of formula samples and bags, an action proven to increase breastfeeding rates. Even the Mayor of New York City, Mayor Bloomberg was getting in on the act recently, with his city’s “Latch On NYC” campaign that limits access to formula by hospital staff among other things.

Most recently, I read a piece by Jane E. Brody, in the Personal Health section of The New York Times,  titled “The Ideal and the Real of Breastfeeding,” where Brody referenced a Scottish study, “A serial qualitative interview study of infant feeding experiences: idealism meets realism.” (Hoddinott, Craig, Britten, 2012) published in the BMJ Open online journal.  The researchers stated in their results and conclusions that;

Unanimously families would prefer the balance to shift away from antenatal theory towards more help immediately after birth and at 3–4 months when solids are being considered. Family-orientated interactive discussions are valued above breastfeeding-centred checklist style encounters.

Adopting idealistic global policy goals like exclusive breast feeding until 6 months as individual goals for women is unhelpful. More achievable incremental goals are recommended. Using a proactive family-centred narrative approach to feeding care might enable pivotal points to be anticipated and resolved. More attention to the diverse values, meanings and emotions around infant feeding within families could help to reconcile health ideals with reality.

Clearly, from the results of this study, and the recently released “Breastfeeding Report Card- United States, 2012,” there is still a long way to go toward reaching the World Health Organization’s recommendations that mothers worldwide ”exclusively breastfeed infants for the child’s first six months to achieve optimal growth, development and health. Thereafter, they should be given nutritious complementary foods and continue breastfeeding up to the age of two years or beyond.”

Reading the Brody article and the referenced study brought me right back to when I worked for a major medical center in my community, as a childbirth educator, (I now teach independent classes) and my responsibilities included teaching a 2 1/2 hour breastfeeding class.  This class, offered as part of a group package with other classes or available as a stand alone class, was well attended by both expectant mothers and usually their partners too.

I covered the usual topics, that I suspect pretty much any other breastfeeding instructor might hit upon, cramming a ton of information into the time allotted in the most interactive way possible.  We talked about breast anatomy, how the breast makes milk, latch, positioning, feeding cues and needs of the newborn, potential problems, benefits, fears, when to reach out for additional support and specific resources in our community and so much more.  Pumping, returning to work strategies and introducing a bottle were also covered.  I recall sharing the preferred food for a newborn is its own mother’s milk at the breast, pumped mother’s milk, donor human milk and then artificial milk (formula) in that order.  I explained that there are lots of ways to feed a newborn and I trust that each mother will find the way that works best for her and her baby.

Class evaluations were handed out at the end, and for years, I enjoyed the positive feedback and enthusiasm from the attendees, who stated time and time again that the class was fun, engaging and helpful, they felt more confident and should things be difficult, they knew they had resources for help.  And then it happened.  After years of teaching and hundreds and hundreds of students, I received an evaluation that struck me to the core.  One that I still think about every time I teach breastfeeding classes or work with a birth doula client helping her and her newborn to get breastfeeding off to the right start. In blue pen, exclamation point included…“Instructor has a clear bias toward breastfeeding!”

I felt like the air had been sucked out of the room.  Left on the back table, in a pile of other evaluations, with no name or contact information.  No way to follow up with someone who I clearly failed to connect with.  Did I have a bias towards breastfeeding?  It *was* a breastfeeding class.  The objectives, as provided by the medical center had been met, but clearly, that night, I had not met a student’s personal expectations. I felt horrible. And I still do, to this day.

What were the expectations of this expectant mother from the breastfeeding class she signed up for?  What pressures was she facing, from me, from others, that maybe I did not address, what fears or concerns did she (or her partner) have that I was not able to assuage? Did I “overpromote” breastfeeding? Breastfeeding is the biological norm for all mammals.  It was a class to learn about breastfeeding her newborn.  I went over every word I spoke that night in my mind, wondering if I crossed a line, even an invisible one that only she was aware of. Upon reflection, yes, I suppose I do have a bias towards breastfeeding.  How could I not?

When I read all these articles, I feel like that line in the sand is being drawn all over again.  How can birth professionals support the biologic norm while meeting new mothers where they are at?  Providing support but not creating additional pressure. Set families up for success, but be ready to help them when the road is bumpy and even at times unsuccessful.  How can we leave women feeling stronger after their breastfeeding experience, no matter how it goes down?  How can we stand together with these new mothers, acknowledging what is best for babies, recognizing that all mothers inherently want to do their best and for reasons, sometimes within the mother’s control and sometimes outside their control, things do not go as planned.  Just like birth.

We must not leave mothers less than whole.  For if we do, we do not create women who are well equipped to parent.  We should stand united, supporting each other, teaching each other, letting children and young adults observe breastfeeding, talking about it to our peers, and co-workers and community.  If I remember correctly, I never saw a baby breastfeeding, where I could observe closely, before I had my own children.  I do not recall conversations with breastfeeding mothers, before I became an expectant parent, and we discussed breastfeeding in my childbirth class.  We should not tolerate the sensationalistic articles published by attention grabbing media or be sucked in to their “feeding” frenzy, (pun intended) pitting one woman against another, forcing everyone to take sides.

I want to own that I do have a clear bias toward breastfeeding, but I want to support all women.  Those that choose to breastfeed and those that don’t.  Or can’t.  I want to offer classes that are open and unbiased, provide accurate information and make myself accessible to all new mothers, who seek support, resources or just a listening ear and strong shoulder.  I want a re-do with that mother in my class, so many years ago.  I carry this unknown student’s comment with me in every breastfeeding interaction I have.  I also remember the wise words of my friend, colleague, mentor and hero, Penny Simkin; ““She has good reason for feeling this way, behaving this way, believing these things, and saying these things.”  I just may not know what those reasons are.

Please share with me, your thoughts on my experience.  About your own “bias toward breastfeeding” and how you handle that with your students, clients and patients.  I welcome respectful discussion and comments as we all celebrate and support women on their breastfeeding journey, whatever that looks like. – SM

References

Centers for Disease Control and Prevention , (2012). Breastfeeding report card—United States, 2012. Retrieved from website: http://www.cdc.gov/breastfeeding/data/reportcard.htm

Hoddinott P, Craig LCA, Britten J, et al. A serial qualitative interview study of infant feeding experiences: idealism meets realism. BMJ Open2012;2:e000504. doi:10.1136/bmjopen-2011-000504

Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003517. DOI: 10.1002/14651858.CD003517.

Sharon Muza Babies, Breastfeeding, Childbirth Education, Doula Care, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, informed Consent, Parenting an Infant, Research breastfeeding, breastfeeding support, Childbirth Education, childbirth in the media, infant formula samples, infant nutrition, media, newborns, Sharon Muza, social media for childbirth educators, tips for the childbirth educator