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Sleeping Like a Mammal: Nighttime Realities for Childbirth Educators to Share With Parents

August 21st, 2014 by avatar

By, Linda J. Smith, MPH, IBCLC, LCCE, FACCE

In recent days, there has been much press and discussion about a new book written by pediatricians that professes to help parents “train” their new baby to sleep through the night. The scathing criticism of the book by both parents and professionals alike are consistent with what we know about the needs of a newborn baby and their sleep and feeding patterns. Today on Science & Sensibility, Linda Smith, MPH, IBCLC, LCCE, FACCE shares accurate, evidence based information that childbirth educators and other professionals can use to talk to new families about newborns and their sleep and feeding patterns. Linda is one of the authors of La Leche League International‘s newest book; Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family.

This book written by Smith along with co-authors Diane Wiessinger,  Teresa Pitman and Diana West provides families with information to help the entire family get more sleep and do so safely, while meeting the nutritional and developmental needs of newborns. Preparing families for life with a newborn is one of the challenges we face as educators. The information Linda provides here along with the resources included in this post can help you to be sure that your information is backed by research and appropriate for your new families. – Sharon Muza, Community Manager, Science & Sensibility

How do I address sleep with my childbirth class participants?

261653 ML Algebra1 2007New parents are instantly thrust into the reality of life with a baby. As Dr. Helen Ball writes, “Sleep (or the lack of it) looms large for parents-in-waiting—and it is pointless to pretend that your sleep will not be disrupted by your new bundle of joy. His body clock, which until recently was controlled by your own, is now free-running, and a day-night pattern does not start to emerge until he is around three months old. His stomach is tiny, and he will need frequent feeds all around the clock—he cannot wait eight hours through the night to be fed just because you need to sleep. If you don’t feed him, he will cry. If he’s cold, he will cry. If he hurts, he will cry. If he misses being in close contact with you, he will cry. He doesn’t know that you will come back once you leave his sight. If he feels abandoned, he will cry frantically—it’s his only method to attract attention and bring himself to safety. If he cries frantically, it will take a long time for him to calm down and you will have to help him.”

“The experience of sleep, and of being left alone for sleep, is very different for babies than it is for adults. The more quickly you can understand your baby’s needs—for comfort, food, reassurance, contact, love—the less disruptive nighttime baby care will become, and the less anxious you will feel. Some of the decisions you make early on about nighttime baby care will affect how you manage sleep disruption and cope with your new baby.” Dr. Helen Ball

What is normal sleep?

  • Pregnant women do not sleep in long unbroken stretches, i.e., “all night.” Neither do postpartum mothers – not for many months, regardless of how they feed their babies.1 Breastfeeding mothers get more sleep than formula-feeding mothers; breastfeeding mothers who bedshare get the most sleep of all new mothers.2,3
  • Before birth, babies sleep rather randomly, not necessarily closely synchronized to their mothers’ body clock. After birth, babies sleep in short (1 to 1½ hour) cycles and need to be fed approximately hourly because of their very small stomachs.4 They do not even begin to develop day-night sleep patterns for several months, regardless of how they are fed.5
  • Frequent feeding day and night is normal, essential for the baby, yet is often called ‘inconvenient’ for parents. Let’s face it – all babies are “inconvenient.” Most of us didn’t get pregnant just to make our lives less complicated. Babies need to be touched – a LOT, day and night, and skin-to-skin.6 Touch is nearly as important to babies’ overall development as food.7 Breastfeeding is an easy way to assure plenty of touch; so is safe bedsharing.8 Most breastfeeding mothers nurse their babies to sleep and sleep with their babies at least part of the night.9

LLLI | Safe Sleep 7 Infographic

Safety issues

  • SIDS (Sudden Infant Death Syndrome) and suffocation are two distinct and rare risks to infants in the early months. SIDS is a diagnosis of exclusion: there’s no obvious reason for a baby’s death. Risk factors for SIDS are well- documented, so avoiding these can help parents reduce the already-small risk: (1) smoking;10 baby sleeping prone;11 formula feeding;12 and baby sleeping unattended.13 (details below)
  • Suffocation is a more easily-preventable risk to babies than SIDS. The main risks for suffocation (entrapment) are putting the baby to sleep on a sofa with or without an adult,14 and/or a drunk/drugged adult sleeping with a baby on any surface.15 “Never bedshare” warnings don’t tell tired parents/mothers where they CAN safely feed their babies at night. A new infographic by La Leche League, “Safe Sleep Seven: Smart Steps to Safer Bedsharing,” lists seven steps that vastly reduce the major SIDS and smothering risks.
  • Prenatal smoking is very bad for babies and increases risk of SIDS at least five-fold. Smoking is a significant hazard to babies if the mother smokes during pregnancy, and smoking in the household (and everywhere) continues to be a risk to the baby after the baby is born. Smokers exhale carbon monoxide for many hours after each cigarette,16 and secondhand smoke is harmful to babies.17 Smoking is a well-known risk to adults, too.
  • Every health authority in the world recommends exclusive breastfeeding for the first six months starting in the first hours after giving birth, then continued breastfeeding while adding family foods till the child is at least two years old.18 Formula-fed babies are less arousable from sleep than breastfed babies;19 have more than double the risk of (SIDS);12 and have many other health problems.20 If families need help with breastfeeding, contact WomensHealth.gov or La Leche League International or the federal government Women, Infants and Children program (WIC).
  • Unattended babies (sleeping out of sight and sound of a competent adult) are at higher risk of SIDS and entrapment/smothering accidents. People are better monitors than electronic devices. Babies should always sleep face-up, in a safe container, and within sight and sound of a competent adult for all sleeps, naps and nights – unless they are safely tied on someone’s body or safely in someone’s arms or sleeping next to their sober, nonsmoking, breastfeeding mother on a safe surface. Baby should be lightly clothed (not overheated. One study reported swaddling as an independent risk factor for SIDS. 21).
  • Recommend that parents baby-proof the family bed, even if they think they won’t ever bedshare. Sleep happens, and exhaustion overrules common sense. No thick covers, no toys, no pets, firm clean flat mattress. Most breastfeeding mothers sleep with their babies at least part of the night, and breastfeeding mothers have the lowest rates of SIDS and other sleep-related accidents.12 Accidental bedsharing is riskier than planned bedsharing.22 A side-car attached to the bed can be a good option – baby is close enough for touching and feeding, yet separate enough to avoid rollovers and exhaled breath of smokers. A safe crib for the baby in the bedroom is safer than baby sleeping unattended in another room.
  • Adults should never lie down with a baby on a sofa or in a recliner, even “just for a minute” – the threat of suffocation, entrapment or dropping the baby is high especially when (not if) the adults falls asleep.23 If a sofa or recliner is the only option for sleep, the adult can lean back and tie the baby securely onto their chest with a scarf, shawl or soft carrier so their arms aren’t holding the baby when the adult dozes off.
  • Wearing a baby many hours a day in a soft-tie-on carrier or sling is a great way for everyone to nap, and helps baby’s motor development besides. Baby’s face should be fully visible and her head should be close enough to kiss. This babywearing guide has information on how to safely wear an infant.

The 4 big questions

1. When will the baby sleep through (longer) the night?

Probably not for many months. Welcome to parenthood! (Sorry, biology rules!)

Babies are growing faster in the early months than they ever will, and need food and comfort very often for normal physical, emotional, and psychological development. A famous scientist described the first 9 months of a baby’s “outside” life as the period of “external gestation.24” The best way to get enough sleep is for parents to plan to safely bedshare with their breastfed baby, and take naps with the baby. (see the Safe Sleep Seven and “Sweet Sleep25 for more information.)

Beware of “sleep training” programs, books and advice, which have a long sad history.26 New strong evidence of baby’s biological and emotional needs suggests that babies remain highly stressed even when the parents think sleep training “worked,” with serious long-term negative consequences for the baby. Babies cry because they need to be touched held, fed, rocked, and nurtured, and simply cannot meet their own needs for any of those comforts.

2. When will the mom sleep like she did before she got pregnant?

The research definition of “sleeping through the night” range is inconsistent and arbitrary.27 Parents can make up any definition they want when quizzed about the baby “sleeping through.” A useful (and vague) response: “Of course the baby is a good sleeper.”

3. Will parents ever have sex again?

Beds aren’t the only places where sex can happen.

4. Will parents ever get the baby out of their bed?

Babies who bedshare get their emotional needs met sooner and more fully than those who sleep separately.28 All babies are inconvenient for a while.

Where can parents get more information?

What do you talk about with families in order to prepare them for parenting a newborn? How do you find the balance between providing accurate information and not “frightening” them with the realities of newborn sleep patterns. Have you read this new book? Would you recommend this book to families who are desiring more information about how to provide a safe sleep environment for their breastfeeding newborn? – SM

References

1. Montgomery-Downs HE, Stremler R, Insan SP. Postpartum Sleep in New Mothers and Fathers. Open Sleep Journal. 2013;6(Suppl 1: M11):87-97.
2. Doan T, Gay CL, Kennedy HP, Newman J, Lee KA. Nighttime Breastfeeding Behavior Is Associated with More Nocturnal Sleep among First-Time Mothers at One Month Postpartum. J Clin Sleep Med. 2014;10(3):313-319.
3. Doan T, Gardiner A, Gay CL, Lee KA. Breast-feeding Increases Sleep Duration of New Parents. J Perinat Neonatal Nurs. Jul-Sep 2007;21(3):200-206.
4. Bergman NJ. Neonatal stomach volume and physiology suggest feeding at 1-h intervals. Acta Paediatr. May 10 2013.
5. Rivkees SA. Emergence and influences of circadian rhythmicity in infants. Clin Perinatol. Jun 2004;31(2):217-228, v-vi.
6. Feldman R, Rosenthal Z, Eidelman AI. Maternal-Preterm Skin-to-Skin Contact Enhances Child Physiologic Organization and Cognitive Control Across the First 10 Years of Life. Biol Psychiatry. Jan 1 2014;75(1):56-64.
7. Feldman R, Singer M, Zagoory O. Touch attenuates infants’ physiological reactivity to stress. Dev Sci. Mar 2010;13(2):271-278.
8. Hofer MA. Psychobiological Roots of Early Attachment. Current Directions in Psychological Science. April 1, 2006 2006;15(2):84-88.
9. Ward TC. Reasons for Mother-Infant Bed-Sharing: A Systematic Narrative Synthesis of the Literature and Implications for Future Research. Matern Child Health J. Jul 2 2014.
10. Zhang K, Wang X. Maternal smoking and increased risk of sudden infant death syndrome: a meta-analysis. Leg Med (Tokyo). May 2013;15(3):115-121.
11. Dwyer T, Ponsonby AL. Sudden infant death syndrome and prone sleeping position. Ann Epidemiol. Apr 2009;19(4):245-249.
12. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. June 13, 2011 2011.
13. Moon RY, Fu L. Sudden infant death syndrome: an update. Pediatr Rev. Jul 2012;33(7):314-320.
14. Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. Bmj. 2009;339:b3666.
15. Ball HL, Moya E, Fairley L, Westman J, Oddie S, Wright J. Bed- and sofa-sharing practices in a UK biethnic population. Pediatrics. Mar 2012;129(3):e673-681.
16. van der Vaart H, Postma DS, Timens W, et al. Acute effects of cigarette smoking on inflammation in healthy intermittent smokers. Respir Res. 2005;6:22.
17. Tong EK, England L, Glantz SA. Changing Conclusions on Secondhand Smoke in a Sudden Infant Death Syndrome Review Funded by the Tobacco Industry. Pediatrics. March 1, 2005 2005;115(3):e356-366.
18. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics. March 1, 2012 2012;129(3):e827-e841.
19. Mosko S, Richard C, McKenna J. Infant arousals during mother-infant bed sharing: implications for infant sleep and sudden infant death syndrome research. Pediatrics. Nov 1997;100(5):841-849.
20. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General,; 2011.
21. Richardson HL, Walker AM, R SCH. Influence of Swaddling Experience on Spontaneous Arousal Patterns and Autonomic Control in Sleeping Infants. J Pediatr. Mar 12 2010.
22. Volpe LE, Ball HL, McKenna JJ. Nighttime parenting strategies and Sleep-related risks to infants. Social Science & Medicine. 2012(0).
23. Kendall-Tackett K, Cong Z, Hale T. Mother–Infant Sleep Locations and Nighttime Feeding Behavior: U.S. Data from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation. 2010;1(Fall 2010):27-31.
24. Montagu A. Touching: the Human Significance of the Skin. Third ed. New York: Harper & Row; 1986.
25. La Leche League International, Wiessinger D, West D, Smith LJ, Pittman T. Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family. New York: Random House – Ballantine Books; 2014.
26. Middlemiss W, Granger DA, Goldberg WA, Nathans L. Asynchrony of mother–infant hypothalamic–pituitary–adrenal axis activity following extinction of infant crying responses induced during the transition to sleep. Early human development. 2012;88(4):227-232.
27. Adams SM, Jones DR, Esmail A, Mitchell EA. What affects the age of first sleeping through the night? J Paediatr Child Health. Mar 2004;40(3):96-101.
28. McKenna JJ, Mosko SS. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl. Jun 1994;397:94-102.

About Linda J. Smith, MPH, IBCLC, LCCE, FACCE

© Linda J. Smith

© Linda J. Smith

Linda J. Smith, MPH, IBCLC, LCCE, FACCE, is a lactation consultant, childbirth educator, author, and internationally-known consultant on breastfeeding and birthing issues. Linda is ILCA‘s liaison to the World Health Organization’s Baby Friendly Hospital Initiative and consultant to INFACT Canada/IBFAN North America. As a La Leche League Leader and Lamaze-certified Childbirth Educator, she provided education and clinical support to diverse families over 40 years in 9 cities in the USA and Canada. Linda has worked in a 3-hospital system in Texas, a public health agency in Virginia, and served as Breastfeeding coordinator for the Ohio Department of Health. Linda was a founder of IBLCE, founder and past board member of ILCA, and is a delegate to the United States Breastfeeding Committee from the American Breastfeeding Institute. Linda holds a Masters Degree in Public Health and is currently an Adjunct Instructor at the Boonshoft School of Medicine at Wright State University in Dayton, Ohio. She owns the Bright Future Lactation Resource Centre, on the Internet at www.BFLRC.com.

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

It’s World Breastfeeding Week! Test Your Knowledge of Evidence Based Breastfeeding Information

August 7th, 2014 by avatar
© Annie Stoner

© Annie Stoner

In recognition of World Breastfeeding Week 2014, Science & Sensibility invites you to take this quick little quiz on breastfeeding information to check how up to date you are on current, evidence based breastfeeding practices.  As discussed in our earlier post this week, celebrating World Breastfeeding Week, childbirth educators play a key support role in providing families with accurate breastfeeding information as part of a thorough childbirth education curriculum.

Staying up to date with the newest information can be difficult to do.  But it is imperative.  There are many sources of misleading or inaccurate breastfeeding information available, and students and families should rely on childbirth educators to help with providing the proper resources.  Take our quick quiz to see if you can answer some questions on breastfeeding information that has changed in the past few years. Follow the links provided with each answer if you need more information! Then share in the comments section below what you do to stay current on breastfeeding topics. What are your favorite breastfeeding continuing education resources?  Let us know!

 

Babies, Breastfeeding, Childbirth Education, Newborns , , , ,

World Breastfeeding Week 2014 – Breastfeeding: A Winning Goal for Life

August 5th, 2014 by avatar

wbw2014-logo3August 1-7, 2014 is World Breastfeeding Week and this year’s theme is Breastfeeding: A Winning Goal for Life.  This year’s theme builds upon the Millenium Development Goals (MDGs) developed by the United Nations and global partners.  Breastfeeding plays a critical role in achieving all eight of the MDGs.  The World Alliance for Breastfeeding Action created a dynamic and clear graphic demonstrating how increasing global breastfeeding rates has the ability to impact every single one of the MDGs.

With this in mind, the World Breastfeeding Week theme, “Breastfeeding: A Winning Goal for Life” calls on celebrants to “Protect, Promote and Support Breastfeeding: It is a Vital Life-saving Goal.”  The theme recognizes the critical role that excellent support plays in achieving this goal and childbirth educators are right up there as one of the critical players, as childbirth educators are prepared and qualified to help new families learn about breastfeeding in their childbirth education classes.

Lamaze International supports getting breastfeeding off to a good start with the sixth Healthy Birth Practice: “Keep mother and baby together – It’s best for mother, baby and breastfeeding.”  Your role as a childbirth educator in normalizing breastfeeding, providing prenatal instruction on breastfeeding basics and sharing additional breastfeeding resources for families to utilize after their baby arrives contributes to the Millenium Development Goals with each and every family  you reach.

wbw2014-goals

Childbirth educators, along with doctors, midwives, labor & delivery nurses, lactation consultants, doulas, and others help support families in reaching their breastfeeding goals, and celebrate breastfeeding with every mother and new family they reach. Breastfeeding is a team effort and everyone plays a critical role.

Have you shared World Breastfeeding Week information with your families that are in your childbirth education classes?  Can you recall the times when a family followed up with you and thanked you for the evidence based information that you provided in their childbirth class, helping them to be prepared to breastfeed their baby after birth. What you do matters every day to mothers and babies and that includes the efforts to share accurate information about breastfeeding and breastfeeding resources with your students.  Thank you, childbirth educators, for making a difference. For more information about World Breastfeeding Week 2014, check out the World Alliance for Breastfeeding Action website.

 

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Lamaze International, Newborns, Uncategorized , , , , ,

Kathy Morelli Shares Highlights from the 2014 Postpartum Support International Conference

July 15th, 2014 by avatar

Regular contributor Kathy Morelli attended the Postpartum Support International conference in Chapel Hill, North Carolina this past month.  In today’s post, Kathy shares her thoughts, some big take-aways and checks in with the keynote speakers, who share important messages on postpartum mood disorders with our S&S readers.  We all have a responsibility to increase awareness and treatment options for pregnant and postpartum women.- Sharon Muza, Science & Sensibility Community Manager.

PSI QuiltI want to shout from the rooftops that there are so many well-educated, caring and ethical professionals who are focusing on Maternal Mental Health! I was so fortunate to be able to attend this year’s Postpartum Support International 27th Annual Conference at the University of North Carolina (UNC) campus at Chapel Hill on June 18 – June 21, 2014.

PSI’s theme this year was “Creating Connections between Communities: Practitioners and Science: Innovative Care for Perinatal Mental Health.” It was a wonderful meeting where scholar-practitioners in the Perinatal Mental Health field met and exchanged information and best practices in order to hone their collective craft. Researchers, clinicians and identified survivors met and shared their professional and personal stories. PSI’s outgoing president, Leslie Lowell Stoutenburg, RNC, MS, reports that PSI had its largest attendance ever this year.

The keynote speakers were a group of experienced professionals, researchers and clinicians presenting on clinical, scholarly and advocacy topics: Dr. David Rubinow, of UNC Chapel Hill, Dr. Samantha Meltzer-Brody of UNC Chapel Hill, Dr. Marguerite Morgan, of Arbor Circle Early Childhood Services in Grand Rapids, Michigan, Ms. Joy Bruckhard of California’s 20/20 Mom Project, and Dr. Susan Benjamin Feingold, clinical psychologist, all presented about their work in the different aspects in the field of Maternal Mental Health. Advocate Katherine Stone of Postpartum Progress served as emcee at the Saturday night banquet.

Dr. David Rubinow presented on his team research regarding female hormonal fluctuations and the relationship to postpartum mood disorders in sensitive women. Dr. Rubinow is an internationally known expert in the evaluation and treatment of women with mood disorders that occur during periods of hormonal change. Regarding the team’s research, he states “Our data demonstrate that normal changes in reproductive hormones can produce affective disturbance in a susceptible group of women.” The study (Bloch et al, 2000) examined the role of endocrine factors in the etiology of postpartum depression (PPD) by comparing women with a history of PPD and without PPD. Progesterone and estriadiol was measured at baseline, addback, withdrawal, and folIow-up. 67% of the women who had PPD had a recurrence of significant affective symptoms, including a constellation of depressive and hypomanic affect, while none of the control group experienced significant affective symptoms. This indicates that women who suffer from PPD may have a trait vulnerability that isn’t present in women who do not suffer from PPD.

Dr. Susan Benjamin Feingold, the keynote speaker on Saturday evening, presented on her clinical work around the transformational nature of surviving postpartum depression, documented in her newly released book, Happy Endings, New Beginning: Navigating Postpartum Mood Disorders. Dr. Feingold presented inspirational journal entries from women in her clinical practice. She says: “ In my book, I focus on a new view of the postpartum experience and how this difficult time can be a catalyst for change, personal growth and positive transformation. Postpartum depression can be the opportunity for not only healing, but ultimately, it can be a life-changing event.”

Ms. Joy Bruckhard, MBA, of Cigna, presented on her advocacy work in as one of the founders of the Maternal Mental Health Care Collaborative in California called the 20/20 Mom Project. The 20/20 Mom Project is a national campaign and movement for moms and by moms to create specific pathways to treatment for maternal mental health disorders, to address barriers to mental health care. The 20/20 Mom Project has teamed up with Postpartum Support International, a sister non-profit to launch first-of-a-kind web-based training for clinical professionals with the aim of addressing the shortage of mental health and medical professionals who specialize in maternal mental health. Joy says: “I’m so honored to be a part of this important work. Three years ago, my worlds collided: my training through Junior League, my experience in health care working at Cigna and having had two babies myself (and perhaps mild postpartum depression), and some family experience with mental illness, I felt compelled to step up and do more.”

Dr. Samantha Meltzer-Brody, a psychiatrist at UNC Chapel Hill, presented about the ongoing stigma about using psycho-pharmaceuticals during pregnancy and breastfeeding. She expressed frustration that other medications are readily accepted for use during pregnancy, but that there is an ongoing stigma against using medications that treat the mother’s mental health.

Dr. Marguerite Morgan, LCSW, presented on her successful program with African American women at the Arbor Circle Early Childhood Services in Grand Rapids, Michigan. She emphasized that she drops her “PhD-Dr” demeanor and constantly strives to connect at a human level with the people she serves. She is well versed in Christianity and quotes biblical passages about helping oneself during dark times, thus normalizing the experience of depression to her population in an accessible manner.

The psychodynamic approach to perinatal mood disorders was presented by Ms. Lorraine Caputo, LMFT, which addresses the mental health of women across the lifespan. Research and clinical practice indicates that a woman’s previous life experiences can have an impact on her transition to parenthood. On the lifelong care of a woman’s mental health, Ms. Caputo says: “I believe it’s crucial to help women with a history of trauma to make connections between the past and present in a way that psychodynamic treatment is uniquely poised to provide. The perinatal period is a natural time of enormous change, and in the best of circumstances will cause dysregulation, psychological transformation and re-identifications and dis-identifications with one’s own parents. And, given how entirely a pregnant woman and a postpartum mother surrenders her body to her child, childhood sexual traumas in the mother’s past can be triggered by this intense period of physical and emotional bonding with her baby. A psychoanalytic intervention that involves the development of a coherent narrative about how she was parented, and making connections between unrelenting anxiety, ruminations, self blame, and her past history can free a new mother from self doubt, guilt, and fear that she will not be a good mother. This work is done in a carefully paced way, using self reflection and the relationship with the therapist to help the mother feel safe and her powerful feelings contained and held by the therapist.”

Dr. Kelly Brogan, of Womens Holistic Psychiatry, discussed holistic clinical pathways to reproductive mental health.

Of note was the unique reproductive psychiatric sharing session, where reproductive psychiatrists came together to discuss clinical situations which they have encountered. This session was an extension of the collaborative professional LISTSERV that PSI hosts for clinical member reproductive psychiatrists.

Sessions on Healthy Postpartum Relationships were presented by both Ms. Elly Taylor and Ms. Karen Kleiman, LMFT, of the Postpartum Stress Center. Karen Kleiman has recently published her book, Tokens of Affection: Reclaiming Your Marriage after Postpartum Depression, informed from her extensive clinical experience with postpartum couples. Ms. Kleiman presented her overarching framework for treating distressed postpartum couples, identifying 8 tokens to be cultivated in the therapeutic encounter. One of the tokens she refers to as a “Token of Affection.” Ms. Kleiman notes: “Recovery from postpartum depression does not happen overnight, thus, creating a lag between the crisis and a sense of well-being for the couple. During this transitional period both partners are anxious to return to normal while they are simultaneously challenged by buried negative emotions and unmet expectations. Tokens of Affection are gift-giving gestures on behalf of the relationship. As a reparative resource, the Tokens lead the way toward renewed harmony and reconnection.”

Elly Taylor remarks: “It’s common for couples – even happily married ones – to find that the bond between them becomes stretched following the birth of their baby. This comes as a shock for most and increases the risk for perinatal mood disorders for some. But prepare for this, and its possible not only to protect the bond, but build on it as the foundation for family.” She has recently published her book about the postpartum couple’s experience called, Becoming Us, in the United States.

Included here are some closing thoughts from the incoming PSI president, Ann Smith, RN, MSN, CNM:

“PSI is the original and leading organization dealing with perinatal mood disorder which we now know affects approximately 1 in 7 moms. It’s the leading complication of childbearing. All women can be affected regardless of age, race, socioeconomic status and whether the pregnancy was wanted. When treated promptly and by someone who has familiarity with these disorders, moms get better quite quickly. PSI has training programs nationwide which train providers in evidence based treatments. Many women need a combination of medication and talk therapy to get better as quickly as possible. There are a number of medications which have been proven safe for pregnancy and breastfeeding. Support groups are also helpful.

PSI wants everyone to remember three things:

You are not alone, you are not to blame, with help you will be well.

For assistance, call the PSI Warmline at 800-944-4PPD or visit online

References

Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Nieman, L., & Rubinow, D. R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. American Journal of Psychiatry157(6), 924-930.

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Babies, Birth Trauma, Childbirth Education, Guest Posts, Infant Attachment, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Trauma work , , , , , ,

Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety“ that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

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