Science & Sensibility

Maddy Oden is not an imposing woman at first sight.  She looks wise and slightly bohemian like many of the women present at the Healthy Mothers Healthy Birth Summit.  She walks to the front of the crowded but silent conference room, quietly lights a candle, and explains that the light is for her daughter Tatiana, granddaughter Zorah, and all other women lost during childbirth.

She then looks across the audience, the expression on her face seeming to continue “…and we’re going to do something about this right now.”  She sits down as a blessing is read for all present, quietly, but radiating lightning bolts of resolve that seem to echo through the whole audience.

And then, we got to work.

First to present was Nan Strauss from Amnesty International.  Strauss shared research from the well-known Amnesty International report, Deadly Delivery: the Maternal Health Crisis in America. Among many other facets surrounding the maternal mortality issue, Ms. Strauss explained how Amnesty holds maternal mortality to be a human rights issue, as people of color and those with low income are disproportionately affected.  She also shared Amnesty’s belief that all people have a right to [good] health (as delineated in 1948′s Universal Declaration of Human rights sent by Amnesty International to the United Nations) and also the conviction that most of these maternal deaths are preventable.  Strauss’s presentation was research-rich, well-cited, and contained several  jolting case studies that brought many in the audience to tears.

Following Strauss was Jennie Joseph, whose presentation “Bridging the Gap of Racial Disparity in Birth” was marked by Joseph’s ebullient humor as well as a passionate proposal for a more holistic model of maternal care (“The JJ Way”) similar to the Centering Pregnancy approach.  “It’s amazing that a body of water can make such a difference,” Joseph (who is originally from Britain) wryly observed. “I got off a plane – that’s all I did – and I was in the land of teeny tiny pelvises that don’t work and huge babies that somehow can’t fit.”  Joseph provided a thorough explanation of her “JJ Way,” which places the emphasis in maternal healthcare on forming families and involving partners in prenatal care with the goal of eliminating the currently vast racial disparities in perinatal care.

A collective discussion was held next, addressing the topic: “What is Broken?” and the panel was composed of Strauss, Joseph, Christine Isaacs MD, a representative from ACOG, and Lamaze’s own Barbara Hotelling and Debra Bingham among others.  Dozens of proposals were made from the panel and audience alike with the following being a representative sample of the Summit’s answers:

* not enough midwives / other practitioners

* sexist culture

* not enough attention to mother-baby dyad

* poor access to quality healthcare

* not enough data transparency / accountability

* inadequate RN staffing, appreciation

* inadequate communication between healthcare team

* vast disparities in care

* closed community – the natural birth community tends to preach to itself

* not enough positivity

 

Following the group’s shared answers, the question was posed “How do we fix it?”  The following are representative answers from those present:

* more midwives

* baby steps at a political level

* know your community’s statistics

* grassroots advocacy

* better community relationships

* more resources (federal funding, healthcare workers)

* more peer reviewed research on perinatal mortality

After the panel discussion and input, Ms. Basmah Karriem from the International Center for Traditional Childbearing – an organization dedicated to infant mortality prevention and indigenous midwife promotion – shared a statement of solidarity from Shafia Monroe, the organization’s president.  All present then broke out into small work-groups to answer the question “How do we define Maternal Mortality?”  Most groups began with clinical definitions similar to that of the World Health Organization (“the death of a woman while pregnant or within 42 days of termination of pregnancy…”)1 and then moved outward with their definition, including impact on communities, individuals, and implications for the American healthcare industry.

After lunch, Ina May Gaskin gave her eagerly-awaited presentation “Maternal Mortality and the Safe Motherhood Quilt.” Gaskin related many anecdotes of the women featured on the quilt .  When sharing the mothers’ stories, Gaskin spoke extemporaneously and as though she knew every woman personally.  “Lemme tell you about Angela here,” she would say to illustrate a point.  Gaskin also raised questions about factors not commonly associated with maternal mortality such as primarily assisted reproductive technology and higher-order multiple pregnancies.

In the Panel Discussion following, Gaskin stressed the importance of getting insurance and malpractice concerns out of the picture.  “Who invited these guys in?” she asked in her earthy mid-western cadence.  “We need to elbow them back out of here!” she exclaimed to a room full of chuckles.  Regarding reform of the mortality reporting system, Gaskin reminded the audience that “it’s complicated, but we can’t get disheartened.”  She also reminded all present to focus on the power of loving, kind human relationships to enable healthy birth outcomes.

The Healthy Mothers Healthy Birth Summit of 2011 was a complex and emotional affair, attended by an audience both impassioned and clinical.  The end of the summit was marked with hope as all present discussed ways to continue reforming birth culture in the United States so that every future mother and baby will be safer throughout the childbearing process.

 

Posted by:  B. Kristine Burneko LCCE, BSIN who is the mother of Loudoun Lamaze as well as two boys, 2 years and 6 months.  She holds a Bachelors of Science in Health Promotion from George Mason University, and received her Lamaze Certification from the University of Pittsburgh Medical Center program.

[Editor’s Note:
On April 10 at 2:00pm, several members and attendees of the Summit gathered at the US Capitol for a rally surrounding Gaskin’s Safe Motherhood Quilt project.  To read about the rally, go here.]

 

References:
1 http://www.who.int/healthinfo/statistics/indmaternalmortality/en/index.html

 

 

 

Amnesty International, Childbirth Education, Deadly Delivery, Healthcare Reform, Maternal Mortality, Uncategorized Amnesty International, Cenetering Pregnancy, childbirth education conference, Deadly Delivery, Healthy Mothers Healthy Birth Summit, http://www.scienceandsensibility.org/?p=2291, Ina May Gaskin, International Center for Traditional Childbearing, Jenny Joseph, Kristine Burneko, Loudon Lamaze, Nan Strauss, Safe Motherhood Quilt Project, the JJ Way

Wednesday night, I attended my first childbirth education class as a student, in nine years.  My goal: experience childbirth education as a student again.  What’s not to learn by revisiting the classroom as a consumer?

Upon arriving at the community lecture room in our local hospital, each class participant was met with a copy of InJoy Birth & Parenting Education’s Understanding Birth workbook—a series which is accompanied by the website, SeeWhatYouRead.com.  This website is a great resource, acting as a supplement to the workbook and in-class discussions and video observations.  Many of InJoy’s video segments on birth and the perinatal period are available for student/teacher viewing.  Being a Log In protected site, each workbook has a PIN printed on the back—granting access to paid programs/students, only.

The instructor began with a 20 minute introduction to the class, including herself and her background as a labor and delivery nurse at the same facility where the classes take place, as well as a Lamaze Certified Childbirth Educator for the past three years. When it was the rest of the group’s turn, we went around the room in typical opening class format, introducing ourselves, and sharing the particulars of why we were there—including the three of us who are observing:  myself, a doula and a nursing student—and details about pregnancies, maternity care providers and sex of the expectant babies (if known).  All six couples had already found out the sex of their baby: 4 girls and 2 boys.  It seems the art of waiting for the surprise at the end of the journey is becoming a lost one.

The remainder of the class consisted of a body mechanics demonstration by a staff physical therapist, discussion on the head-to-toe physical (and mental!) changes that accompany pregnancy, and highlights on important elements of nutrition for the third trimester.

Some folks will caution against the milieu induced by bringing hospital staffers into childbirth ed. class.  By locating the classes at the same  facility  in which a woman will subsequently give birth (any facility, for that matter), you risk sending her the message, “This is how we ‘do’ birth here.”  Add to that environment, medical providers talking about (shall we say, “promoting”?) their services, and a skeptical class participant might leave the experience feeling coerced.

In the compilation of cross-cultural essays, Childbirth and Authoritative Knowledge (R. Davis-Floyd, C. Sargent, ed., 1997), the issue of authoritative knowledge as a means of altering the birth process and experience itself is addressed—looking at birth and its preceding preparations from sixteen different societies and cultures around the world.  From Ellen Lazarus’ essay, What Do Women Want?  Issues of Choice, Control and Class in American Pregnancy and Childbirth:

“In a study looking at childbirth education and childbirth models, Carolyn Sargent and Nancy Stark (1989) found that their informants, mainly middle class, received “ideological messages” from both health professionals and relatives but that patients “bought” the medical model…Margaret Nelson makes the point that the reason a middle-class model of childbirth has dominated much of the literature is that much feminist writing focused on the natural as a contrast to medicalized birth (Oakley 1986; Romalis 1981).  She writes, however, that the middle-class model is coming closer to a hospital birth, catering to a clientele for which the hospitals compete.”

In her June, 2000 Medical Anthropology Quarterly article, (Volume 14, Issue 2, pages 138–158) Preparing for Motherhood: Authoritative Knowledge and the Undercurrents of Shared Experience in Two Childbirth Education Courses in Cagliari, Italy, Suzanne Kelter discusses authoritative knowledge in terms of the childbirth education setting.  She argues that, while institutionalized childbirth education courses have the potential to be singularly authoritative, the encouraged interaction, and sharing of experiential knowledge between class participants can de-medicalize the overall take-home  message. “When so [legitimized], women’s experiential knowledge can provide an alternative to the biomedical knowledge that sometimes compromises their subjective agency and personhood as they become mothers.”

In this week’s class I attended, I think the presence of “authorities” (L&D nurse who also happens to be a mother of four young children and a physical therapist—mom to three) proved beneficial, particularly due to a large emphasis on student participation.  The P.T. spoke emphatically about exercises pregnant women can and should be doing in their last trimester to prepare for birth (squatting, lunges, Kegels, hip abductor stretches, abdominal strengthening) and measures she and her partner can do both now and after the baby’s arrival to protect the low back from injury (such as when improperly lifting a baby-containing car seat).   She guided the willing group through cat/cow pose on all fours, the aforementioned stretches and strengthening techniques, and even taught moms and partners how to assess for the presence of a diastasis recti.

The focus on nutrition was well-delivered, garnered a decent amount of group participation via question/answer format, and seemed to maintain the eager students’ attention.  Basing a justification for attention to nutrition “this late in your pregnancy” on the still-developing needs of the fetus (building iron stores for first six months of baby’s life; taking in adequate amounts of calcium so baby doesn’t leach calcium stores from mom’s skeletal structure; adequate water consumption to prevent dehydration-related uterine hyper-irritability…) seemed to hit home with the audience.

Of concern, no less than 10 minutes into the class, the instructor explained the primary motivation for developing the hospital’s program, now five years old.

“There were lots of childbirth education programs in the community that were basically teaching people to be afraid of what happens here in the hospital.”

Having been one of those private childbirth educators, I sat back quietly—not sure if I should be offended at the broad statement, or congratulatory of her correctness.   I know several local CEs (and doulas) who would respond, “You’re darned right we’re teaching them to be afraid.”  Others, like me, would prefer the party line, “We’re teaching them to be fully informed.”  Either way I looked at it, I still wondered if the underlying message was the same:  In an “us” versus “them” system, we are competing for the same clientele, rather than working together to reach them, hoping to be the first to share our knowledge—delivered authoritatively, or not.

I’m hoping to do some bridge building while participating in this class.  After all, the class instructor and I:  we’re both LCCEs.  We’ve got a great thing in common.

Posted by:  Kimmelin Hull, PA, LCCE

Kimmelin Hull Authoritative Knowledge, Childbirth Education, Continuing Education, Films about Childbirth, Uncategorized authoritative knowledge, exercises for pregnancy, hospital childbirth ed classes, Kimmelin Hull, Lamaze Certified Childbirth Educator, Lamaze Classes, nutrition in late pregnancy, physical therapy in pregnancy, private childbirth ed classes

Preterm birth estimates are 5-13% and the principal cause of morbidity and mortality for newborns¹.  70% of spontaneous preterm births occur with preterm labor and preterm prelabor rupture of fetal membranes². While medical science continues to examine diagnostic and treatment protocol, the etiology of preterm delivery is still unknown².  A 2009 collaborative paper between ACOG and the APA noted  that 14% to 23% of pregnant women experience depression or anxiety in pregnancy, and that in 2003 13% of pregnant women took an antidepressant during pregnancy 3.   There is a growing body of evidence demonstrating a relationship between depression and an increased risk of preterm birth.^4,5,6,7,8

Featured Study:
Antenatal Depressive Symptoms and Preterm Birth: A Prospective Study of a Swedish National Sample ⁹ offers a study with a large sample size, well-validated screening tool, and solid statistical data analysis.  The conclusion: “Pregnant women reporting antenatal depressive symptoms are at elevated risk of preterm birth.”

Participants:
The Swedish Medical Birth Register (SMBR) provided the ability to track gestational length for 2,904 women from their first prenatal visit to birth. The average gestational age at time of recruitment was 16 weeks. Of the 608 prenatal clinics in Sweden, authors received a 97.5% (n=593) participation rate. 5,150 women were assessed for eligibility; 4,600 women designated eligible. Of that group, 3,113 women signed informed consent; 3,061 women were enrolled in study, and authors received 2,904 completed questionnaires.

Variables and Screening:
The outcome variable, preterm birth, was defined as delivery prior to 37 weeks gestation. Depressive symptoms as a predictor variable were scored using the Edinburgh Post-natal Depression Scale (EPDS) ¹⁰. The EPDS is the gold standard, self-reporting scale for sensitivity and specificity for depressive symptoms as listed in the Diagnostic and Statistical Manual of Mental Disorders¹¹.  Usually, a cutoff score of ≥15 is used, but in comparison to two other Swedish studies using a lower cutoff (≥10), the authors used a ≥12 cutoff to most accurately validate the Swedish population.

 

Analysis:
With the assistance of the SPSS¹², authors applied multiple logistic regression, and bivariate analyses. Results demonstrated an estimated risk of preterm birth, for women who had antenatal depressive symptoms of a score of ≥12 on EPDS, as significantly increased: (OR 1.56; 95% CI: 1.03-2.35). The risk is threefold among young women (<25 years old).

 

 

Authors reiterated current understanding of possible underlying factors “behind depressive symptoms” including increased inflammation in pregnancy leading to preterm birth^13,14,15 and increased HPA activity resulting in over production of cortisol, leading to preterm birth¹⁶.

 

Conclusion:

What is stunning here is that even moderate levels of depressive symptoms (≥12) elevate the risk of preterm birth. And that the risk is much greater for women younger than 25.  Clearly the relationship between depression and inflammation, and HPA axis-overdrive will offer future insight into the etiology of preterm birth, and shed light on the reproductive biology of depression/anxiety.

We incorporate evidence-based research regarding risks of pre-term birth in our childbirth classes: prenatal vitamins, exercise, smoking cessation, pre-eclampsia, and nutritional guidelines are covered.   Are we covering depression/anxiety in pregnancy?  Are we training the next generation of childbirth educators and doulas about screening, symptoms, risk factors, and effects of this major pregnancy complication (as listed by March of Dimes)?  What might be most important, are we supporting those who ask for assistance in bringing this to the forefront of maternal health advocacy? This study is yet another demonstration of the need for increased awareness of the effects of untreated perinatal mental health.  Just as we use evidence to support our advocacy of natural birth, and VBAC, why not mental health– when it is demonstrated over and over to be a risk factor for preterm birth?

Universal screening for perinatal depression/anxiety is happening, with ACOG & AAP recommendations and practices in place. I would like to suggest that the universe includes childbirth educators and doulas—and we should claim our rightful place at the table and begin to participate in this matter as first responders.

If not now, when? And on a deeper level, why not?

For more information regarding the role of inflammation and HPA, I highly recommend the work of Michael Lu, MD, MPH http://www.harpercollins.com/author/microsite/about.aspx?authorid=35261

Get Ready to Get Pregnant: Your Complete Pre-Pregnancy Guide to Making a Smart and Healthy Baby

 

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

[Editor's note:  Go here to read a related article, posted this week on MSNBC.com regarding antenatal depression and its effects on mom and baby.
For references pertaining to Ms. Karraa's post, go here: References_walker_antenatal depression and preterm birth post.]

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Walker Karraa Uncategorized

At Childbirth Connection, one of our mantras is: A high-quality, high-value maternity care system is within reach, but none of us can do it alone. The Transforming Maternity Care “2020 Vision” and “Blueprint for Action” reports, released last year, involved intense collaborative work by all stakeholders – from delivery system leaders, providers, and consumers to health plan and purchaser leaders, liability insurers and quality experts. But these consensus documents are just the beginning. The devil is in the details, and much more work is needed to implement the Blueprint’s recommendations and continually refine quality improvement efforts.

To foster and accelerate implementation, Childbirth Connection just launched a new Transforming Maternity Care web site. Whereas ChildbirthConnection.org offers evidence-based information to women and health professionals to aid decision making, the Transforming Maternity Care site addresses system reform. We thought about four major factors that could get in the way of our collective ability to seize unprecedented opportunities to effect real change, and set out to offer solutions.

Problem: The 2020 Vision and Blueprint for Action are robust but dense and may be hard to digest at once.

Solution: This problem was easy to address. The Vision and Blueprint now each have home pages of their own, and the content is delivered in smaller chunks in both HTML and PDF. Want to know about how performance measurement fits into maternity care system improvement? Go straight to the performance measurement page. From there you have the key messages available at a glance or you can drill deeper to understand the problems in the current system and read the in-depth recommendations and action steps. You can also download the full-text of that Blueprint section (pdf). Also at your fingertips: watch a webinar, access a bibliography of studies, reports and other background materials, and search for projects in our Transforming Maternity Care Directory that address performance measurement.

Performance measurement isn’t your cup of tea? Just pick any of the 10 other focal areas (like care coordination, informed decision making, or liability reform) and drill down the same way.

Problem: Many individuals and organizations want to help fix maternity care, but stakeholders may not know where to begin.

Solution: Behold: the Action Center. No matter what kind of stakeholder you are, there’s something you can begin doing today to help improve maternity care. We’ve pulled together the most promising opportunities for consumers, health professionals, hospital and health system administrators, purchasers, and quality experts.

Problem: Energy and resources are easily wasted reinventing the wheel.

Solution: There are many examples of high-performing maternity care services and successful quality improvement efforts. But it can be difficult to translate effective models into widespread practice. What’s more: all change is local – stakeholders need tools and support to adapt innovations to their own settings and populations.

To foster, coordinate, and accelerate maternity care quality improvement, we put the tools and resources in one place and set up a way to connect individuals and organizations with common interests. The site features a directory of quality improvement projects that users can browse by Blueprint area or by quality improvement strategy. Are you improving maternity care quality where you live or work? Add your project to the directory.

Other resources include a list of quality improvement toolkits, links to obstetric and perinatal safety courses for health professionals, a directory of quality collaboratives, and a bibliography of the quality improvement literature.

One stop shopping!

Problem: Data to track and improve maternity quality are collected by many different agencies and reported on many different web sites.

Solution: We’ve created a Data Center where you can find statistical reports, interactive maps, and raw data files to help understand and improve maternity care quality. The data center is where you’ll find Childbirth Connection’s Listening to Mothers surveys, our continually-updated Facts & Figures page, and cost and payment data. We’ve also collected all provider-, facility-, and state-level maternity care data that we know is available, and provided links in one place. Last but not least, the data center includes our interactive maternity care map from Mapping Health, the winner of Childbirth Connection’s Health 2.0 Developer Challenge.

We hope these resources help and inspire you to make change. If there is a quality improvement toolkit or resource that you think should be listed on the site, please let us know. If you have any other feedback about the new site, contact me at romano@childbirthconnection.org. And don’t forget, if you are involved with a quality improvement project, there’s someone else who wants to know about it, and might even want to replicate it. Please fill out our project submission form to share your story.

Posted by:  Amy Romano, CNM

Amy Romano Uncategorized Amy Romano, Childbirth Connection, maternal, maternity care quality, maternity care systems, quality improvement, Transforming Maternity Care

Editor’s note:  In this guest post from Lamaze International’s Debby Amis, we receive an excellent overview of the new Lamaze Study Guide.  The Study Guide is accessible on Lamaze’s website and is available in both English and Spanish.  Additionally, for those approaching certification for the first time or renewal, an examination preparation course is accessible online here.

 

Last spring, a group of Lamaze leaders met in Texas to revise the Study Guide for the Lamaze Childbirth Educator Training Program. Organized around the competencies of a Lamaze Certified Childbirth Educator, the “old” Study Guide contained over 700 pages with redundancies because topics appeared under more than one competency. For instance, you could find breastfeeding topics and references in almost every competency. We were told that more than one student burst into tears upon seeing the size of the Study Guide. On the other hand, recent students also told us that the Study Guide was a fabulous resource that prepared them perfectly for the Lamaze Certification Exam. Many students told us that the Study Guide is an important resource in their childbirth libraries. In addition to updating the Study Guide, our goal was to reorganize it to minimize duplication and cut its size, yet retain a comprehensive foundation for the new childbirth educator.

We invited two newly certified LCCE educators, Kirsten James and Jeanie Portinari, who gave us direction for our meeting. Kirsten told us that, as she was reading through the Study Guide, she wondered if many topics and references were critical knowledge or just something someone thought it would be “nice to know.” Throughout the weekend, our litmus test for topics and references was, “Is this vital information or is it nice to know?”

We reduced the core (required) books for the Lamaze Childbirth Educator Program from ten to four. The new core books are:

1. The Official Lamaze Guide – Giving Birth with Confidence (second edition) by Lothian & DeVries

2. Pregnancy, Childbirth, and the Newborn, 2010 edition, by Simkin, Bolding, Keppler, Durham, & Whalley

3. Prepared Childbirth – The Educator’s Guide, 2011 or current edition, by Amis &Green

4. A current, good book on breastfeeding

We then organized the Study Guide around topics into the following six modules:

 

I. Changing the World of Birth

II. Professional Role of the Childbirth Educator

III. Promoting a Safe and Healthy Pregnancy

IV. Promoting a Natural, Safe, and Healthy Birth

V. Healthy Baby, Breastfeeding, and Early Parenting

VI. Teaching

Because each module focuses on a specific topic, it is much easier to navigate the new Study Guide. For instance, all the breastfeeding topics and references are in Module V – Healthy Baby, Breastfeeding, and Early Parenting. The six Healthy Birth Practices are highlighted in Module IV.

Each module has objectives, core content (topics), core reading and learning activities, and an evaluation section. In addition, there are “bonus” features such as brief summaries on important topics (ie. informed decision-making) and several book reviews.

Several years ago, the Lamaze Study Guide went online. When you read the Study Guide on your computer screen, the various components are marked by colorful icons. Links are provided to all the core journal articles. There are also links to the core reading on the Web.

Each module contains all the core articles (other than those on the Web) for that module.

We didn’t want to eliminate the “Nice to Know” references. Our students come from a wide variety of backgrounds from elementary school teachers and massage therapists to doulas and nurses. Each student has unique learning needs depending on her education and experience. We pulled out all the “Read, Learn, and See More About It” references and put them in a separate Appendix. The “core” reading and learning recommendations are no longer overwhelming, yet there are plenty of up-to-date resources in the Appendix for the student who needs or wants to learn more about a particular topic. There is a second Appendix with the forms for the learning activities required by some Lamaze Accredited Childbirth Educator programs, such as birth observations. Even with two Appendices, the 2011 Study Guide is about 35% smaller than the previous version, now a little under 500 pages.

Each time that a new edition of William’s Obstetrics is published, I order one. Some of the information is the same from edition to edition, but it is important to me to read the new research and recommendations from the prestigious University of Texas Southwestern Medical Center. In the same way, if it has been a while since you have read or referred to the Lamaze Childbirth Educator Program Study Guide, you may want to order the 2011 online copy to see the current foundation of knowledge for childbirth educators. I think you will be impressed.

 

The 2011 Lamaze Childbirth Educator Study Guide Committee included Debby Amis, Beth Day, Elena Carrillo de Reyes, Joyce DiFranco, Caroline Donahue, Sharron Gibbs, Jeanne Green, Judy Lothian, and Teri Shilling.

Note: If you want to print a hard copy of the Study Guide, there is a large file on the Study Guide webpage that you can use to do so. If you have access to a duplex (prints both sides of the paper) printer, you can print the Study Guide yourself. Otherwise, send it electronically to a print shop such as FedEx Office. However, before sending it to FedEx Office, we recommend that you to apply for the Lamaze FedEx Office discount card. (Just follow the directions in the “Members Only” section of the Lamaze website). If you have your Study Guide printed at a commercial print shop, request that they print it in black and white on both sides of the paper using standard copy paper. You can have it 3-hole punched so that you can put it into a binder or you can have them bind it.

 

 

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