Try being a primary care provider treating a pregnant woman who is on antidepressants. Dr. Michael Klein’s recent S&S post [about his newly published research] aptly considered the power of attitudes and beliefs to shape practices and maintain problematic paradigms. The same attitude-driven care dynamic is alive and well in the ongoing battle to understand perinatal mood disorders, and how to treat these disorders in pregnancy.
Primary care physician’s attitudes and practices regarding antidepressant use during pregnancy: A survey of two countries (Bilszta, Tsuchiya, Han, Buist, & Einarson, 2011) explored how lack of practice guidelines, and conflicting and confusing data makes it “difficult to provide definitive evidence-based information” (p. 71). The study explored the primary care physician’s beliefs about perinatal depression as evidenced in their decision-making to continue or discontinue the use of antidepressant medication during pregnancy. In addition, the authors surveyed PCP’s attitudes from two developed countries, Australia and Canada, where physician awareness of perinatal depression has been increased (Bilszta, et al., 2011, p. 71).
Study Snapshot: The Abstract
Little is known about the practices of primary care physicians regarding the prescribing of antidepressants during pregnancy. An anonymous survey was administered to a group of non-randomly selected Australian general practitioners (n=61 out of 77) and randomly selected Canadian family physicians (n=35 out of 111) (Canada…what’s up?). Responses to a hypothetical scenario and questions regarding beliefs about the use of antidepressant medication during pregnancy were collected. Physicians from both countries feel strongly that antidepressant use during pregnancy is a decision complicated by conflicting reports of safety and risk. (Bilszta, et al. 2011, p. 71)
Care providers make decisions—continue or discontinue medication in pregnancy. Making this decision is riddled with confusion over conflicting literature, fear of legal liability, and influenced by patient concern. Care providers overwhelmingly consider and are influenced by patient concerns in decision making (Canadian FP’s 82.8% vs. 95% of Australian GP’s). Keeping that in mind, take a look at the trends in similarities and differences regarding beliefs and attitudes:
Similarities in attitudes, concerns
Perceived levels of misinformation about safety of antidepressant medication in pregnancy: (Australia 74.6% vs. Canada 82.1%)
Pregnant depressed women should be treated differently from nonpregnant depressed women (Australia 53.3% vs. Canada 48.3%)
Concerns over legal liability (Australia 55% vs. Canada 55.2%)
Differences in perceptions and confidence
Perceived safety of antidepressants for mother during pregnancy (Australia 41.7% vs. Canada 82.8%).
Perceived safety of antidepressants for fetus during pregnancy (Australia 10% vs. Canada 48%).
Confidence in giving advice about antidepressant use during pregnancy (Australia 33.3% vs. 57.1%).
Are you positive?
The quantitative data regarding benefits and risks of antidepressant use in pregnancy is conflicting. Bilszta et al., (2011) presented one example of how conflicting data, concern for patient and legal liability, and shaky care guidelines creates a perfect storm for lack of care provider confidence. Decision making in this atmosphere is difficult at best, injurious at worst. From a strictly positivist perspective, it is easy to just dig our data-based heels in and proceed to pick apart studies, methods, sample size, statistical significance and eventually talk treatment until we get mad at each other. But I argue there is something else here—there is potential. From a postpositivist perspective, the issue brought to light by Bilszta et al. (2011), and by Dr. Klein, is the nature of how care providers attitudes manifest (that’s us, too). In essence, there is as much, if not more, to glean from unpacking the nature data-driven attitudes, as there is from individual data present.
“Our perceptions about reality are dependent on the beliefs that we hold about it, belief-dependent realism. Once we form beliefs and make commitments to them, we maintain and reinforce them through a number of powerful cognitive biases that distort our percepts to fit belief concepts.” (Scientific American, July, 2011 p. 85).
Unpacking how attitudes are collectively created, birth advocates included, we will begin to shift the paradigm from “What are they doing or not doing to disadvantage childbearing women?” to “How are WE co-creating this reality and how do we change it”?
Walker’s note: The last author on this study, Adrienne Einarson, has published prolific empirical research on teratogenicity issues of medication in childbearing and breastfeeding women. Hearing her speak was a pivotal moment in my career, and in deconstructing my own paradigms. I will always be tremendously thankful for that, and for her. Her decades of research at Motherisk merits recognition. She has devoted her career to pregnant and breastfeeding women, could research circles around the lot of us —and speaks truth to power with humor and tenacity that would make any advocate proud.
Posted by: Walker Karraa, MFA, MA, CD (DONA)
Bilszta J. L., Tsuchiya S., Han K., Buist, A. & Einarson, A. (2011). Primary care physician’s attitudes and practices regarding antidepressant use during pregnancy: a survey of two countries. Archive of Womens Mental Health 14, p. 71-75.
Shermer, M. (2011). The believing brain: Why science is the only way out of the trap of belief-dependent realism. Scientific American, July.
The goal of Lamaze “Healthy Birth Practice #6, Keeping Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding” is to encourage and support mothers so they may confidently insist that they not be separated from their newborns, and be allowed to have ample opportunity for skin-to-skin contact without delay or interruption, as recommended by a multitude of sources concerned with infant and maternal health.
Dr. Lennart Righard’s seminal study1, published in the Lancetin 1990, gave rise to his famous video, “Delivery Self Attachment”2, which illustrated parts of that research. It shows babies who, when left undisturbed on their mothers’ bodies immediately after birth, find the breast by themselves, crawl to it and suckle with competence. It observes also those babies whose abilities are either impaired or negated because of exposure to intrapartum meds, separation from their mothers after birth, or both.
“Newborns have a great need for love which makes a separation between mother and child most unfortunate”3, Lennart is quoted as saying, poignantly, in a blurb on the packaging of his video. A banner below that quote, set in 16-point type and caps, proclaims “THIS SIX MINUTE VIDEO WILL CHANGE PROTOCOLS!”
It is ”unfortunate” indeed that many mothers still experience resistance to this best-evidence protocol; hospital staff and caregivers still whisk newborns away for routine procedures, processing and observation after just a few minutes of time with their mothers. As with so many maternity-care practices, the protocols that Righard thought with certainty would change, are still in place, even as the evidence for keeping mother and baby together mounts. Some state Departments of Health, as that in Ohio, have got it right, and officially recommend skin-to-skin. That state prints and distributes cards for its WIC program that read, in part: “Hold me, Mom. Babies who are held skin-to-skin on their mother‘s chest right after birth are happier and less likely to cry, are more likely to latch on and [sic] breastfeeding well, have better heart rates, have better temperatures than under a warmer, have better blood sugars, burn less [sic] calories than under a warmer. So, be sure to tell your doctor and the hospital nurses that you want to hold your baby for at least the first hour after the birth, skin-to-skin(baby naked, not wrapped in a blanket). That‘s the best way to introduce your baby to the world”4. (Emphasis mine.) How can we account for the fact that a mother is advised by a government agency to “be sure” to tell her doc and staff to give her best-evidence care? Even for this well-documented and uncomplicated course of action, we cannot count on our caregivers to act reliably in the interests of mother and baby. Again, a Healthy Birth Practice can be read as a subtle warning: Do not let them take your baby from you for the first hour!
Mothers have always needed to keep their babies with them, and supporting evidence for that urgent desire has been around for quite a while. In 1979, Michel Odent proposed, in a theory and review article on human ecology, and under the aegis of his Primal Research Center, that the natural ecology for an infant is to be skin-to-skin (S2S) with the mother. The Human Ecolog deals with “primal” health, a branch of epidemiology that brings together studies exploring correlations between what happens during the primal period (fetal life, perinatal period and the year following birth) and what occurs later in life in terms of health and personality traits. The treatment of mother and newborn as an inseparable dyad is the basis for those studies and can be found compiled in the Primal Health Research Data base 5.
With the understanding of what is best for the “primal” health of the newborn, and in light of the wisdom of Healthy Birth Practice #6, the Baby Friendly Hospital Initiative of the WHO and UNICEF very specifically and unequivocally advises that mothers and infants remain together 24 hours a day. As of May 2011, out of 3,000 or so hospital maternity centers and free standing birth centers in this country, only 110 have achieved the status of Baby Friendly. No wonder women must be advised and exhorted to ask or demand treatment that should be just pro forma in every LDR. Why must women spend precious energy and focus during labor to advocate for best-evidence care for themselves when that kind of care should just be expectations met? Period.
Kangaroo Care, “a universally and biologically sound method of care for all newborns,” 6 incorporating S2S, breastfeeding and support of mother and baby, has become a standard of care in many NICUs. While there is no citation to back up that statistic, Wikipedia represents that fully 82% of NICUs in the US practice KC. That is not surprising, given the wealth of studies going all the way back to 1979 that show how effectively KC helps at-risk babies i.e., improving and normalizing vital signs, stabilizing breathing and heart rate and normalizing glucose and stress levels. Many studies can be accessed at the kangaroo care website: http://www.kangaroomothercare.com. Kangaroo Care babies have been shown to have significantly higher scores in visual and auditory orientation, alertness, cuddliness, self-quieting, attention and state regulation, and higher scores at 6 months on the Infant Temperament Questionnaire than standard-care infants. Kangaroo care has been shown to promote neonatal behavioral organization and enhanced developmental outcomes through the first year of life. 7Is it such a stretch to extrapolate that practice to all term healthy newborns whose need for their mothers is just as acute as that of those in NICUs?
There are some fascinating studies about interactions between mother and baby immediately after birth that investigate “the ‘smellscape’ of mother’s breast: the effects of odor on neonatal arousal, oral and visual responses”.8 Here are just a couple of observations from a multitude of studies available: “volatile compounds originating in areolar secretions or milk, release mouthing, stimulate eye-opening and delay and reduce crying in newborns”.9 “The odor of human milk is more attractive to human newborns than formula milk…independent of postnatal feeding experience.”10
The skin-to-skin interactions between mother and babe are maturational for newborn; the contact stimulates the vagal nerve, causing increased growth in size of the villi in the newborn gut, which provides a larger surface area for the absorption of nutrition. Nancy Mohrbacher, author and breastfeeding expert, in her article “Rethinking Swaddling” 11 has pointed out the differences between the infant held skin-to-skin and those who were wrapped and held by their mothers. She cites studies showing that swaddling delays the first breastfeed and leads to less effective suckling, greater weight loss, and more jaundice. Routine swaddling has negative effects on the infant whether in the hospital or at home.
In the main, Healthy Birth Practice #6 addresses a mother’s time in the hospital, to promote behavior that is really just a prelude to how mother and baby should proceed together when they go home. But along with that vital and valuable information, another aspect of a new mother’s experience needs to be examined and promoted… we must begin to examine with mothers something that is rarely mentioned, rarely talked about by OBs, and rarely discussed as part of the normal and natural part of a new life coming into the world…the remarkable abilities and competence of the newborn. Birthing of the placenta gets more coverage in birth literature than do the stellar capacities of a new baby.
The Righard video of newborn behavior amazes because we see the antithesis of what first-time mothers imagine that their infants will be like. Popular images show a greasy-eyed newborn, wrapped up and be-blanketed as tight as a little taco, handed over to mom to hold. The Righard video, familiar to many of us, causes gasps at the first images of that lively newborn pushing its little legs against its mother’s abdomen, bobbing its little head with power and purpose, and performing the initial latch with brio. Mothers need to be told that, even if they have had intrapartum medications, they must continually give their newborns the opportunity to perform as they are hard-wired to do, and we must emphasize that newborns are capable and competent. Dr. Christina Smillie’s approach to breastfeeding…and her video “Baby-Led Breastfeeding” 12 rely on the baby’s instinctive responses to seek and find the breast when they are allowed to stay on their mother’s bodies. It demonstrates without equivocation how well babies can navigate about to find the breast. Every mother-to-be should be told about the amazing capabilities of her newborn, and encouraged to spend time every day with her newborn skin-to-skin. That information should be part of every childbirth education syllabus.
A couple of videos that came out this year also address that important hour or so after birth, and illustrate the nine stages through which the newborn progresses. Sponsored by the Healthy Children Project, the video called The Magical Hour13 and based on the research of Anne-Marie Widstrom and colleagues, is aimed at parents-to-be, and shows newborns in all the stages of adaptation to life outside from Stage One, the Birth Cry, to Stage Nine, Sleep. The other video, Skin to Skin in the First Hour after Birth: Practical Advice forStaff after Vaginal and Cesarean Birth 14, also from the Healthy Children Project, is aimed at hospital staff, delineating the same nine stages as The Magical Hour. It lays out guidelines for the treatment of mother and baby immediately after birth, whether vaginal or cesarean, with the view that the implementation of direct and uninterrupted contact between mother and newborn is the perfect beginning for a new family.
1- Lancet, Vol. 336,1105-07
2- Delivery Self Attachment, 1995 Lennart Righard & Kittie Franz, Geddes Productions, Los Angeles, CA
4- Ohio Department of Health. (2008). Hold me, Mom. Columbus, Oh: Ohio Dept. of Health Printing, Warehouse # 3977.23.
5- www.primalhealthresearch.com Odent, M. (2006). Homo Super-predator to Homo Ecologicus. http://www.wombecology.com/homo.html#top.
7-Fukida M, Moriuchi, Akiyama T, Nugent JK, Brazelton, TB, Arisawa K, Takahashi T, & Saito H (2002) The effects of kangaroo care on neonatal neurobehavioral organization, infant development and temperament in healthy infants through one year. J Perinatology, 22(5).384-379
8-Doucet S, Soussignan R, Sagot P, Schaal B, Dev Psychobiol 49(2); 129-38, 2007 Equipe d’Ethologie et de Psycholbiologie Sensorielle Centre des Sciences du Gout Umr 5170 CNRS Dijon, France. firstname.lastname@example.org
10-Mizuno K, Mizuno N, Shinohara T, et al; Mother-infant Skin-to-skin contact after delivery results in early recognition of own mother’s milk odour. Acta Paediatrica 93(12):1640-1645, 2004 email@example.com
11-Rethinking Swaddling, International Journal of Childbirth Education, 2010
12-Baby-Led Breastfeeding, Geddes Productions, Los Angeles, CA, 2007, Christina M Smillie, Ivy Makelin, Kittie Franz
13-The Magical Hour; Holding Your Baby for the First Hour After Birth. DVD Produced by Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc
14-Skin to skin in the First Hour After Birth: Practical Advice for Staff after Vaginal and Cesarean Birth, DVD Produced by Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc
Research by our UBC affiliated Child and Family Research Institute has revealed that the increase in Caesarean section rates across Canada may be largely due to the attitudes and beliefs of the obstetricians and other providers towards birth technology and Caesarean sections. 81 per cent of obstetricians 40 years or younger were women versus 40 per cent over 40 years of age. The attitudes and beliefs vary by age of practitioner. In contrast to their older counterparts, younger obstetricians were significantly more likely to favour a hospital based medically managed birth and the routine use of epidural analgesia in normal births. They were less likely to support vaginal birth after Caesarean section or to appreciate the importance of mothers’ role in their own birth. They also appeared to be more “fearful” of the consequences of vaginal birth, particularly in relation to urinary incontinence and sexual problems and more likely to select Caesarean section for their own births. Older obstetricians, the majority of which are male, were more supportive of a woman-centered model of care, more positive about birth plans, and were more likely to see vaginal birth as more empowering to the mother than Caesarean section. (1) The finding that younger obstetricians, who are mostly women, appeared to have less appreciation of the role of a woman in her own birth than older usually male obstetricians is counterintuitive and requires further study. These attitudes appear related to experiences in training rather than to gender, as younger male obstetricians have attitudes similar to their female counterparts. Without addressing the educational system, attitudes will be difficult to change.
Another study by our group (2) found that clients of midwives, were more supportive of women’s roles in their own deliveries and less likely to support the use of technology, compared to physicians’ patients. It should be noted that regardless of the type of care provider, many women reported inadequate knowledge of common procedures. Women’s lack of knowledge about procedures such as epidural analgesia, Caesarean section and episiotomy, raise concerns about prenatal education and prenatal care. Attendance at prenatal education classes is decreasing in all regions of Canada and most pregnant women indicated they use health care providers, books and the internet as their main sources of prenatal information. (2) When combined with evidence on the nature of obstetrical power and control, and research showing that many providers are not evidence-based in their views, (3) this suggests that even a woman with strong values and beliefs could find it challenging to assert her choices in the professionally controlled process of birth. Women, especially first time mothers, who do not have evidence-based knowledge, are likely to be particularly sensitive to negative attitudes toward birth procedures and processes, from providers and other sources.
A third study from our group found that family doctors who do not provide intrapartum care have more negative attitudes toward birth and are less evidence-based about what is going on in the delivery suite. (4) Since this group provides more than 50% of the antenatal care in Canada, efforts to keep them up to date need to be implemented, lest they transmit their negative attitudes to women before transfer for birth care to other providers.
Finally as Caesarean section rates are steeply rising, with BC having the highest rates in Canada, and for the first time, maternal mortality and morbidity rates are increasing in the US and Canada due to overuse of Caesarean sections, (2)it is time for the public to realize that Caesarean section, while life-saving when needed, is not as safe a vaginal birth (5-7), and it is not just another way to have a baby.
And lest you think that this is a Canadian problem, the educational and training systems for medical students and obstetrical and family practice residents is the same both sides of the border. Educational, rather than health care models, trumps evidence. We are teaching directly and indirectly that childbirth is just an opportunity for things to go wrong. Medical students, obstetrical and family practice residents rarely see normal birth, and they are not exposed to midwives in hospital or at home births. It is going to take a revolution driven by women to change this, as practitioners are not going to change very soon. To the barricades!
Posted by: Michael Klein, MD
[Editor's note: As an example of the debate Dr. Klein introduces here, proposing that Caesarean birth is "not just another way to have a baby," check out this article in today's edition of The Sun, questioning whether or not Caesarean birth is "normal."]
1. Klein M, Liston R, Fraser W, Baradaran N, Hearps S, Tomkinson J, et al. The attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors. Birth. 2011.
2. Klein M, Kaczorowsk J, Hearps S, Tomkinson J, Baradaran N, Hall W, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. JOGC. 2011(June):598-608.
3. Klein M, Kaczorowski J, Hall W, Fraser W, Liston R, Eftekhary S, et al. The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences But Important Similarities. Journal of Obstetrics & Gynaecology Canada: JOGC. 2009;31(9 ):827-40.
4. Klein M, Kaczorowski J, Tomkinson J, Hearps S, Baradaran N, Brant R. Family physicians who provide intrapartum care and those that do not: very different ways of viewing childbirth. Can Fam Phys. 2011 57(4):e139-e47.
5. SOGC. Joint Policy Statement on Normal Childbirth. JOGC. 2008;221(December):1163-5.
6. SOGC. C-sections on demand—: SOGC’s position. [Press Release]. Society of Obstetricians and GynecologistsMar 10, 2004.
7. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Cmaj. 2007 February 13, 2007;176(4):455-60.
It’s probably fair to say that most women who decide to have an epidural during labor don’t consider its possible impact on breastfeeding. Perhaps this is because no thought is given generally to any possible links between drugs and breastfeeding success (or otherwise). Instead, both pregnant (or laboring) women and caregivers usually assume that breastfeeding is a separate issue. Evidence from early research certainly doesn’t seem to support that view and a little common sense would also lead us to challenge it further…
Considering drugs used in labor generally, Jordan, et al (2009) provide some evidence that drug use in labor and birth has an impact on breastfeeding rates at 48 hours postpartum. (Of course, when women have already given up on breastfeeding two days after giving birth, it’s unlikely that they will re-establish breastfeeding later, even though this might be possible.) However, although Jordan et al’s conclusions are fairly clear, we also need to take into account the fact that many anesthesiologists wouldn’t accept these researchers’ conclusions simply because their data is retrospective (i.e. it looks back at what happened in the past, and tries to establish causal links); anesthesiologists (like many other specialists) consider prospective randomized studies to be more reliable. In any study, cause-effect relationships are difficult to prove—and epidural usage and its impact on breastfeeding success is no different in this respect.
Nevertheless, there are also prospective studies which have reported fairly clear problems with narcotics used in labor (Beilin, et al, 2005; Camann, et al, 2007; Torvaldsen, et al, 2006). In the study by Beilin, et al researchers concluded: “Among women who breastfed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breastfeeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl.” (Most women nowadays receive fentanyl as part of the epidural cocktail. Bupivicain, the drug it partly replaces in the epidural cocktail, causes paralysis in the lower part of the body so substituting part of this with fentanyl reduces this effect. However, some research suggests that problems with breastfeeding develop as a result of using fentanyl in the epidural cocktail. The study by Torvaldsen, et al concluded: “Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breast-feeding in the first 24 weeks”. Despite making this statement, the researchers felt they were unable to say whether there was a causal link between epidural anesthesia and breastfeeding difficulties. This was despite the fact that “Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week” and the fact that women who had epidurals were more likely to stop breastfeeding than women who used non-pharmacologic methods of pain relief.
Having said all that, an article by Pandya (from a Department of Anaesthesia in India) in 2010 claims that any impact on breastfeeding is not statistically significant. A study conducted on a small number of women (87) in Toronto, Canada, by Wieczorek et al (2010) also concludes that breastfeeding is unaffected by epidural use. An editorial by Camann (see references below) provides a good overview of research done up to and including 2007 and an article by Loubert et al (2011) summarises research up to the present day.
A study by Lin et al (2011) somewhat less clearly but nevertheless significantly, indicates a possible link between the use of narcotic analgesia in the epidural mix and later actual or perceived breastfeeding problems. Another study by Reynolds at St Thomas’ Hospital in London (2009) concludes: “Successful breastfeeding is dependent on many factors, therefore randomized trials are required to elucidate the effect of labour analgesia.” Wilson et al’s randomized controlled trial did take place after this recommendation (2010) and the conclusion was, in fact, that epidurals had no impact on breastfeeding. Devroe et al (2009) came to a similar conclusion.
Common sense might lead us to view even these studies which find no link between epidurals and breastfeeding with some caution. After all, the following need to be taken into account as well:
Epidurals are associated with a general medicalization of birth (since they usually and/or frequently involve IV lines and urinary catheters, as well as electronic fetal monitoring and ongoing monitoring of blood pressure) and this may contribute to greater maternal discomfort postnatally, meaning that breastfeeding could be affected.
Epidurals are known to be associated with a higher rate of instrumental delivery and caesarean. Postpartum perineal discomfort, or pain as a result of abdominal surgery, will also inevitably make breastfeeding less comfortable, and therefore less likely to occur.
Epidurals can influence the fluctuation of hormone levels that play an important role in breastfeeding. A study conducted by Handlin et al (2009) found that medical interventions in connection with birth influence the activity of the hypothalamic-pituitary-adrenal axis 2 days after birth. (Adrenal gland activity, which is dependent on pituitary gland activity, which in turn is dependent on the activity of the hypothalamus is affected.) As a result of this influence, hormonal production is likely to be compromised, which will of course affect the success of breastfeeding, which depends on the release of the hormones oxytocin and prolactin.
Furthermore, most studies conducted so far are unlikely to have compared physiological, unmedicated active labor with epidural labors. Comparing breastfeeding success after epidural birth to opiate-medicated birth (or birth with other forms of analgesia, such as Entonox) is not the same as comparing physiological birth to epidural birth. Of import are the sizes of the associated studies which inform our understanding of epidural analgesia and its impact on breastfeeding. While the studies by Belin, et al, Wieczorek, et al and some of the studies cited in Loubert’s review are all modest in size (Belin, n=66; Wieczorek, n=87) others boast larger numbers (Wilson via Loubert, n=1054; Torvaldson, n=1280; Jordan, n=48,366).
Our overall conclusions then are clearly not only based on incomplete evidence, but also on research which is perhaps comparing two scenarios which are both unconducive to successful breastfeeding: birth with opiate analgesia (e.g. Demerol) and birth with epidural analgesia. Clearly, too, many people involved in the debate have vested interests in continuing to promote epidurals. Caregivers who are unfamiliar (and therefore uncomfortable) supporting ‘noisy’, mobile and ‘demanding’ women (who are laboring without an epidural) are perhaps unlikely to want to change their more convenient practice; anesthetists have their livelihood to think about; drug companies which manufacture drugs such as fentanyl also have enormous profits to lose should women decide that epidural is, after all, not ideally conducive to breastfeeding success.
Posted by: Sylvie Donna, author of Birth: Countdown to Optimal published by Fresh Heart Publishing. Available from www.freshheartpublishing.com or from any other online shop (e.g. Amazon). Read the Science & Sensibilityreview of Birth: Countdown to Optimal by Christine Hurst Praeger.
Beilin Y, Bodian C, Weiser J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double blind study. Anesthesiology, 2005, Dec;103(6):1211-7
Camann W. Labor analgesia and breast feeding: avoid parenteral narcotics and provide lactation support. International Journal of Obstetric Anesthesia, 2007, Jul; 16(3):199-201
Cardiff Births Survey. BJOG: International Journal of Obstetrics & Gynaecology, 2009, online publication on 1 Sept
Devroe S, De Coster J, Van de Velde M. Breastfeeding and epidural analgesia during labour. Curr Opin Anaesthesiol. 2009 Jun; 22(3):327-9.
Handlin L, Jonas W, Petersson M, Ejdeback M, Ransjo-Arvidson AB, Nissen E, Uvnas-Moberg K. Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period. Breastfeed Med. 2009 Dec;4(4):207-20.
Jordan S, Emery, S, Watkins A, Evans JD, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the
Lin SY, Lee JT, Yang CC, Gau ML. Factors related to milk supply perception in women who underwent cesarean section. J Nurs Res. 2011 Jun;19(2):94-101.
Loubert C, Hinova A, Fernando R. Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years. Anaesthesia 2011 Mar;66(3):191-212. doi: 10.1111/j.1365-2044.2010.06616.x.
Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth. 2010 Sep;54(5):400-8.
Reynolds F. The effects of maternal labour analgesia on the fetus. Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):289-302. Epub 2009 Dec 11.
Torvaldsen S, Roberts CL, Simpson JM, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal, 2006,Dec11;1:24
Wieczorek PM, Guest S, Balki M, Shah V, Carvalho JC. Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study. Int J Obstet Anesth. 2010 Jul;19(3):273-7. Epub 2010 Jun 2.
Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A, COMET Study Group UK. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia. 2010 Feb;65(2):145-53. Epub 2009 Nov 12.
How Much do Expectant Women (and their partners) Really Know about Childbirth?
There has been much ado in the popularmedia as well as the blogosphere in recent days, about a trioofstudies recently released, demonstrating attitudes about childbirth—from both the maternity care providers’ perspectives, and those of their patients. Next week, our own contributor, Dr. Michael Klein—a primary author in all of these studies—will share with us some thoughts on the results of these studies.
The line item journalists seem to have cleaved to is how little expectant women know about birth as evidenced by the article title from the LA Times piece, “Pregnant women show an amazing lack of knowledge about childbirth options, study shows.” And yet, to take a close look at the data revealed in Klein et al’s Birth Technology and Maternal Roles in Birth: Knowledge and Attitudes of Canadian Women Approaching Childbirth for the First Time (JOCG, June 2011) the numbers are less disparaging.
To the selection, “The most important thing in having a normal birth is the woman’s own confidence in her ability to give birth,” a total of 61.7% of respondents answered “Agree.” (74.7% of respondents cared for by a registered midwife agreed.) To the item, “For women, Caesarean section is as safe as vaginal birth”, a little over half (54.1%) of respondents disagreed (correctly) with this statement, while 74.9 % of respondents receiving prenatal care from a registered midwife disagreed. The overall theme of this study’s findings? From the study’s Discussion section:
In examining nulliparous women’s attitudes towards and knowledge of important elements in contemporary maternity care, we found that women attending midwives consistently reported attitudes supporting vaginal birth over Caesarean section and less frequent use of technology than those receiving care from physicians, particularly patients of obstetricians. Moreover, as demonstrated in Figure 2 of the study, across the board women attended by midwives were less likely to answer “I Don’t Know” to one of the 21 survey questions, followed by patients of family practice providers and, lastly, women attended by OBs.
Clearly, the type and amount of information delivered by a maternity care provider, to an expectant woman, influences how much she “knows” about birth.
And the information relayed from medical school professors to medical students influences how obstetricians think and feel about birth, suggests another recently published work of Dr. Klein and colleagues. To read an excellent commentary on Klein et al’s study about Attitudes of the New Generation of Canadian Obstetricians…read Dr. Christopher Glantz’s commentary in Birth(June, 2011).
One blogger responded to Klein et al’s work in a humbling, self-deprecating way, acknowledging her lack of awareness of her birth options, as she quickly approached the birth of her twins. So where does the fault lie, when pregnant women approach childbirth with less than full awareness about the birthing process, and the options contained therein? And what about the women (and their partners) who do approach labor and birth fully aware, and ready to advocate for their hopes and desires? Is it really reasonable to accept a popular news media claim that “Pregnant women show an amazing lack of knowledge about childbirth options?”
The LA Times article reports from Klein et al’s study that, “ Fewer than 30% of the women, all first-time mothers, said they had attended prenatal childbirth classes” and yet, when looking back at the Public Health Agency of Canada’s What Mothers Say: the Canadian Maternity Experiences Survey, 65.6% of primiparous (first time) mothers attended a prenatal class. This is similar to the findings of the 2002, U.S.-based Listening to Mother’s (LTM) Survey in which it was found that 70% of first-time expectant mothers attended class. (Unfortunately, in the follow-up, 2006 version of LTM, only 56% of first-time mothers attended prenatal classes.)
In a recent post by childbirth educator, Robin Elise Weiss (pregnancy.about.com) she describes the type of prenatal class as mattering as much—if not more—than whether or not a class is taken at all. She describes some childbirth education programs as little more than “an orientation to the hospital, doctor’s office or other entity.” She also explains that, in her curriculum, her students do learn a whole heck of a lot about birth: about normal birth, medical interventions…you name it.
I can echo that sentiment: that in a really good childbirth education class, women and their partners do come away with an enormous amount of knowledge.
Klein et al’s study published in JOGC brings to light an important element in the equation: the influence of power paradigms on a woman’s knowledge and ability to self-advocate. Again, from the Discussion section:
…studies about the nature of obstetrical power and control, suggest that even a woman with clearly articulated attitudes, beliefs, and values could have difficulty navigating the professionally controlled environment of birth. (Emphasis, mine)
In my own location, an interesting battle has played out over the years: independent childbirth education programs versus the hospital-sponsored program. When I first began teaching classes, there were seven different independent childbirth ed. teachers vying for the studious attentions of the relatively small number of women—most likely first time mothers and their partners—who would give birth in our town of 27,000 people. At that time, the hospital did not even offer a class. But a few years ago, the hospital began offering its own series of classes—perhaps a program for which local allopathic maternity care providers could largely control the content of information. Within three years of the hospital starting their program, the number of independent teachers began to dwindle. We were suddenly competing with short, cheap hospital classes that our would-be students were opting for.
The local indes cried “unfair,” in that hospital staff L&D nurses could conduct the programs on site—rent free—with their employer picking up the tab on childbirth education materials. Teaching out in the community, our measly one or two-hundred dollar/couple price tags were justified by the rent we paid for classroom space, childbirth education videos and other teaching aids. And yet, our “customers” were signing up with us less and less.
Is our paradigm all wrong?
In a capitalistic, supply and demand society where price point matters, is there more than one entity losing out on quality childbirth education? Are independent educators losing out on would-be students, and are expectant parents losing out on the quality of childbirth education they deserve? Are the numbers of poorly-informed expectant parents growing due to lack of learning opportunity, or inundation with less-than-helpful information in this techno-savvy era? Are expectant parents overwhelmed by access to so much information (good, bad, somewhere in between) that they lack the energy to seek out a good old fashioned, well-informed childbirth preparation course? Are the folks who do appear to be well educated on childbirth options the people who still opt for the more expensive—and more in-depth—childbirth preparation experiences, along with perinatal care from providers who still invest the time in fully educating their patients?
What if we taught all childbirth educators the skill of grant writing? What if all independent educators wrote—and received—grants to fund their programs, allowing them to offer classes for expectant parents for no charge? Would this “free” price tag entice more soon-to-be moms and partners to sit in on full-length, in-depth classes that seem to be a thing of the past in some hospital settings? Would studies like those mentioned in this post show higher levels of participation in prenatal classes—and increased confidence in and knowledge about childbirth options—if there weren’t a financial barrier to that education? Would for-profit, on-line childbirth education platforms wane in popularity while in-person programs re-gained attendance?