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Recent Study Finds that Controlled-Crying Causes No Apparent Long-term Harm: Should We Recommend This Practice to Parents?

October 30th, 2012 by avatar

 

 

“Crying it out” and sleep issues have always been a “hot” topic amongst parents and many of today’s parents look to childbirth educators and others for information on how best to prepare for and deal with their infant’s sleep habits.  Talking about infants and sleep can be as flammable a topic as talking politics.   Today’s post is by regular contributor Kathleen Kendall-Tackett takes a look at recent study on the long-term effects of controlled crying and shares her thoughts on the validity of the study and examines the potential shortcomings and limitations.  How do you speak about sleep and infants in your classes or with your clients and patients?  Do you have information that parents have found particularly helpful? Let us know in the comments section of today’s post.- SM

Image credit: Fotolia stock photo

A recent article in Pediatrics (Price, Wake, Ukoumunne, & Hiscock, 2012) reported on the long-term effects of a controlled-crying intervention for parents of infants 8 to 10 months old. The children were assessed five years post-intervention and showed no apparent harm. The media response to these findings has been overwhelming. Could this be the answer that weary parents have been waiting for? The authors certainly thought so. In fact, they concluded that practitioners could “confidently” recommend this approach.

Before we recommend this approach to parents, let’s step back for a moment and consider whether this recommendation is warranted. We must critically evaluate both the current study and where it fits within the larger literature in maternal-child health. In my view, there are a number of serious limitations to this study that call into question whether we should recommend this practice to parents.

Study Design

In the Price et al. (2012) study, the researchers randomly assigned parents to either intervention or control groups. In the intervention group, parents received instruction in controlled crying, i.e., to wait an increasing amount of time before responding to their infants’ cries, or “camping out,” which involved staying with their infants until the infants fell asleep on their own. The parents in the control group received “usual care,” which meant no specific recommendation regarding infant sleep. At earlier time points, the authors found that the controlled-crying intervention prevented depression in mothers and improved babies’ sleep.

At the five-year follow-up with 225 families (69% of the original sample), the researchers found that the intervention did not adversely affect the parent-child bond, the mother’s depression level, the child’s level of adjustment, or their cortisol levels. Indeed, they noted, that there were no adverse effects. However, there were also no long-term benefits. Still, the authors concluded that practitioners could recommend this technique to prevent postpartum depression and improve infant sleep.

Study Limitations

There were a number of limitations to this study. Below is a brief synopsis.

The Impact of Context: The Cumulative Effect of Childhood Adversities 

Context is an important consideration when evaluating potential harm caused by a parenting technique. In other words, how many parental missteps does it take for children to show evidence of lasting harm? Fortunately, children are resilient and don’t require perfect parenting.  However, chronic bad parenting does harm children and the effects are cumulative (Shonkoff, Boyce, & McEwen, 2009). Chronic bad parenting has also been described as childhood adversity in such major research studies as the Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2010) and New Zealand’s Dunedin Multidisciplinary Health and Development Study (Danese et al., 2009).

So does controlled crying cause infant harm? If it occurs in families with generally warm, responsive, and loving parents, probably not. Because children are resilient, they can endure a lot. Family strengths can buffer any potential negative effects.

I am more concerned about the impact of controlled crying when it takes place in high-risk families. This is a key limitation in Price et al. study. A full 31% of their original sample was lost to follow-up. Most of these families were identified as “high disadvantage.” In other words, the group most likely to be negatively affected by controlled crying was not in the follow-up study.

Assessing “Dose”: The Chronicity and Severity of the Experience

When assessing potential harm of a practice, it’s also important to consider chronicity and severity. In terms of infant sleep, we need to know how often controlled crying was used in an average week, how many weeks or months that the parents employed these techniques, and in an average episode how many minutes elapsed before the parents responded to their babies. I would expect more long-term negative effects if parents did not respond to their babies’ cries for long periods of time (such as 45 minutes or longer), and that they used this technique for months on end. In contrast, if parents used this technique a few times and for a few minutes, there probably wouldn’t be any negative effects.

Chronicity and severity is basically a way of factoring in “dose” of the intervention. This important nuance was totally absent from the Price et al. study. From their article, we know little about what the parents actually did. A full range of practices was grouped together in the “intervention group.” Indeed, we also don’t know what the “control” group did. These parents could have easily implemented a controlled-crying program for themselves using one of the myriad of books for parents on sleep training. Given the wide range of practices that likely occurred in both the “intervention” and “control” groups, I am again not surprised to see no significant difference.

Was the Intervention Actually Effective, Even in the Short Term? Accounting for the Hawthorne Effect

Another problematic aspect of this study has to do with the research design’s inability to account for the Hawthorne Effect. The Hawthorne Effect was first noted by industrial psychologists who were testing the impact of minute changes in illumination on productivity in factory workers. When they raised the level, employees reported that it was “better” and productivity increased. When they lowered the level, it was also “better” and productivity increased.  In other words, any intervention was described as helpful. It’s basically a placebo effect for behavioral interventions.

The Hawthorne Effect could also be behind the positive results for the controlled-crying intervention. Earlier papers from this same research sample found lower rates of depression and better sleep among the mothers in the intervention group. Yet these results do not demonstrate that it was the controlled-crying technique per se that actually caused the effect. Perhaps it was simply a matter of the mothers appreciating that someone was listening to their concerns. Controlled crying was compared to “usual care.” A better test for the effectiveness of this technique would have been to compare it with another intervention (such as educating mothers about the developmental normality of infant waking at 8 to 10 months, and brainstorming about ways the mothers could get more rest and cope with fatigue). Given that the authors are actually recommending this technique, this standard of evidence is a minimum.

Does Controlled Crying Cause Long-term Change to Cortisol Levels? 

One concern that critics of controlled crying raise is that this technique changes infant physiology and alters the production of the stress hormone cortisol. To address this concern, the authors assessed cortisol levels of the children at two different points during a single day at age 6. They found no significant differences in cortisol levels at age 6 between the intervention and control groups, which further reassured them that their techniques were not harmful.

Unfortunately, these findings alone do not mean lack of physiological harm. To demonstrate lack of harm, the authors needed to measure cortisol levels during infancy: before, during, and after the intervention. Did controlled-crying elevate cortisol levels? How high were those levels and how long did they remain elevated? The authors did not measure this.

The question we need to ask is what happens to babies when their mothers do not respond to their cues? One way this has been studied is by examining the impact of maternal depression on infants. Maternal depression impairs mothers’ ability to respond to their infants’ cues. Infants whose mothers do not respond to their cues  tend to have elevated cortisol levels (Feldman et al., 2009). Even when non-response is temporary, babies still find it stressful. In the still-faced mother paradigm, mothers are asked to not respond to their infants’ cues in a laboratory setting. This research is designed to mimic the effects of maternal depression. The still-faced-mother experiments increase babies’ cortisol levels (Grant et al., 2009). And the effect of chronic maternal non-response can last long past infancy (Douglas & Harmer, 2011; Luijk et al., 2010; Murray, Halligan, Goodyer, & Herbert, 2010).

So why the concern about cortisol? Mainly, it’s this: cortisol is quite toxic to brain cells. If cortisol is elevated for short time, it likely causes no damage. But if cortisol levels are repeatedly elevated because the infants are experiencing long and repeated incidents of being ignored when they cry, it can be a problem. The brain is at its most vulnerable in the first five years, so soaking the developing brain in cortisol is not a good idea (Buss et al., 2012).

The authors of the current study claimed no effect of cortisol just because there was no difference between the groups at age 6. In my opinion, the lack of difference between the groups does not mean lack of harm. For some of these children, the effects of elevated cortisol in infancy could be more subtle. Cortisol levels likely returned to normal in the intervening five years, unless there was ongoing adversity. Unfortunately, cortisol that was elevated in infancy could have still affected vulnerable brain cells, even if current levels are normal. The measures Price et al. used were not particularly sensitive. And these effects would likely not show up without more sensitive measures.

What About Breastfeeding?

The final limitation of this study is rather stunning. Price et al. did not measure the effect of infant feeding method on sleep or maternal depression. Yet feeding method has a direct effect on both maternal sleep and postpartum depression, which are the two main factors the authors claim to address with their sleep intervention. This omission is particularly surprising given that Australia, the authors’ home country, has one of the highest rates of breastfeeding in the world. It is far from a marginal issue.

Recent studies have demonstrated that exclusively breastfeeding mothers get more sleep and are less likely to be depressed than their mixed- or formula-feeding counterparts. They take fewer minutes to fall asleep, sleep longer over the course of a night, and report more daytime energy and better physical health than their mixed- or formula-feeding counterparts (Doan, Gardiner, Gay, & Lee, 2007; Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a, 2009b; Kendall-Tackett, Cong, & Hale, 2011).

Given these findings, isn’t it strange that breastfeeding was not even enquired about, let alone controlled for? If the study was conducted in a country with low breastfeeding rates, this omission would be somewhat understandable. But it makes no sense from a study conducted in a country with one of the highest breastfeeding rates in the world.

Conclusion

So what can we take away from the Price et al. study? Should we recommend the controlled-crying technique to parents? Based on the limitations of this study, I do not recommend this approach. The sample size is small, the follow-up sample is missing the children most likely to be negatively affected, their assessment of their intervention did not account for the Hawthorne/placebo effect, they have not measured dose of the intervention, nor have they accounted for feeding method, which recent research has soundly demonstrated as being related to both variables that are of key interest: maternal fatigue and postpartum depression.

My objections to this approach are not new. When I first encountered the Price et al. study, I remembered a study this same group of researchers published 10 years ago in the British Medical Journal demonstrating that controlled crying lessened the risk of postpartum depression (Hiscock & Wake, 2002). I was specifically struck by this response to it from a German physician (Perl, 2002).

As a German, I am unhappy to find fairly undiluted ideas of militaristic Nazi infant care uncritically repeated by these Australian care providers. The Nazis understood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990s completely escaped the authors’ notice.

In closing their article, Price et al. stated that organizations, such as the Australian Breastfeeding Association, were unduly negative towards controlled-crying techniques and based their positions on research that had not been “updated since the mid-2000s.”

Thus, there is a pressing need to deliver evidence-based information to parents and health care providers, which could be achieved, in part, by updating position statements, policy documents, and training curricula to reflect our current findings that behavioral sleep techniques are both effective in the short- and medium-term and safe to use in the long-term (p. 8).

Given recent findings in neuroscience, childhood trauma and adversity, and breastfeeding and maternal sleep, which are not accounted for in the Price et  al. study, I’d respectfully advise the authors to do the same. I’d further urge healthcare providers who are considering recommending these techniques to consider the limitations to the current study and to consider alternative approaches that can meet the needs of both mother and baby.

References

Buss, C., Davis, E. P., Shahbaba, B., Pruessner, J. C., Head, K., & Sandman, C. A. (2012). Maternal cortisol over the course of pregnancy and subsequent child amygdala and hippocampus volumes and affecive problems. Proceedings of the National Academy of Sciences USA, 109(20), E1312-E1319.

Centers for Disease Control and Prevention. (2010). Adverse childhood experiences: Major findings  Retrieved May 16, 2011, from http://www.cdc.gov/ace/findings.htm

Danese, A., Moffitt, T. E., Harrington, H., Milne, B. J., Polanczyk, G., Pariante, C. M., & Caspi, A. (2009). Adverse childhood experiences and adult risk factors for age-related disease: Depression, inflammation, and clustering of metabolic risk factors. Archives of Pediatric and Adolescent Medicine, 163(12), 1135-1143.

Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breastfeeding increases sleep duration of new parents. Journal of Perinatal & Neonatal Nursing, 21(3), 200-206.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009a). Sleep and depression in postpartum women: A population-based study. Sleep, 32(7), 847-855.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009b). Subjective and objective sleep among depressed and non-depressed postnatal women. Acta Psychiatrica Scandinavia, 119, 128-136.

Douglas, J.-L., & Harmer, C.-J. (2011). Early morning cortisol response and emotional processing in adults exposed to postnatal depression in infancy. European Psychiatry, 26, 479-481.

Feldman, R., Granat, A., Pariente, C., Kanety, H., Kuint, J., & Gilboa-Schechtman, E. (2009). Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9), 919-927.

Grant, K.-A., McMahon, C., Austin, M.-P., Reilly, N., Leader, L., & Ali, S. (2009). Maternal prenatal anxiety, postnatal caregiving and infants’ cortisol responss to the still-face procedure. Developmental Psychobiology, 51, 625-637.

Hiscock, H., & Wake, M. (2002). Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. British Medical Journal, 324(7345), 1062-1065.

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2011). The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clinical Lactation, 2(2), 22-26.

Luijk, M. P. C. M., Saridjan, N., Tharner, A., Van Ijzendoorn, M., Bakermans-Kranenburg, M. J., Jaddoe, V. V. W., . . . Tiemeier, H. (2010). Attachment, depression, and cortisol: Deviant patterns in insecure-resistant and disorganized infants. Developmental Psychobiology, 52, 441-452.

Murray, L., Halligan, S. L., Goodyer, I., & Herbert, J. (2010). Disturbances in early parenting of depresssed mothers and cortisol secretion in offspring: A preliminary study. Journal of Affective Disorders, 122, 218-223.

Perl, F. M. (2002). Infant sleep intervention or Nazi drill? Rapid response to Hiscock & Wake. British Medical Journal. Retrieved from http://www.bmj.com/content/324/7345/1062?tab=responses

Price, A. M. H., Wake, M., Ukoumunne, O. G., & Hiscock, H. (2012). Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomized trial. Pediatrics, 130(4). Retrieved from www.pediatrics.org/cgi/doi/10.1542/peds.2011-3467

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA, 301(21), 2252-2259. doi: 301/21/2252 [pii] 10.1001/jama.2009.754

About Kathleen Kendall- Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press, a new small press specializing in women’s health. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. www.KathleenKendall-Tackett.com

 

Babies, Breastfeeding, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Parenting an Infant, Research , , , , , ,

Lamaze Toolkit for Childbirth Educators: A Valuable New Resource For Any Childbirth Educator

October 25th, 2012 by avatar

This is a big weekend for Lamaze International for many reasons.  The 2012 Innovative Learning Forum is happening starting tomorrow in Nashville, TN, and right now, childbirth professionals and those interested in improving maternity care for childbearing women are making their way to Nashville via plane, train and automobile to network, listen to a fantastic line up of keynote speakers, participate in interactive learning sessions taught by creative and dynamic presenters, shop and meet sponsors and exhibitors, enjoy good food, Nashville hospitality and socialize with men and women who share the belief that birth is normal.

If you are not able to join the party in Nashville, you do have the option of participating in the four general sessions presented by the keynote speakers through the virtual conference option.  Either way, there is an opportunity for expanding your knowledge and getting important new information about teaching pregnancy, birth, parenting and breastfeeding topics to expectant families.

New Resource for Educators

There is another exciting event happening at this weekend’s gathering.  Lamaze International unveils a brand new resource for childbirth educators; The Lamaze Toolkit for Childbirth Educators. If you are at the conference this weekend, you can preview this toolkit at the Lamaze booth and participate in a contest to be entered in a drawing for the Lamaze Six Healthy Birth Practices PowerPoint Presentation with Videos, a valuable part of the new toolkit.  (More info on the how to enter later in this post.)

The Lamaze Toolkit for Childbirth Educators (Toolkit) is a brand new 317 page workbook created by Debby Amis, RN, BSN, CD(DONA), LCCE, FACCE and Jeanne Green, CD(DONA), LCCE, FACCE.  Debby and Jeanne have both held leadership roles in Lamaze International for many years, as well as contribute to other birth related organizations.  Together, Debby and Jeanne are the owners and directors of The Family Way Publications and Childbirth Educator Programs.

I wanted to review this Toolkit and let you know some of the highlights, so that you can be sure to allow time to check it out yourself at the Lamaze booth at the Forum or online, and consider adding the Toolkit to your own personal teaching resources.  After purchasing, I was easily able to download an electronic version of the Toolkit to my laptop.  For the purpose of this review, I chose to print out the Toolkit for easy access using my substantial Lamaze/FedEx discount that I receive as a benefit of being a Lamaze member.  An educator could easily chose to keep the electronic version handy and just choose to print out any handouts that will be utilized in class.

What’s Inside

The Toolkit is divided into 8 sections, starting off with “Dynamic Childbirth Education.”  Immediately, ideas are jumping off the pages on different methods of curriculum development, the components of a great class and preparations you might want to consider even before your class begins. There is something for everyone, no matter if you are a right brained creative thinker or a left brained in-depth organizer.  I found several new ideas for opening my childbirth classes and was excited to give some new things a try the next time I teach.

The Toolkit follows along with The Lamaze Fundamentals for Pregnancy, Birth, and Parenting with a section devoted to each one.  In each section, I found a list of selected materials and teaching aids that you might want to consider, along with information on where or how to acquire different items.  Teaching ideas, interactive learning methods, and active learning activities are so abundant throughout the book that it could be very easy to quickly choose a few favorites and immediately have a handful of ways to teach each topic you cover.  Another feature that I very much appreciated was the Lamaze web resources for each topic as well as other web links to useful pages, outstanding online videos and resources to share with class students.  In every section, the Lamaze principles that pregnancy and birth is normal, natural and healthy are apparent and the activities and teaching suggestions reinforce those principals while giving students confidence-building tools and ideas for pregnancy, birth and parenting.

Section V provides class outlines for all kinds of classes, including early pregnancy classes, series classes, and weekend classes, with a lesson plan for whatever your needs might be. Section VI: Resources provides suggestions for dozens of teaching aids and where to locate them for purchase if necessary. Sample presentation slides are outlined slide by slide, should you wish to supplement your class activities.  Lists of websites useful to childbirth educators are included, where no doubt you could get lost for days, mining the different sites for more useful and relevant information for you and your students.

Section VII: Handouts has an extensive collection of share-able handouts and worksheets loaded with fun activities, as well as examples of practical forms, such as sign in sheets, class evaluations, and review material for class participants.  Even items that you might email in advance of class or send as a follow-up to reinforce the material or facilitate discussions.  The 317 page Toolkit wraps up with Section VIII: References with the websites and research articles that support the preceding sections, should you wish to reference the original sources or seek more information.

There is an accompanying Lamaze Six Healthy Birth Practices PowerPoint Presentation with Videos included with the Toolkit.  This presentation is modifiable and includes over 80 colorful slides and embedded videos.  Or you may choose to purchase the PowerPoint Presentation alone for a reduced price.  The Lamaze Toolkit for Childbirth Educators (including PowerPoint and Videos) is $175 for Lamaze members and $350 for non-members.  Lamaze Six Healthy Birth Practices PowerPoint Presentation with Videos alone is $65/$140. These items are one-time purchases, and you do not need to purchase additional license for continued use.

No matter if you are a new educator, or one who has been teaching for years, I think you will be amazed at the sheer number of practical ideas, creative teaching methods, effective activities and course outlines that will be new to you and create excitement for you to mix things up with some of the Toolkit ideas.  I have just about 10 years of teaching childbirth classes under my belt and I found myself taking notes of new things I can’t wait to try!  You can teach an old dog new tricks.  I can only imagine how valuable a tool like this would have been when I was just starting out!  The days and days of work it would have saved me in preparing to teach my classes. Even now, I feel like it is fun for both students and myself, to mix things up, it keeps me on my toes and enjoying my work, and lets me offer fun and effective learning opportunities to the families I work with.  This Toolkit is a wonderful and fresh way to share the all the new messages, such as “Push For Your Baby” and others that Lamaze worked so hard to make just right!

I Am Lamaze Photo Contest- Win a Healthy Birth Practice Power Point presentation with videos

Lamaze Forum Attendees: show your pride! Share a photo of yourself at the conference via social media and you’ll have a chance to win a Healthy Birth Practice Power Point presentation with videos, just one of the resources in the brand new Lamaze Toolkit for Childbirth Educators. The full toolkit is a comprehensive online toolkit (312 pages), which offers interactive teaching strategies, ready-to-use handouts, class outlines, and an 88 slide complete PowerPoint presentation on the Lamaze Six Healthy Birth Practices with teaching notes, and a full range of teaching resources. The Lamaze Toolkit also includes access to the easy-to-use resources and an online community with a discussion forum for sharing tips with other educators. Be sure to stop by Lamaze booth #104/106 to take a “test drive!”! Retail value of the Power Point Presentation is $65 for members and $140 for non-members.

There are three ways you can be eligible to enter:
1. Twitter: tweet a photo of yourself at the Forum and tag @lamazeadvocates and #lamaze12 to be eligible
2. Facebook: Post a photo of yourself at the Forum and tag LamazeEducators or post your photo to our wall:
htttp://www.facebook.com/lamazeeducators.
3. Email a photo of yourself at the Forum to info@lamaze.org and we’ll post it to our Facebook album.

A winner will be chosen at random and announced on Sunday, October 28!

 

Added Bonus: Toolkit Forum
 There is an added bonus for anyone who purchases the Lamaze Toolkit for Childbirth Educators; Full access to a specialized forum on the Lamaze website, where you can interact with other community members who have also purchased this resource.  Have discussions, share ideas, successes and improvements you made, ask questions and learn how others are using this valuable tool.  Reach out and collaborate virtually with others who are also using the Toolkit in their classrooms.
If you are at the Innovative Learning Forum, stop by the Lamaze Booth and “test-drive” this new resource.  Remember to enter the drawing for the Lamaze Six Healthy Birth Practices PowerPoint Presentation with Videos during your stay in Nashville, to be awarded on Sunday, October 28th.  Or you can purchase the Toolkit here on the Lamaze site.  Once you have had a chance to take a peek, either at the booth or once you return home, let us know what you think and how your classes have changed using the resources available to you.

 

 

Book Reviews, Breastfeeding, Childbirth Education, Continuing Education, Evidence Based Medicine, Films about Childbirth, Films about Pregnancy, Healthy Birth Practices, Healthy Care Practices, informed Consent, Lamaze 2012 Annual Conference, Lamaze Method, Push for Your Baby, Uncategorized , , , , , , , , , ,

The Wax Home Birth Meta-Analysis: An Outsider’s Critique

October 23rd, 2012 by avatar

Today’s post is a fascinating interview that took place between Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth and Kyoung Suk Lee, PhD, MPH, RN, APRN. Rebecca asked Dr. Lee to provide a review of the Wax Home Birth Meta-Analysis, as an “unbiased outsider”, but highly skilled researcher.  Dr. Lee’s comments and critique are fascinating and provided me with many further thoughts.  Please enjoy Rebecca’s interview and share your comments. – SM

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http://www.flickr.com/photos/eyeliam/7353095052/

Shortly after starting my website, www.evidencebasedbirth.com, I had several people ask me if I could write an article about the research evidence on home birth. However, I was hesitant to do so for several reasons. Mainly, I was worried that I could not look at the evidence in an objective manner. My husband and I had recently chosen a home birth for our second child. I was worried that it would be difficult to objectively examine the research evidence on home birth, given my personal experience. The blogosphere is full of people who are strongly pro-home birth or anti-home birth, and their evaluations of the evidence are usually written through the lens of their own biases. I didn’t want to add to the plethora of biased articles already out there.

Then I had a sudden burst of inspiration. What if I asked one of my colleagues—who has no biases about childbirth—to review the home birth literature for me? In particular, I wanted to find someone who could review the Wax home birth meta-analysis (Wax, Lucas et al. 2010) and give me a fair assessment of its scientific value.

I chose the Wax meta-analysis for this review because in 2011, the American Congress of Obstetricians and Gynecologists emphasized the results of the Wax study in its official statement on home birth. Their statement said: “Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.”(ACOG, 2011)

Dr. Kyoung Suk Lee, PhD, MPH, RN, APRN

It did not take me long to figure out who I would ask to review the Wax study. Dr. Kyoung Suk Lee is considered by her colleagues to be a rising star in the field of cardiovascular research. She recently graduated with a PhD in Nursing, and she just accepted a job at a research university. People who work with Dr. Lee say that she is extremely intelligent, hard-working, and a future leader in her field. Dr. Lee’s expertise has been recognized with research awards from the Heart Failure Society of America, the Society for Heart-Brain Medicine, and the Cleveland Clinic Heart-Brain Institute, among others. She has published her work in nursing and cardiology journals. Furthermore, I knew that Dr. Lee did not have any biases about childbirth, home birth, or hospital birth. I asked Dr. Lee if she would be willing to review the Wax meta-analysis for me, and she kindly agreed.

What follows is my interview of her about the study and its results (RD in bold, KSL unbolded).

Do you have any biases or conflicts of interest related to home or hospital birth?

I do not have any biases related to home or hospital birth.

Could you summarize the methods and results of the Wax study?

The purpose of this meta-analysis was to compare maternal and neonatal outcomes between planned home-and hospital-births.

Using an electronic database search and bibliography search, the authors retrieved 237 articles and included 12 articles in their meta-analyses. Of 12 articles included, 3 were conducted after 2000 while 9 were conducted before 2000. Of 12 articles, 2 were conducted in the US (one was a retrospective design) while 10 were conducted outside US.

Women in the planned home birth group had better maternal outcomes than women in the planned hospital group. They had fewer interventions such as epidurals and episiotomies, and lower morbidity (infection, 3rd or 4th degree lacerations, hemorrhages, and retained placenta). There were no differences in cord prolapse between the two groups.

For neonatal outcomes, babies born to women in the planned home birth group were less likely to experience prematurity and low birth weight. However, babies born to women in the planned home birth group were more likely to experience neonatal death compared to women in hospital birth.

What is the difference between neonatal and perinatal mortality? What does this have to do with the results?

Based on the definitions given by the authors, neonatal mortality was defined as “death of live born child within 28 days of birth.” This is a subset of an overall outcome– perinatal mortality, which was defined as “stillbirth (of at least 20 weeks or 500g) or death of live born child within 28 days of birth.”

According to the authors, there were no differences in perinatal death (the overall outcome) between planned home birth and hospital birth groups. However, homebirth was associated with 2 times higher risk for neonatal death (the subset of deaths occurring 28 days after birth) in all infants and 3 times higher risk for neonatal death in infants who did not have any congenital birth defects.

Interestingly, if you look at page 243.e3, the authors did a sensitivity analysis. In this analysis, they excluded the studies that had home births that were not attended by certified midwives or certified nurse midwives. In this analysis, they found that there were no differences in neonatal deaths between the home birth and hospital birth groups. This means that in the studies in which midwives with certification of some kind attended home births, the outcomes were the same except there was no increase in the neonatal death rate. In my opinion, we have to pay attention to results of sensitivity analyses because this allows us to see the results based on studies which were definitely known to be eligible or clearly described their methods and outcomes.

What is your opinion on the scientific rigor of this meta-analysis?

One thing that was strange to me is the odds ratios (ORs) in the tables. For example, in table 2, under morbidity, the percentages of infection between home births and hospital births were 0.7 vs. 2.6 (its OR was 0.27) while percentages of perineal laceration were 42.7 vs. 37.1 (its OR was 0.66). To a researcher, these numbers don’t make sense.

Many of the studies included were older (half of the studies were conducted more than 20 years ago) so results may not reflect the current practice at home births or hospital births.

The authors did not provide detailed information on how they evaluated the quality of studies included, although they cited a paper describing the method of study evaluation. This makes it difficult if not impossible to determine whether the studies they included were of good or poor quality.

The authors mentioned that women with high risks would prefer hospital births so that it would expect that home births have better outcomes than hospital births in some maternal and neonatal outcomes. If this was a concern, I wonder why the authors didn’t just focus on only the studies that used matching methods, in order to minimize confounding factors.

What is the difference between relative risk and absolute risk, and how does that apply to women who want to have a home birth?

Absolute risk is the probability of something occurring. They may be expressed as percentages or ratios. For example, neonatal mortality rate in the United States is 2.01 per 1,000 live births. This is .201 percent (2.01/1000 = .201/100).

http://www.flickr.com/photos/mikeporcenaluk/3789756395/

Relative risk is a comparison between different risk levels, such as the neonatal mortality rate of home birth compared to the neonatal mortality rate of hospital birth. The researchers found that there was a higher relative risk in neonatal mortality at home births compared to hospital births, but the overall absolute risk for both was small.

How can women know whether the Wax study results would be applicable to their own individual situation?

Meta analysis is one way to generalize findings from different studies. However, women and clinicians should interpret these results cautiously because the studies included were very different from one another and some of the studies included may not have been of good quality. Also, it would be important to note that the overall neonatal death rate that they report reflects home births that were attended by midwives as well as those that may not have had any kind of certified midwife present.

Because this study seems to have some flaws, the conclusion is tentative. I do not know if this article has any implications for pregnant women.

What do you think is the value of asking someone with no conflicts of interest to evaluate controversial research? Does Dr. Lee’s even-handed critique make you view the results of this study any differently? How do you feel about Dr Lee’s conclusion that the study’s results are tentative, and that the Wax study might not have any implications for pregnant women? Please share your thoughts and comments with other readers.

References

(2011). “ACOG Committee Opinion No. 476: Planned home birth.” Obstetrics and gynecology 117(2 Pt 1): 425-428.

Wax, J. R., F. L. Lucas, et al. (2010). “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” Am J Obstet Gynecol 203(3): 243 e241-248.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

Babies, Childbirth Education, Evidence Based Medicine, Guest Posts, Home Birth, Metaanalyses, Midwifery, New Research, NICU, Research , , , , , , , , , , , ,

Book Review: Optimal Care in Childbirth: The Case for a Physiologic Approach Reviewed Through a Childbirth Educator’s Eyes

October 18th, 2012 by avatar

I had waited excitedly for the release of Henci Goer and Amy Romano’s new book for a long time and was delighted to receive it after it was published in May 2012. Optimal Care in Childbirth: The Case for a Physiologic Approach was a robust, updated successor to Henci’s previous book; Obstetric Myths Versus Research Realities which was a well used source on my office bookshelf.

Both authors have a long history with Lamaze International. Prior to her current position with Childbirth Connection, directing the Transforming Maternity Care Partnership, Amy launched Science & Sensibility, and provided a keen and critical eye when analyzing, reviewing and sharing research items with readers. Henci Goer has been the long time resident expert on the “Ask Henci” forum hosted by Lamaze International, providing and sharing resources on a wide variety of pregnancy and childbirth topics with consumers and professionals alike, as well as a regular contributor to this blog. Please read the full bios of Amy and Henci on their website, where you can find complete information on their work, background and other works that they have authored.

As the title clearly states, this book is about childbirth, and as such, you will not find information on pregnancy, breastfeeding or newborn topics. Nor is this the type of text that childbirth educators would hand out in class for consumers to use. This book is heavy with sources, study outcomes and insights into current obstetric practices. But, as a guide to best practice, the book becomes a great repository of information that allows consumers and professionals alike to learn and make decisions about care that can help keep birth as physiological as possible. The book focuses on what factors affect, both positively and negatively, birth, so that an optimal outcome can occur.

The authors define optimal outcomes as “the highest probability of spontaneous birth of a healthy baby to a healthy mother, who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and goes on to breastfeed successfully.”

The chapters are well organized, with the topic of cesareans starting things off. Cesarean rates have never been higher, and many of the topics that Goer and Romano discuss later in the book often have the unintended consequence of contributing to the skyrocketing cesarean rates in this country. I think it is an important topic and one that receives a thorough evaluation by the authors.

Each chapter starts off with “contradicting” quotes from researchers working in the field of obstetrics, and I have to say, that reading these at the beginning of each chapter was something I looked forward to, a nice added bonus and really made me pause and consider the different viewpoints and how they influence practice today. The lead in for chapter 12 on epidurals and spinals contains one of my favorites:

“There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe interventions, while under a physician’s care.” ACOG 2006

“Epidural anaesthesia remains one of childbirth’s best exemplars of iatrogenesis. It is a wonderful intervention for managing labour complications, especially as an alternative to general anaesthetic for caesarean sections, but has significant side effects that constantly need weighing alongside benefits. Though its rising popularity almost grants it the status of normative practice on some [U.K.] maternity unites, it remains incompatable with physiological labour.” Walsh 2007

Each chapter begins with a wonderful perspective on each topic, sharing history and cultural practices so the reader can understand how standard protocols found in most birthing facilities have come to be, even when not backed up by research. I think it is critical to include this information, for if there is to be a shift to more evidence based care in the field of obstetrics, we need to be aware and acknowledge that some practices may have evolved for legal, cultural, social or policy reasons having nothing to do with sound research.

The authors ask and answer the very questions that I find myself asking out loud, helping the reader to understand why we continually observe care that is known to not improve outcomes. For example, when discussing electronic fetal monitoring, the question “Why does use of continuous EFM persist?” in normal low risk labors is asked (and thoroughly answered) with supporting references for further information.

Each chapter contains a brief summary of action steps that women can take to receive optimal care, along with the supporting research that backs up these steps. These lists are great talking points both for educators to integrate in their classrooms, but also for consumers to discuss with their health care providers and understand why their care might deviate from that supported by research.

The conclusion of each chapter has what the authors call a “mini-review” and neatly summarizes the important topic statements and provides (and references) outcomes of studies so that the reader can evaluate for himself or herself the validity of the research. Though these sections are called reviews, I found them to be a very helpful component of the book, when looking for solid sources.

At the end of each chapter, all of the sources referenced in that chapter are listed.

Henci Goer

I was very appreciative throughout the book, for the definitions that the authors provided when discussing a topic. It is important (and helpful) to know how terms are defined, so that the reader can best understand the discussion. For example, in one of the cesarean chapters, one can find a list of “rate” terms, so when “primaparous cesarean rate” is discussed, this term has already been explained.

Several places throughout the book, in various callout boxes, Goer and Romano discussed the selective language that health care providers use when talking about childbirth and presenting information to families. I found these small detours fascinating, as I am very interested in the language that HCPs use to discuss risk, procedures and events with their patients.

The last chapters of the book take a look at choice of birth location, what the ideal maternity care system might include and includes information on maternal mental health. The appendices speak to common “less than optimal” situations, such as the OP fetus in labor, meconium staining and other circumstances that frequently cause concern and labor interventions. Again, the authors include information on optimal care in these cases that can help.

It is clear from some of the phrasing, chapter titles and choice of words in some of the discussions, that the authors have a bias towards a childbirth process that unfolds in a natural and physiological manner. This language, while potentially off-putting to those who firmly believe in the medical model, is effective in causing the reader to consider standard practices that make no logical “sense”, and certainly, references are provided for further research should the reader wish to investigate further.

I must say that I very much enjoyed this book, and I will find it very useful in my doula and Lamaze childbirth education practice. It is the type of book that one thumbs through frequently, when asked a question by a student or client, or when helping a client to prepare to speak to their health care provider about best practices and birth preferences. I think that any birth professional would do well to have this book on their shelf and be able to refer to it when necessary. This book represents a significant amount of research and I find great comfort in knowing that all the resources and references supporting the statements made in the book are available for me to source myself.

Amy Romano

I look forward to the release of the e-book version of this title, expected this fall, for the Kindle, iPad and other tablets, so that I could have easy access from wherever I am. I would be delighted if the references and sources could be routinely updated as new research is released and published, so that I can use this guide for many years to come, confident that it reflects the newest and most valid research. I know that is a formidable task, but I would gladly pay a small subscription fee to have an updated version as often as necessary.

This book is available for purchase from both Amazon.com and the Optimal Care in Childbirth website. The book is on the expensive side, costing approximately $50.00, but very well may become the go-to source for evidenced based research on your office shelf, so worth the investment. If you choose to purchase from the book’s site, there are bulk and wholesale discounts available.  For purchases made from the book’s website, the authors are providing a 15% discount for our Science & Sensibility blog readers and conference attendees. Enter code UXJXI52F at checkout to receive the discount.

I hope that you are planning to attend the upcoming Lamaze International Innovative Learning Forum next week, where both Amy Romano and Henci Goer have been invited to speak. You will have an opportunity to meet these authors, ask them questions, purchase this book and hear their powerful presentations. As a General Session Speaker, Amy’s session will be available as part of the “Virtual Conference” option for those unable to attend the conference in person.

Have you read Optimal Care in Childbirth?  Are you using it already in your practice?  Please share your thoughts and comments in our comment section here on the blog.  I look forward to hearing your views. – SM

References

ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol 206;107(6):1487-8.

Walsh D. Evidenced Based Care for Normal Labor and Birth. London: Routledge; 2007.

Book Reviews, Cesarean Birth, Childbirth Education, Epidural Analgesia, Fetal Monitoring, Healthcare Reform, informed Consent, Lamaze 2012 Annual Conference, Maternal Mental Health, Medical Interventions, New Research, Pain Management, Practice Guidelines, Research, Systematic Review, Transforming Maternity Care , , , , , , , , ,

Location, Location, Location! Choosing a Teaching Space for Maximum Learner Value and Retention

October 16th, 2012 by avatar

Lamaze Childbirth Educators work hard to be innovative and creative when designing their childbirth classes.  Today’s post is another in an occasional series highlighting different methods for teaching birth classes.  Kim James, CD(DONA), CD(PALS), ICCE, LCCE, BDT(DONA), who demonstrates that with some planning and thinking “outside the box,” childbirth educators can enhance the learning experience and confidence of the families that are going through their childbirth classes. Kim shares her techniques for using her local hospital’s “Easy Street® Rehabilitation simulation environment” for her Lamaze classes in Seattle, WA.  

Here is the first post in the series. Do you teach in an unusual location, an uncommon way or a unique population.  Please contact me, Sharon Muza, S&S Community Manager if you are interested in being profiled and sharing your individuality!- SM

When you train for a marathon, practicing on the actual race course helps you familiarize with what to expect, uncover potential challenges and pitfalls and increase your confidence that you’ll know what to do when the time comes.  Route familiarity equals increased confidence about one’s ability to navigate the course by removing uncertainty and results in more satisfaction with the race event.

Easy Street View

Couldn’t the same be true for teaching Lamaze classes?  What if we taught our classes in the actual places where women have their babies?  We know the birth environment critically influences the laboring woman’s behavior, often by increasing or decreasing her fear, tension and pain. (Nolan and Foster, 2005 and Hodnett, et al, 2009)  What if women felt like they owned their childbirth space, free to move, sing, and manipulate the environment to her advantage and comfort?

By choosing to teach in the very rooms where women will give birth, we as Lamaze childbirth educators can help women and their families:
1) Increase their control over their responses and reactions to their labors

2) Create realistic expectations about what is possible

3) Become confident and challenging consumers of maternity care services

4) Increase the value and relevance of our classes to the families we serve

Very few of the families who take our classes plan to have their babies in the conference rooms, lecture halls and lobbies where classes are often scheduled.  Let’s expand our vision of where classes need to be located for maximum relevance and skill retention.

The idea is not new.  In “Birth and Parenting Skills:  New Directions in Antenatal Education” (2005), Mary Nolan and Julie Foster describe the “Birth Ideas Workshops” at Birmingham Women’s Hospital (United Kingdom) where sessions are held in a labor and delivery rooms.  The genesis of birthing room childbirth preparation classes come from this idea:

“Women need to know that they aren’t merely visitors to the labor and delivery floor.  They have the right to negotiate and to adapt the environment where possible to fit with their needs.”

Car and Home available for practice

When I first heard about the Birth Ideas Workshops, teaching Lamaze classes in an actual labor and delivery room captured my imagination.  In 2012, I finally had the opportunity to try it.

Teaching Lamaze classes outside the classroom wouldn’t have been possible without the incredible team at Northwest Hospital and Medical Centerin Seattle, Washington.  The encouragement by Cheryl Cummings BSN,RN,CDE, Clinical Coordinator, Diabetes Services and Community Education leader to use all available resources within the hospital was particularly valuable.

The importance of team-wide support cannot be overstated.  In Nolan and Foster’s experience of setting up the Birth Ideas Workshops at Birmingham Women’s Hospital, the biggest challenge were the attitudes of staff whose practice over the years had become entrenched in the medical model and routine ways of conducting childbirth classes and labor and delivery tours.  The gracious,  collaborative and can-do attitude of the clinical and support staff at Northwest Hospital and Medical Center meant my requests for trying something new were always met with “How can we help?”

Besides the fantastic staff, Northwest Hospital and Medical Center has another element that made this the right place for teaching Lamaze classes outside the classroom:  The Easy Street® Rehabilitation simulation environment.  This life-size replica of a city street, including a grocery store, restaurant, bank, laundromat, bus stop, movie theater and home with a kitchen, dining room, bedroom and car allows class members to practice physical coping skills and comfort measures in a real-world setting.  It’s enough to make any childbirth educator drool.  See all the amenities of Easy Street at the virtual tour here.

When Do I Get Out of the Classroom? 

I teach an eight-week Lamaze series of two-hour-long classes.  In the first five weeks, we spend 30% of our class time practicing physical and mental coping skills.  In classes 1-3, we are mostly in our classroom, learning and practicing basic coping skills.  By class 4 and 5, we’re ready to apply our skills in real-world settings.

Here’s our typical physical coping skill practice schedule:Class 1(classroom):  Body awareness, relaxation and conditioning exercises (30 mins)

Class 2(classroom, Easy Street):  Positions, movement and touch relaxation techniques (30 mins).  We visit Easy Street to talk about how to manage early labor at home.  The simulation area provides real life opportunities to practice and imagine using coping skills while in a restaurant, movie theatre and grocery store.  Parents can visualize going about their day and how they’d plan their reactions if they had a few contractions in public places.

Class 3(classroom):  Positioning, strategies and techniques for pushing in the second stage (30 minutes)

Class 4(Easy Street):  Coping skills and positioning techniques for long, slow labors and labors complicated by back pain.  (45 mins).  By holding class in the Easy Street simulation, we have access to:

• Curbs to practice curb walking for asymmetric pelvic positioning

• Kitchen counters where partners and pregnant parents can practice dangle squatting.

• A dining room table for forward-leaning positions.

• Stairs to practice lunges.

• A plush, full size bed for getting into open-knee chest and exaggerated sims positions.

• A full size car for strategizing how to cope with contractions on the ride to the birth place while in labor.

• Chairs, both straight-back and upholstered for practicing knee presses.

• A freezer and microwave for hot and cold back pain comfort measures.

• Comfortable, clean carpeting and rugs for getting on the floor to practice the double hip squeeze

 Class 5(labor and delivery room):  All coping skills, positioning and relaxation techniques learned in the previous four classes.  (45 minutes)  On our final night we apply everything we’ve learned in an actual labor and delivery room using a labor rehearsal game.  Class members a play Cranium-style game where they act out a variety of labor scenarios.  During the labor rehearsal, class members get to:

• Configure the bed for a variety of pushing positions

• Set up the squat bar

• Locate and use the birth balls

• Strategize on a variety of positions and coping techniques for the bath and shower.

• Practice lunging, squatting and dangling using the counters, chairs tray tables, stools and benches in the labor and delivery room.

• Retrieve ice and water from the nutrition area

• Locate where towels and wash cloths are kept.

• Figure out how to manipulate the room’s ambience (lights, temperature, fresh air) to suit their needs.

By the end of class five, class members by and large feel they “own” their labor and delivery space.  Comments from class members in July, 2012:

“I’m feeling a lot more confident about being here.  My anxiety and fear are so much lower. ”  “I know what to ask for”.  “I could really see myself just staying in the bathroom with the door closed for most of the time”.  “Could I just have my baby in that little house?  Will the nurses come down there?”

Bedroom, dining room and kitchen (not visible) available for practice)

To conclude, I urge my fellow Lamaze educators to think about the location where you teach.  Does your location add value and relevance to your content?  Are you able to easily practice physical and mental coping skills?  What would it take to teach all or part of your Lamaze classes outside the classroom for increased value and relevance to your class members?

References

Hodnett, E. D., Stemler, R., Weton, J. A. McKeever, P., Re-Conceptualizing the Hospital Labor Room:  The PLACE (Pregnant and Laboring in an Ambient Clinical Environment) Pilot Trial, May 2009.

Nolan, M. L., and Foster, J., Birth and Parenting Skills:  New Directions in Antenatal Education  (Elsevier, 2005) 85.

About Kim James

Kim James is an ICEA and Lamaze International certified childbirth educator teaching at Parent Trust for Washington Children/Great Starts where she sits on the Education Committee. She owns and operates www.DoulaMatch.net and is a DONA International and PALS Doulas certified birth doula as well as a DONA-approved birth doula trainer working at the Simkin Center/Bastyr University. Kim also volunteers her time on the Lamaze International membership committee and serves as Washington State DONA SPAR. Her daughters are 7 and 14 years old.  Kim and her family live in Seattle, Washington.

Childbirth Education, Guest Posts, Healthy Birth Practices, Healthy Care Practices , , , , , ,