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Teacher Turned Student: Week One of Childbirth Education Class: What Effect Does Authoritative Knowledge Have on Childbirth Education Classes?

April 22nd, 2011 by avatar

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted by:  Kimmelin Hull, PA, LCCE

Authoritative Knowledge, Childbirth Education, Continuing Education, Films about Childbirth, Uncategorized , , , , , , , ,

When Conflict of Interest Threatens the Quality of Education

December 21st, 2010 by avatar

A few weeks ago, I was invited to teach a one-time, free, community education class on breastfeeding basics.   As an independent, Lamaze Certified Childbirth Educator in my community, I was happy to oblige—recognizing that low-cost or no-cost community health education classes play an important role in any and all communities.  Being passionate about the dissemination of accessible, evidence-based lactation information, I was more than happy to volunteer the information normally apart of my eight-week childbirth preparation series.

But there was a catch.

My invitation to teach came from a neighbor of mine who owns the local baby supply store in town.  While her secondary reason for offering occasional classes on location, in her store was to further her hard-earned reputation as a one-stop-shopping depot for all things baby—even to the point of providing monthly free classes on varying topics of interest to pregnant, nursing and new mothers during which new and expectant women can mingle and make social connections—her primary purpose was to increase store traffic and, therefore, sales.

A sub-section of Lamaze International’s Code of Ethics for Childbirth Educators speaks to the issue of Conflict of Interest:

1.06 Conflicts of Interest

(a)    Childbirth educators should be alert to and strive to avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. When a real or potential conflict of interest arises, childbirth educators should first disclose the conflict to clients and then take reasonable steps to resolve the issue in a manner that prioritizes the clients’ interests and protects clients’ interests to the greatest extent possible.

How did this invitation to teach (on a volunteer basis) a single class challenge the code of ethics I, as an LCCE, have promised to abide by?  The possibility that my instruction would include subversive or overt recommendations of in-store products the store owner hoped I would incorporate into the two-hour class.

“Feel free to stop on by the store a day or two before the class to see what all we have in stock—that way you’ll know which products to mention when talking about breastfeeding,” my neighbor suggested.  “We’ll probably offer some sort of discount the night of the class for anything purchased that evening.”

Should I have been concerned with the amount of sales generated by my overview on the anatomy, physiology, practice and benefits of breastfeeding?  Of course not.  Would I have been in breach of my promise to uphold Lamaze’s Code of Ethics in regards to Conflict of Interest, had I accepted the invitation to teach this class?  Well, let’s see:

Disclaiming a conflict of interest entails confessing any sort of financial reimbursement given to a conference speaker, health care provider, instructor or administrator (or to his/her family member) that might influence his/her decision to use, recommend or employ a certain product, service or practice of care.  So, by definition, because I was not being paid to teach this class, I would not have technically been in breach of my Lamaze Code of Ethics commitment.

The slippery slope, however, became evident in this business owner’s expectation that the content of my presentation would directly entice class participants to buy certain products, based on my recommendations under the guise of authoritative knowledge.  If, for example, I swore by the functionality of the most expensive breast pump in the store—raving about its ability to support the continuation of breastfeeding over long periods, including mother’s-return-to-work-scenarios, and its status as a “must have” product for all moms with infants, despite the previous ten-minute mini-lecture I’d provided on the supply and demand system of lactation—that could have been perceived by my students as advice on a product they “should” have at home in order to succeed at breastfeeding.

If, however, I mentioned and even showed examples of breastfeeding-related products in conjunction with curriculum content—for example, providing a visual demonstration of how to determine a “good” versus “bad” nursing bra in terms of support, proper fit, lack of underwire structure and easy release of cup latch—would this be considered entering the dangerous waters of Conflict of Interest?  I would argue the answer here is, “No.”

Obviously, receiving a monetary kick-back for each sale made of a particular item, or a percentage of total sales on the night of my class would be a brazen breach of ethics on my part and I’m happy to say such an arrangement was never discussed by business owner nor educator.

I did, in fact, go on to teach the one-time class in question—Conflict of Interest and guilt free, and in the presence of a lovely, invested, intelligent, un-coerced audience!

Ethics can be a tricky thing and, I for one, am thankful for Lamaze International’s clear delineation of the Ethical Standards by which it expects its certified educators, employees and agents to abide.  Wouldn’t it be fantastic to see all professional organizations follow suit?

Posted By:  Kimmelin Hull, PA, LCCE

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