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Epidural Analgesia: To Delay or Not to Delay, That Is the Question

October 23rd, 2014 by avatar

By Henci Goer

Unless you have been “off the grid” on a solitary trek, surely you have read and heard the recent flurry of discussion surrounding the just released study making the claim that the timing of when a woman receives an epidural (“early” or “late” in labor) made no difference in the rate of cesarean delivery.  Your students and clients may have been asking questions and wondering if the information is accurate.  Award winning author and occasional Science & Sensibility contributor Henci Goer reviews the 9 studies that made up the Cochrane systematic review: Early versus late initiation of epidural analgesia for labour to determine what they actually said.  Read her review here and share if you agree with all the spin in the media about this new research review. Additionally, head on over to the professional and parent Lamaze International sites to check out the new infographic on epidurals to share with your students and clients.- Sharon Muza, Science & Sensibility Manager. 

Epidural infographic oneArticles have been popping up all over the internet in recent weeks citing a new Cochrane systematic review- Early versus late initiation of epidural analgesia for labour, concluding that epidural analgesia for labor needn’t be delayed because early initiation doesn’t increase the likelihood of cesarean delivery, or, for that matter, instrumental vaginal delivery (Sng 2014). The New York Times ran this piece. Some older studies have found that early initiation appeared to increase likelihood of cesarean (Lieberman 1996; Nageotte 1997; Thorp 1991), which is plausible on theoretical grounds. Labor progress might be more vulnerable to disruption in latent than active phase. Persistent occiput posterior might be more frequent if the woman isn’t moving around, and fetal malposition greatly increases the likelihood of cesarean and instrumental delivery. Which is right? Let’s dig into the review.

The review includes 9 randomized controlled trials of “early” versus “late” initiation of epidural analgesia. Participants in all trials were limited to healthy first-time mothers at term with one head-down baby. Five trials further limited participants to women who began labor spontaneously, three mixed women being induced with women beginning labor spontaneously, and in one, all women were induced. Analgesia protocols varied, but all epidural regimens were of modern, low-dose epidurals. So far, so good.

Examining the individual trials, though, we see a major problem. You would think that the reviewers would have rejected trials that failed to divide participants into distinct groups, one having epidural initiation in early labor and the other in more advanced labor, since the point of the review is to determine whether early or late initiation makes a difference. You would think wrong. Of the nine included trials, six failed to do this.

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

The two Chestnut trials (1994a; 1994b) had the same design, differing only in that one was of women who were laboring spontaneously at trial entry and the other included women receiving oxytocin for induction or augmentation. Women were admitted to the trial if they were dilated between 3 and 5 cm. Women in the early group got their epidural immediately while women in the late group could have an epidural only if they were dilated to 5 cm or more. If late-group women were not dilated to 5 cm, they were given systemic opioids and could have a second dose of opioid one hour later. They could have an epidural when they attained 5 cm dilation or regardless of dilation, an hour after the second opioid dose. Let’s see how that worked out.

Among the 149 women in the trial that included women receiving oxytocin (Chestnut 1994b), median dilation in the early group at time of epidural initiation was 3.5 cm, meaning that half the women were dilated more and half less than this amount. The interquartile deviation was 0.5 cm, which means that values were fairly tightly clustered around the median. The authors state, however, that cervical dilation was assessed using 0.5 increments which meant that dilation of 3-4 cm was recorded as 3.5. In other words, women in the early group might have been dilated to as much as 4 cm. The median dilation in the late group was 5.0 cm, again with a 0.5 cm interquartile deviation. Some women in the late group, therefore, were not yet dilated to 5 cm when their epidural began, and, in fact, the authors report that 26 of the 75 women (35%) in the late group were given their epidural after the second dose of opioid but before attaining 5 cm dilation. The small interquartile deviation in the late group tells us that few, if any, women would have been dilated much more than 5 cm. Add in that assessing dilation isn’t exact, so women might have been a bit more or less dilated than they were thought to be, and it becomes clear that the “early” and “late” groups must have overlapped considerably. Furthermore, pretty much all of them were dilated between 3 and 5 cm when they got their epidurals, which means that few of these first-time mothers would have been in active labor, as defined by the new ACOG standards.

Overlap between early and late groups must have been even greater in Chestnut et al.’s (1994a) trial of 334 women laboring spontaneously at trial entry because median dilation in the early group was greater than in the other trial (4 cm, rather than 3.5) while median dilation in the late group was the same (5.0 cm), and interquartile deviation was even tighter in the late group (0.25 cm, rather than 0.5 cm). As before, dilation was measured in 0.5 cm increments, which presumably means that women in the early group dilated to 4-5 cm would have been recorded as “4.5,” thereby qualifying them for the “early” group even though they might have been as much as 5 cm dilated.

Based on my analysis, I would argue that there was no clinically meaningful difference in dilation between early and late groups in either trial.

A second pair of trials, one a mixed trial of spontaneous labor onset and induction and the other all induced, also had the same design in both trials (Wong 2005; Wong 2009). All women were less than 4 cm dilated at first request for pain medication. In the early group, women had an opioid injected intrathecally, i.e. the “spinal” part of a combined spinal-epidural, and an epidural catheter was set. At the second request, an epidural was initiated. In the late group, women were given a systemic opioid. At second request, they were given a second dose of systemic opioid if they hadn’t reached 4 cm dilation and an epidural if they had dilated to 4 cm or more. At third request, they were given an epidural regardless of dilation. Women who had no vaginal exam at second request and were given an epidural were “assumed,” in the authors’ words, to be dilated to at least 4 cm. What were the results?

Wong (2005) included 728 women, some beginning labor spontaneously and some induced. You may already have noticed the flaw in the trials’ design: Wong and colleagues confused the issue by considering intrathecal opioid to be equivalent to epidural anesthetic in the early group, although women didn’t actually receive anesthetic until their second request for pain medication some unknown time later. So far as I know we have no evidence that opiods, spinal or epidural, have any effect on labor progress. As to dilation at the time of epidural initiation, 63% of women in the so-called “early” group were either determined or assumed to be at 4 cm dilation or more while in the late group, some unknown proportion were less than 4 cm dilated either because they got their epidural at third pain medication request regardless of dilation or they were assumed to be at 4 or more cm dilation at second request, but weren’t assessed.

Wong (2009), a study of 806 induced women, was set up the same way but reported data somewhat differently. Early-group women were administered a spinal opioid at a median of 2 cm dilation and an interquartile range of 1.5 to 3 cm, which means that values in the middle 50% of the dataset ranged from 1.5 to 3 cm. We have no information on dilation at the time they received their epidural. The median dilation at which late-group women had their epidural initiated was 4 cm with an interquartile range of 3 to 4 cm, that is, in the middle 50% of the dataset ranged from 3 to 4 cm dilation.

As with the Chestnut trials, dilation at time of epidural initiation in the two Wong trials must have overlapped considerably between groups. And, again, few women in the late epidural group would have been in active labor. The Wong trials, however, muddy the waters even further by considering spinal opioid to be the same thing as epidural anesthetic, and while the authors were careful to use the term “neuraxial analgesia,” the Cochrane reviewers made no such distinction.

This brings us to Parameswara (2012), a trial of 120 women that included both spontaneous onset and induced labors. This trial defined the early group as women less than 2 cm dilated at time of epidural initiation and the late group as women more than 2 cm dilated. That’s all the information they provide on group allocation.

Last of the six, we have Wang (2011), a trial of 60 women in spontaneous labor. All women were given intrathecal anesthetic plus opioid. The early group was started on epidural anesthetic plus opioid 20 minutes later whereas the late group had their epidural initiated when they requested additional pain relief. No information is given on dilation at time of epidural initiation. Not only do we have no idea whether early and late groups differed from one another, women in both groups received neuraxial anesthetic at the same time.

In summary, “garbage in, garbage out.” No conclusions can be drawn about the effect of early versus late epidural administration from these six studies.

The other three studies are a different story. They achieve a reasonable separation between groups. Luxman (1998) studied 60 women with spontaneous labor onset. The early group had a mean, i.e., average, dilation of 2.3 cm with a standard deviation of + or – 0.6 cm while the late group had a mean dilation of 4.5 cm + or – 0.2 cm. Ohel (2006) studied a mixed spontaneous onset and induced group of 449 women. The mean dilation at initiation in the early group was 2.4 cm with a standard deviation of 0.7 cm, and the late group had a mean dilation of 4.6 cm with a standard deviation of 1.1 cm. Wang (2009), the behemoth of the trials, included 12,629 women who began labor spontaneously. The early epidural group had a median dilation of 1.6 cm with an interquartile range of 1.1 to 2.8 and the late group a median of 5.1 cm dilation with an interquartile range of 4.2 to 5.7. Cesarean and instrumental delivery rates were similar between early and late groups in all three trials, so had reviewers included only these three trials, they would still have arrived at the same conclusion: early epidural initiation doesn’t increase likelihood of cesarean and instrumental delivery.

We’re not done, though. Wang (2009) points us to a second, even bigger issue.

The Wang (2009) trial, as did all of the trials, limited participants to healthy first-time mothers with no factors that would predispose them to need a cesarean. The Wang trial further excluded women who didn’t begin labor spontaneously. Nevertheless, the cesarean rate in these ultra-low-risk women was an astonishing 23%. Comparing the trials side-by-side reveals wildly varying cesarean and instrumental vaginal delivery rates in what are essentially homogeneous populations.

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

Comparing the trials uncovers that epidural timing doesn’t matter because any effect will be swamped by the much stronger effect of practice variation.

Analysis of the trials teaches us two lessons: First, systematic reviews can’t always be taken at face value because results depend on the beliefs and biases that the reviewers bring to the table. In this case, they blinded reviewers from seeing that two-thirds of the trials they included weren’t measuring two groups of women, one in early- and one in active-phase labor. Second, practice variation can be an unacknowledged and potent confounding factor for any outcome that depends on care provider judgment.

Conclusion

So what’s our take home? Women need to know that with a judicious care provider who strives for spontaneous vaginal birth whenever possible, early epidural administration won’t increase odds of cesarean or instrumental delivery. With an injudicious one, late initiation won’t decrease them. That being said, there are other reasons to delay an epidural. Maternal fever is associated with epidural duration. Running a fever in a slowly progressing labor could tip the balance toward cesarean delivery as well as have consequences for the baby such as keeping the baby in the nursery for observation, testing for infection, or administering prophylactic IV antibiotics. Then too, a woman just might find she can do very well without one. Epidurals can have adverse effects, some of them serious. Comfort measures, cognitive strategies, and all around good emotionally and physically supportive care don’t. Hospitals, therefore, should make available and encourage use of a wide range of non-pharmacologic alternatives and refrain from routine practices that increase discomfort and hinder women from making use of them. Only then can women truly make a free choice about whether and when to have an epidural.

After reading Henci’s review and the study, what information do you feel is important for women to be aware of regarding epidural use in labor?  What will you say when asked about the study and timing of an epidural?  You may want to reference a previous Science & Sensibility article by Andrea Lythgoe, LCCE, on the use of the peanut ball to promote labor progress when a woman has an epidural. – SM 

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology210(3), 179-193.

Chestnut, D. H., McGrath, J. M., Vincent, R. D., Jr., Penning, D. H., Choi, W. W., Bates, J. N., & McFarlane, C. (1994a). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology, 80(6), 1201-1208. http://www.ncbi.nlm.nih.gov/pubmed/8010466?dopt=Citation

Chestnut, D. H., Vincent, R. D., Jr., McGrath, J. M., Choi, W. W., & Bates, J. N. (1994b). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology, 80(6), 1193-1200. http://www.ncbi.nlm.nih.gov/pubmed/8010465?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Luxman, D., Wolman, I., Groutz, A., Cohen, J. R., Lottan, M., Pauzner, D., & David, M. P. (1998). The effect of early epidural block administration on the progression and outcome of labor. Int J Obstet Anesth, 7(3), 161-164. http://www.ncbi.nlm.nih.gov/pubmed/15321209?dopt=Citation

Nageotte, M. P., Larson, D., Rumney, P. J., Sidhu, M., & Hollenbach, K. (1997). Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med, 337(24), 1715-1719. http://www.ncbi.nlm.nih.gov/pubmed/9392696?dopt=Citation

Ohel, G., Gonen, R., Vaida, S., Barak, S., & Gaitini, L. (2006). Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol, 194(3), 600-605. http://www.ncbi.nlm.nih.gov/pubmed/16522386?dopt=Citation

Parameswara, G., Kshama, K., Murthy, H. K., Jalaja, K., Venkat, S. (2012). Early epidural labour analgesia: Does it increase the chances of operative delivery? British Journal of Anaesthesia 108(Suppl 2):ii213–ii214. Note: This is an abstract only so all data from it come from the Cochrane review.

Sng, B. L., Leong, W. L., Zeng, Y., Siddiqui, F. J., Assam, P. N., Lim, Y., . . . Sia, A. T. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev, 10, CD007238. doi: 10.1002/14651858.CD007238.pub2 http://www.ncbi.nlm.nih.gov/pubmed/25300169

Thorp, J. A., Eckert, L. O., Ang, M. S., Johnston, D. A., Peaceman, A. M., & Parisi, V. M. (1991). Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas. Am J Perinatol, 8(6), 402-410. http://www.ncbi.nlm.nih.gov/pubmed/1814306?dopt=Citation

Wang, F., Shen, X., Guo, X., Peng, Y., & Gu, X. (2009). Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology, 111(4), 871-880. http://www.ncbi.nlm.nih.gov/pubmed/19741492?dopt=Citation

Wang, L. Z., Chang, X. Y., Hu, X. X., Tang, B. L., & Xia, F. (2011). The effect on maternal temperature of delaying initiation of the epidural component of combined spinal-epidural analgesia for labor: a pilot study. Int J Obstet Anesth, 20(4), 312-317. http://www.ncbi.nlm.nih.gov/pubmed/21840705

Wong, C. A., McCarthy, R. J., Sullivan, J. T., Scavone, B. M., Gerber, S. E., & Yaghmour, E. A. (2009). Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol, 113(5), 1066-1074. http://www.ncbi.nlm.nih.gov/pubmed/19384122?dopt=Citation

Wong, C. A., Scavone, B. M., Peaceman, A. M., McCarthy, R. J., Sullivan, J. T., Diaz, N. T., . . . Grouper, S. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med, 352(7), 655-665. http://www.ncbi.nlm.nih.gov/pubmed/15716559?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, informed Consent, Medical Interventions, New Research, Systematic Review , , , , , , ,

The Role of the Childbirth Educator during a Perinatal or Infant Loss

October 14th, 2014 by avatar
Original Painting © Johann Heinrich Füssli

Original Painting © Johann Heinrich Füssli

As we continue to observe Pregnancy and Infant Loss Awareness Month, I would like to discuss a difficult topic that may come up for childbirth educators.  Last week, Robin Elise Weiss shared ways to commemorate the loss of a baby. Today, I would like to talk about when a class member experiences a perinatal loss while taking your class, or after the class is over.  If you work long enough as an educator, eventually this will be an issue that you are going to need to face.

Sometimes, you may be contacted by the family, with a somber email or phone call, letting you know that they won’t be returning to class. Other times, a family just stops coming, with no explanation, midway through a series.  You are not sure why.  Was it your teaching style?  Did they have their baby early?  Has something happened?  You will also have to consider that this family may have experienced a late term loss.

When a family does not return to class, I always suggest that the childbirth educator reach out to the family via phone or email to politely inquire and determine that all is okay.  Possibly the mother has been placed on bedrest and will need some accommodations or arrangements in order to complete her childbirth education.  Often, you will find out that something has come up and the date and time no longer work, and you breathe a sigh of relief at this information.  You may find out that their baby arrived prematurely, and you have an opportunity to connect them with resources that they may find useful while dealing with a baby in the NICU and adjusting to the new reality of having a baby weeks or months before they thought they would.  It is likely that their baby may require additional resources and have some immediate needs they had not thought about.  And sometimes, unfortunately, you learn that they have lost their baby either in utero or after birth.

If you are a successful childbirth educator, you work hard to build community in your childbirth classes, helping families to connect with each other through engaging activities and interactive learning.  The families start to see each other as resources and comrades in the transition to parenthood.  Connections are made, friendships are developed and a feeling of community is established.  You are faced with the task of sharing with the class that a family will not be returning.  They are missed and class members usually will be inquiring as to their absence.

When you learn of such a loss, I believe you have several responsibilities as a childbirth educator.  First, determine if the family is open to receiving resources that can help them as they deal with the loss of a baby.  These resources may included peer to peer and facilitated support groups in their community, counselors and therapists specializing in perinatal grief and loss, lactation consultants who can help with the transition of not needing to breastfeed, online resources to help them and more.

If there is a public funeral or memorial service, I make every attempt to attend if possible, in order to show my respect.  Sometimes this is not possible or the family has decided to keep the event private. Regardless,  I always try and promptly send a sympathy card to the family, expressing my sadness at the loss of their son or daughter.

I also politely inquire if they would like me to share the news with the rest of the class.  This information needs to be handled very sensitively.  The family may not want the news shared, and their privacy and wishes are my first priority.  But no doubt, someone in the class will soon ask where the missing family has gone.  In my experiences, the family usually has given me permission to share the information with the rest of the class.  This can be a huge challenge – finding a balance of informing the class and not creating fear and worry for them.

In my experience, the best way to share the information is toward the end of class, with just a few minutes to go.  I respect the family’s wishes and only share the information I have been asked to share.  I tell the truth, but I don’t feel the need to go into great detail.  I answer any questions from the class as best I can and stick to the facts, while respecting the family’s wishes.  If allowed, I provide information about a service or how to contact the family.  I acknowledge that this event is hard to hear, and may bring up concerns and fears for the class members. Sometimes families get very upset or cry as they hear the news.  I provide some resources where they can get more information and support, and also suggest they speak to their health care provider about their fears.  I make myself immediately available after class and in the future to listen to their concerns if they feel the need to connect.

Sometimes a family loses a baby after the class has ended, but before a reunion (if you do class reunions, which are very common here in my area.)  If I am made aware of the loss by the family, I follow the steps above, but ask how they would like me to handle sharing with the class.  I provide this information to those in attendance at the reunion, sharing only information as allowed by the family.

If you have class email lists, or Facebook groups for your childbirth classes, be sure to find out what the parents’ wishes are regarding remaining on the list or in the group.  Some families will want to be removed and others will want to stay connected.  When in doubt, I would discreetly remove them from further communication about class activities, baby announcements or planned gatherings.

Losing a baby during pregnancy or after birth is one of the most difficult things a family can experience.  Our society does not do a great job in honoring this type of loss.  The role of the childbirth educator becomes very important when one of your class members has lost a baby.  How you handle this loss, with both the family and with other class members is critical and can impact the experience of all.  As childbirth educators, we are in a unique position to help both the family and our other students when given permission by the grieving family.

Have you had this experience as a childbirth educator?  How have you handled this situation?  Do you have any tips for other educators in case they have a similar experience?  What did you find worked?  What did you do?  Please share your thoughts and suggestions along with any resources in our comments section.

 

 

 

 

Babies, Childbirth Education, Trauma work , , , ,

Updated “Birth By The Numbers” – A Valuable Tool for Childbirth Educators and Others

October 2nd, 2014 by avatar

birth by numbers header

One of the highlights of my attendance at the joint Lamaze International/DONA International Confluence in Kansas City, MO last month was the opportunity to hear Eugene Declercq, PhD, present a plenary session entitled “What Listening to Mothers Can Tell Us about the Future Challenges in US Maternity Care.”  Dr. Declercq is a professor of Maternal and Infant Health at Boston University School of Public Health. It is always a true pleasure to listen to Dr Declercq, not only for his delightful Boston accent, but also for the creative and impactful way that he shares data and facts about the state of maternity care, primarily in the United States.

declercq-headshotThis presentation was no exception and Dr. Declercq helped conference attendees to tease apart the information gleaned from the most recent Listening to Mothers III study, and look at this information  in relationship to data from the two previous Listening to Mothers studies.

Dr. Declercq reminded those of us in the audience that the most recent update of “Birth by the Numbers” was just made available on the Birth by the Numbers website.  I am a huge fan of the previous versions of this short film, that highlighted statistics on how the United States is doing on several key maternal and infant indicators in relation to other nations around the world.  The information continues to be both eye opening and sobering at the same time.  I encourage you to view the most recent edition included here.

I have seen Teri Shilling, the director of Passion for Birth, one of the Lamaze Accredited Childbirth Educator Programs, use the Birth by the Numbers video in a very clever way when training both doulas and childbirth educators.  This learning activity could also be adapted to use in your childbirth class.  Teri provides a worksheet with many of the important statistics that Dr. Declercq shares in his video, listed out.  The learner must watch the video and assign the correct definition to each relevant number listed.  It helps the viewer to really capture the significance of the different numbers, when they are closely listening for each one and then the video can be debriefed as a group.

Dr. Declercq’s website has tons of useful information that you can take into the classroom.  I subscribe to/follow the blog on his website and look forward to new articles when they come out.   Dr. Declercq also generously shares PowerPoint slides on both the “Birth by the Numbers” presentation as well as “Cesarean Birth Trends” that educators can freely use in their own classroom.

Should you be interested in maps and details on the cesarean birth trends for several other countries, including Australia, Brazil and Germany, that information is provided along with a state by state breakdown.

You can also find the updated Birth by the Numbers video on the Lamaze websites for professionals and for parents.

If you have not seen them, I also really enjoy Dr. Declercq’s  videos “The Truth about C-Sections” and “Debunking the Myth: Home Births are Dangerous” published in cooperation with Mothers Naturally

One last fun fact – did you know that Dr. Gene Declercq is a Lamaze Certified Childbirth Educator!   Thanks Dr. Declercq for all you do to get solid data to all of us in fun and informative ways.  I appreciate it.

A challenge for you! How might you use the information in the updated video and on the Birth by the Numbers website in your childbirth class, with doula clients or with the patients you care for?  Do you have any teaching ideas that you would like to share with Science & Sensibility readers?  I would love to hear your creative ideas and I know others would too.  Sharing teaching tips helps all of us become better educators.

 

 

2014 Confluence, Cesarean Birth, Childbirth Education, Films about Childbirth, Lamaze International, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, New Research, Research , , , ,

Series: Journey to LCCE Certification – Countdown to the Lamaze Certified Childbirth Educator Exam

September 25th, 2014 by avatar

By Cara Terreri, BA, Community Manager for Lamaze International’s Giving Birth With Confidence blog

Cara Terreri has been documenting her path to become a Lamaze Certified Childbirth Educator since taking her workshop in August of 2012, in our series: Journey to LCCE Certification. Today ,we have another update as she prepares to sit for the exam next month.  The LCCE credentials are the gold standard for childbirth educators and Cara, along with many other men and women worldwide, are seeing the culmination of learning and preparation coming to a close with an exam date scheduled for late October.  Get an update on Cara and share your exam tips for Cara and others in our comments section. Interested in becoming an LCCE? Find out more. – Sharon Muza, Community Manager, Science & Sensibility.

© Cara Terreri

© Cara Terreri

Since my last installment, my life has taken a near 180 degree turn. Birth work still remains my professional priority and passion of course, but after a huge move out of state, I will now pursue doula work and childbirth education – as well as take the LCCE exam — in Myrtle Beach, SC. When I would have been preparing to take the exam in April in Atlanta, I was in the thick of selling my house, packing out, and preparing my family to move to the East Coast. Thankfully, Lamaze gives you the option to defer taking the exam.

With one month to go until the exam date, I am spending my afternoons and evenings poring over the pages of the Lamaze Study Guide, in particular, the “review” sections for each core competency. Reviewing key questions help me to understand my weak points (pregnancy complications and prenatal tests) and give me a tighter focal point for studying. To further boost my knowledge, I attended the fantastic Lamaze International/DONA International joint conference (“confluence”) last week – the timing couldn’t have been better! The insightful sessions echoed many of the themes throughout the Study Guide. But perhaps most important, I was able to speak directly with several LCCEs about their experience with the exam. I heard things like “fair,” “read questions closely,” “common sense,” and “you’ll do great!”

In the days to follow, I plan to take the Exam Prep Course from Lamaze, which includes a practice test. I feel fairly confident about my depth of knowledge, but this is like the extra bit of insurance I want before the big day.

Of course, taking the LCCE exam is just the tip of the iceberg for me professionally, since having relocated to a new area. Now that my kids are in school and we’re more settled, my goal is to build relationships with local educators, doulas, and lactation professionals, along with moms and families. Lots of work to do, and I’m so energized by my drive to help women and families, I want to do it all! But I remind myself that the key is to help, not help everyone. This will likely be my life’s work and because it is not my sole source of income currently, I do as much as I can that works into my stage and place in life.

Readers, I would love to hear your thoughts on the Lamaze exam! Any last-minute tips? Suggestions for studying?  How to calm those last minute jitters? And of course, positive thoughts in my (and all the exam test takers) direction would be much appreciated next month on “game day”!  I will update readers after I take the exam.  And of course, will share my results – hopefully a passing grade.

About Cara Terreri

Cara began working with Lamaze two years before she became a mother. Somewhere in the process of poring over marketing copy in a Lamaze brochure and birthing her first child, she became an advocate for childbirth education. Three kids later (and a whole lot more work for Lamaze), Cara is the Site Administrator for Giving Birth with Confidence, the Lamaze blog for and by women and expectant families. Cara continues to have a strong passion for the awesome power and beauty in pregnancy and birth, and for helping women to discover their own power and ability through birth. It is her hope that through the GBWC site, women will have a place to find and offer positive support to other women who are going through the amazing journey to motherhood.

 

2014 Confluence, Childbirth Education, Giving Birth with Confidence, Lamaze International, Series: Journey to LCCE Certification , , , ,

Black Infant Mortality and the Role of the Childbirth Educator and Doula

September 16th, 2014 by avatar

By Sherry L. Payne, MSN, RN, CNE, IBCLC, CD(DONA)

September is National Infant Mortality Month and today, Sherry L. Payne, MSN, RN, CNE, IBCLC, CD(DONA) shares what she and her organization, Uzazi Village, are doing to help reduce infant mortality in the Black community, where Black babies are disproportionately affected.  You are invited to join Sherry and her team at a reception for Doulas of Color and Allies on Friday.  See below for more information.  I plan to be there and look forward to seeing many of our conference attendees there as well. – Sharon Muza, Community Manager, Science & Sensibility.

© NationalHealthyStart.org

© NationalHealthyStart.org

 

I am fresh off the trail, the Missouri Katy Trail, that is. From September 1-12th, I organized the Black Infant Mortality Awareness Walk. My goal was to walk across the midsection of Missouri talking to clinicians, academics, legislators, and policy makers along the way about the high infant mortality rates in the Black community. I chose to walk during the month of September because it is National Infant Mortality Month. I started off in Kansas City, MO and ended in St. Louis MO, walking along the Katy Trail and driving between towns. Now that the walk is behind me and the DONA/Lamaze Confluence ahead of me, its time to think about the message that doulas and childbirth educators need to hear about Black infant mortality. Black infant mortality is a silent epidemic, that is killing our babies and ravaging our communities.

If we don’t all experience equity in health care, than none of us really does.  Sherry Payne

What is infant mortality? It is a statistical term that refers to the number of infant deaths (from birth to age one) for every 1,000 live births. Infant mortality rates are used as a sensitive indicator of community health. Counties, cities, even countries depend on their infant mortality rates and their rankings to tell them how they are doing in protecting the health and wellbeing of their most vulnerable citizens. The United States currently ranks 55th in the world for infant mortality at about 6 deaths per 1,000 live births.  (CIA Factbook) That doesn’t sound too bad until you compare the US to other industrialized nations like Japan with an infant mortality rate of 2 deaths per 1,000 live births, or Canada with a rate of 4 deaths per 1,000 live births. (CIA Factbook). In fact, compared to other industrialized nations, the US does rather poorly on its infant mortality statistics.

© Jordan Wade

© Jordan Wade

What’s behind the high rates of infant deaths in the US? Well, if you look closely, you’ll see that the high numbers come from within communities of color, particularly the African-American community. In Missouri, for example, if you examine the data by race, you will find that infants in the African-American community are 2-4 times more likely to die prior to their first birthday than their Caucasian counterparts. (Missouri Foundation for Health, 2013.) According to the CDC, infant mortality rates have been dropping among all racial groups, but the difference between death rates among Whites and Blacks persist.  Audiences I spoke to all across Missouri were shocked to learn that the African-American community experiences so much more infant death. Of course, its not just Missouri, these disparities are present throughout the United States.

What are the causes of infant deaths in the Black community?  The March of Dimes lists the frequent causes of infant mortality as prematurity, and complications of prematurity.  Other causes listed in the Kansas City Fetal Infant Mortality Review Report include; low birth weight, lack of access to prenatal care, delayed prenatal care, and poor quality of prenatal care, SIDs and unsafe sleep environments.  These problems are often exacerbated by overarching systemic and structural racism that unfairly targets and penalizes African-American women.  Here in Missouri, low income women can wait up to six months or more to be approved for Medicaid, and often may not be able to start prenatal care until they are approved.  

What can doulas and childbirth educators do about Black infant mortality? Well plenty, actually. Doulas have already been shown to be effective in lowering induction and prematurity rates. (Hodnett, Gates, Hofmeyr, & Sakala, 2013.)  Doulas and childbirth educators by the very nature of their work, assist healthcare consumers in being better informed about their childbearing options. Doulas provide the one on one support that is needed by any woman to boost her confidence in her ability to endure the rigors of childbirth without excessive use of interventions that can place a mother and her baby at greater risk. Childbirth educators can ensure that women understand informed consent and know how to advocate for it. They can both prepare a woman for successful breastfeeding which is protective for sick and vulnerable infants.

But aren’t low income African-American women, the women most likely to be affected by poor birth outcomes, the least likely to interface with doulas and childbirth educators? Yes, that is true. One of the ways to solve that problem is to recruit, promote, and support candidates of color into these fields. There are plenty of women of color who want to do this work, but they often lack the resources. They need the help of allies to provide resources, scholarships, internships, discounts, etc. to assist in getting through expensive trainings. Not all women of color need financial assistance, but for those who do, it can be a formidable barrier. They also need accessible pathways into the profession. If your organization is hosting a training, communicate that within your local communities of color, so that others have a possibility of sharing in the educational opportunities. Do you have women of color as clients in your practice? Invite them to consider becoming doulas or childbirth educators when the time is right for them. They may not consider it a possibility until someone else brings it up as an option.

To learn more about how doulas and childbirth educators can positively impact infant mortality in the Black community, attend my session at the upcoming conference, “Doulas in the Hood: Improving Outcomes Among Low Income Women.” You’ll learn about programs in Missouri and other states that have created successful models that link doulas with low income women. You’ll hear what we are doing here in Kansas City to bridge the needs gap for low income African-American women, for breastfeeding support, for culture specific childbirth education, and for peer model doulas.

Do Black women need Black doulas and childbirth educators?  In a perfect world, my answer would be yes.  It is important for a woman to have a doula or childbirth educator that shares her cultural/world view and understanding of birth and parenting.  However, while there simply are not enough African-American doulas, and childbirth educators out there, those who do serve African-American clients have a responsibility to educate themselves about the issues that impact communities of color.  Examine your own internal biases (everyone has them).  Take a look at your practice.  Would it be inviting to other women of other cultures, races, and ethnicities?  Refer to Science & Sensibility’s Welcoming All Families: Working with Women of Color post from earlier this year.

Until we begin to see the problem of Black infant mortality as a problem for ALL of us, the problems will persist. If we don’t all experience equity in health care, than none of us really does.

I would like to invite any and all of the confluence attendees to join the Board of Directors of both Lamaze International and DONA International and my Uzazi team at our Uzazi Village Reception for Doulas of Color and Allies, on Friday evening, September 19th, 2014 at 7 PM.  Uzazi Village is located at 3647 Troost Ave, Kansas City, MO, 64109.  Hear about programs that are working to lower the infant mortality rate among black infants in our community and connect with others who share your concern and desire to affect change.

References

Amnesty International. (2010). Deadly Delivery: The maternal health care crisis in the USA. Published by Amnesty International.

Beal, A., Kuhlthau, K., and Perrin, J. (2003). Breastfeeding Advice Given to African American and White Women by Physicians and WIC Counselors. Public Health Reports. Vol. 118. p. 368-376.

CIA World Factbook https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

Cricco-Lizza R., (2006)., Black Non-Hispanic mother’s perception about the promotion of infant feeding methods by nurses and physicians. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, Mar-Apr; 35 (2): 173-80.

Fetal Infant Mortality Review 2013. A Program Report of the Mother and Child Health Coalition. Kansas City, Missouri.

Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. In: The Cochrane Library, (9).

Kozhimannil K, Hardeman R, Attanasio L, Blauer-Petersen C. (2013). Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries.
Am J Public Health 2013;103(4):e113-e121.

Lee, H., Rubio, M.R., Elo,T., McCollum, F., Chung, K., Culhane, F. (2005). Factors associated with intention to breastfeed among low-income, inner-city women. Maternal & Child Health Journal Sep; 9 (3): 253-61

Missouri Foundation for Health (2013) Health Equity Series: African American Health Disparities in Missouri. Missouri Department of Health and Senior Services, Section for Epidemiology and Public Health Practice, St. Louis, MO.

MMWR Morbidity and Mortality Weekly Report. (2002). Infant mortality and low birth weight among black and white infants–United States, 1980-2000. Centers for Disease Control and Prevention (CDC). Jul 12;51(27):589-92.

Morbidity and Mortality Weekly Review (2013). Progress in Increasing Breastfeeding and Reducing Racial/Ethnic Differences — United States, 2000–2008 Births 62(05);77-80 Retrieved from CDC: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6205a1.htm?s_cid=mm6205a1_w

National Center for Health Statistics. National Vital Statistics Reports (NVSR). Deaths: Final Data for 2011

Newborn loss. (n.d.). Neonatal death. Retrieved September 15, 2014, from http://www.marchofdimes.org/loss/neonatal-death.aspx

Van Ryn, M. (2002). Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care. Medical Care. Vol. 40, No. 1 pp. 140-151.

About Sherry L. Payne

© Sherry Payne

© Sherry Payne

Sherry L. Payne, MSN RN CNE IBCLC CD(DONA), holds a BSN in nursing and an MSN in nursing education from Research College of Nursing/Rockhurst University in Kansas City, MO. She is a certified nurse educator and an Internationally Board Certified Lactation Consultant. She presents nationally on topics related to perinatal health and breastfeeding among African-American women. Ms. Payne founded Uzazi Village, a nonprofit dedicated to decreasing health inequities in the urban core. She is an editor for the Clinical Lactation journal, and participates in her local Fetal Infant Mortality Review Board (FIMR) Board, where she reviews cases and makes recommendations for improvements. Her career goals include opening an urban prenatal clinic and birth center. She would also like to work towards increasing the number of community-based midwives of color and improving lactation rates in the African-American community through published investigative research, the application of evidence-based clinical practice and innovation in healthcare delivery models. Ms. Payne resides in Overland Park, KS with her husband , where they have nine children, six of whom were home-birthed and breastfed.  Contact Sherry for more information about her programs.

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