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Insta-gram or Insta-gasp? The Ethics of Sharing on Social Media for Birth Professionals

October 24th, 2013 by avatar

Attorney and Lactation Consultant Liz Brooks, President of the International Lactation Consultant Association, takes a look at the issues that childbirth professionals might want to consider before sharing information on a social media platform like Facebook, Twitter, Instagram, Pinterest or others.  Do you follow the HIPAA guidelines, even if you are not bound to do so?  What has been your experience?  Please share your thoughts and experiences in our comments section. – Sharon Muza, Science & Sensibility Community Manager.

By Liz Brooks, JD IBCLC FILCA

Is it ever ethical for a healthcare provider (HCP) to post a photograph or video of a patient on a website or Facebook page? My first reaction is “Heck No!,” but the question deserves a deeper look, especially since social media platforms serve as a predominant means of communication, marketing and information-sharing. It is the way we can speak to today’s mothers, and it is the way they insist on reaching us. 

Privacy and confidentiality are hallmarks of the traditional healthcare professions. I am an International Board Certified Lactation Consultant (IBCLC), and right there, in my ethical code (called the IBLCE Code of Professional Conduct for IBCLCs, or CPC), it says at Principle 3 “Preserve the confidentiality of clients.” Further, I am required under the CPC (a mandatory practice-guiding document) to “Refrain from photographing, recording or taping (audio or video) a mother or her child for any purpose unless the mother has given advance written consent on her behalf and that of her child.” 2011 IBLCE CPC, 3.2. Translation: If I want to take a picture of a mother for any reason at all (to document healing of a damaged nipple, perhaps), even if I drop it into a patient folder only I will ever see, and which I lock away in a file cabinet, I had better get the mother’s written consent first. 

But what about a doula or childbirth educator? Are doulas or educators considered “healthcare providers” in the way a doctor, nurse, midwife or IBCLC would be? Or are they removed from the rules in healthcare?

The Childbirth and Postpartum Professional Association (CAPPA) describes the doula as an important informational and emotional link between the pregnant/laboring woman and her healthcare providers … a part of the birth team. DONA International, another doula organization, describes the role as “a knowledgeable, experienced companion who stays with [the mother] through labor, birth and beyond.”

This is what else we learn from CAPPA and DONA International: It is clear that privacy of the mother is paramount. Any person who is certified through CAPPA is expected to follow a Code of Conduct that is quite plain in its requirement to protect privacy: “CAPPA certified professionals will not divulge confidential information received in a professional capacity from their clients, nor compromise clients’ confidentiality either directly or through the use of internet media such as Facebook or blogs.” (Page 1, Bullet 4, CAPPA Code of Conduct.) The Code of Ethics from DONA International echoes this requirement: “Confidentiality and Privacy. The doula should respect the privacy of clients and hold in confidence all information obtained in the course of professional service.” (DONA Int’l Code of Ethics Birth Doula, 2008.)

Childbirth educators are held to a similar standard. Lamaze International, which offers an international certification for those who are working with pregnant women and their families, has a Code of Ethics for its Certified Childbirth Educators. That Code indicates “Childbirth educators should respect clients’ right to privacy. Childbirth educators should not solicit private information from clients unless it is essential to providing services. Once a client shares private information with the childbirth educator standards of confidentiality apply.” (Standard 1.07, 2006 Code of Ethics, Lamaze International.)

So it seems that healthcare providers, childbirth educators and doulas alike should NOT be posting pictures of their clients/patients on the Internet. So why are we seeing so many of them?

Because if the mother agrees to have her picture or personal information shared, her informed consent changes everything. The notion of protecting privacy is that the patient or client ought to be in control of whatever information gets shared with the outside world. Anyone who has attended a conference, and benefited from education that included clinical photographs, knows that some clients/patients are willing to allow their images to be seen by others. They may require conditions of use (i.e. do not show the face), but they willingly agree.

“So all I have to do is just ask the mother?” you wonder. Well … not so fast. Some other considerations may (dare I say it?) cloud the picture:

  1. Some healthcare providers, hospitals or birth facilities may have rules of their own affecting whether or not images may be taken, by you or even the family. You will need understandings and consent up front, often signed on forms as proof, before you can whip out the smart phone. 
  2. If the doula or childbirth educator has a professional, business relationship with other healthcare providers, or healthcare facilities, she may well be considered a “business associate” for purposes of the privacy-protecting sections of the Health Insurance Portability and Accountability Act (HIPAA), and its first cousin in enforcement, the Health Information Technology for Economic and Clinical Health Act (HITECH). Under HIPAA/HITECH “business associates” who have ANY kind of access to patient information (like: name and address) are held to the same standard for privacy as the healthcare provider. And if there are breaches of privacy, both the business associate AND the HCP are held liable. Enforcement actions recently have included actions against small practices, including the levying of some hefty fines. The person working with the family, who has a professional relationship with a covered entity under HIPAA, should be certain that her own business associate agreement is up-to-date and signed. It is important that she respect the requirements set by her (probably skittish) business partner, before she seeks the mother’s consent.
  3. Make sure you and the mother are very clear in your understanding of what her “consent” really means. Many a mother has been disappointed that her great and wonderful news announcing her baby came from someone else first … even if the plan all along was to have everyone share the great news once mom revealed it.

Discuss all the possibilities with the patient/client. Who can publicly discuss the pregnancy/birth/sonogram? Who can take and post pictures? What and who can be included in the pictures (faces, body parts, location-identifying background all matter). Who can text? Who can tweet? Is a link back to a website or Facebook page by the mother required? When can all of this take place?

As a savvy advocate for the mother, you may want to suggest that she have these same discussions with her own circle of family and friends. While they will not be held to the legal and ethical standards required of a doula or HCP, the disappointment will be no less acute for the mother if the glorious news of her pregnancy or birth is spilled by a friend, first. 

As doulas, childbirth educators, IBCLCs and HCPs who work in maternal-child health, we are privileged to be willingly called into the intensely personal and life-changing events that pregnancy, birth and early parenting represent. Our need to respect the wishes, dignity and privacy of the family are not diminished because modern technology makes news-sharing so easy.

About Liz Brooks

Liz Brooks, JD, IBCLC, FILCA, is a lawyer (since 1983) and earned her International Board Certified Lactation Consultant credential in 1997 after several years as a lay breastfeeding counselor.  Before she left the practice of law, Liz worked as a criminal prosecutor, a lobbyist and a litigator, with a focus on ethics and administrative law.  That expertise followed her to lactation:  She wrote the 2013 book, “Legal and Ethical Issues for the IBCLC,” and was lead author for one ethics chapter in each of three other books.

Liz is on the ILCA Board of Directors (President 2012-2014).  She was designated Fellow of the International Lactation Consultant Association (FILCA) in 2008. She currently is the United States Lactation Consultant Association Alternate to the United States Breastfeeding Committee and is an Elected Representative on their Board of Directors (2012-14).  Liz can be reached through her website.

 

 

Babies, Breastfeeding, Childbirth Education, Guest Posts, informed Consent, Legal Issues , , , , , , , , , , , , , , , ,

Celebrate Fathers; Birth Professionals Play A Critical Role

June 13th, 2013 by avatar

With Father’s Day being celebrated this Sunday, Certified Doula David Goldman shares his experiences as both a birth doula and expecting father, as he ponders the role birth professionals and health care providers have in welcoming or marginalizing the partner during pregnancy, birth and early parenting.  The role of men at births has been questioned, mocked and celebrated over the years.  Read and hear how David has been able to experience it from both sides. – Sharon Muza, Community Manager

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© Patti Ramos Photography

My head was spinning with joy, fear and uncertainty as I walked into the birth room for the first time as a doula. I squatted to the side as I acclimated to the calm energy and slowly made my way toward the laboring mother. A nurse walked in and with unexpected excitement shook my hand and smiled deep into my eyes as she walked passed me. My doula mentor stepped in to explain that I was not the dad but was the doula. I laughed to myself, having once again forgotten the rarity of men, especially those in non-medical roles, in the birth room. Since then, I carry a shirt in my birth bag that reads, “Nope, I’m not the Daddy, I’m the Doula” to avoid the confusion and the awkward and misplaced, but well intentioned congratulations. I also wear the shirt because once the staff knows I’m a birth professional, I’m often accepted as part of the ‘real team’ rather than just a ‘bystander’ who might get in the way and needs to be looked out for.

As we are likely well aware, the history of childbirth in North America has included discrimination, sexism, misogyny and other forms of oppression against women. Birth communities have become a source of strength and have collectively fought and won major battles including public breastfeeding, rights to options and evidence-based care in childbirth and so much more. But as with all forms of oppression and marginalization, we can’t bring one person up by bringing another down.  As one of a very small handful of certified male birth doulas  in North America and a birth professional who has completed a Lamaze International approved childbirth educator workshop on the path to obtaining LCCE status, I feel honored to work among thousands of strong women who are pushing the boundaries every day to make childbirth and parenting less traumatic and more empowering for all birthing women.

As a birth professional, I have worked with many amazing dads who glowed at least as bright as their pregnant partners. At most of the births that I have attended, the tears coming from the eyes of men overwhelmed with joy and relief at the birth of their baby have been just as wet as those of the mothers. I am not trying to equate the experiences of becoming a father with becoming a mother.  However, I do hope to shed light on how birth professionals’ communication with fathers can influence the pregnancy and childbirth experience not just for fathers but also for mothers and babies. Like many birth professionals, I have worked hard to support the whole “client family” and honor the role of each person involved. However, now that I find myself in the role of the client family for the first time, I am quite surprised by my experience.

The presence of a father, birth partner or family member can help to improve women’s birth experience by providing emotional support and reassurance during labour and delivery. While unexpected emergencies may arise, for many couples, birth can be a very positive experience.  Royal College of Obstetricians and Gynecologists

Currently, my partner and I are halfway through a pregnancy and, as you can imagine, I now have the opportunity to see things from a whole new perspective. As a birth professional who has taken many courses, attended conferences, read piles of books, shared dialogue via various internet forums and participated as an active and founding member of the local birth professional group in my community, I feel relatively empowered and knowledgeable on the topic of pregnancy, labor, birth and postpartum.

I’m surprised, however, by how marginalized I feel being the partner in the pregnancy and that I feel less and less central in the birth of our baby as we include and add professionals to our team. Providers make little eye contact with me and ask for decisions almost exclusively from my partner. People frequently ask where she will be birthing and whom she has chosen to attend. I’m finding that images in advertising and instructional materials with partners in primary support roles are not as common as those with birth professionals at the center. Many online birth communities are specific to “Mommas” and a large group that had once made an exception (not at my request) to include me as a birth professional recently removed me from the group now that I am a “Dad-to-be” reducing my access to the very support that I had previously offered to many new families. Overall, while we often intend to honor the role of partners, I’m seeing that we are missing the mark throughout the field.

If a well-trained and experienced birth doula and an active part of the local birthing community is feeling disempowered, how must partners who are brand new to birth feel? After all, we may hold knowledge and experience but as we have all seen, a sweet smile or a kiss from a partner can be an amazingly effective medicine for a birthing mother. We already know that the experience of women and babies is improved by continuous care during childbirth. (Hodnet, 2012). What can we do as birth professionals to better support partners in being fully present and connected?

One of the most significant things that birth professionals and health care providers can do is to welcome partners with mutual respect and honoring their challenging and important roles.  By doing so, we can likely improve the experience overall and help foster attachment between the parents and with the partner and the baby even before the birth. The bonds, attachment and successes fostered in childbirth are likely to be a great springboard into future parenting experiences.

In order to improve the likelihood that partners will feel central in the birth team, we as birth professionals must include them from the beginning. We can frequently make eye contact, ask for their opinions and check in to see how they are feeling about decisions. In our prenatal discussions, we can help partners address any barriers they may feel to fully supporting the birth. We can create communities that include partners to seek advice, support and dialogue. Just as we reassure birthing women throughout the process, we might provide acknowledgement for the hard work and endurance of partners. Discussions that promote collaborative dialogue between partners can be encouraged when decisions are needed. Childbirth educators can offer suggestions on how to ask care providers to include the partner more substantially and role-play scenarios with couples in class.

© Patti Ramos Photography

Birth professionals should stop applying the standard stereotypes that have been around for ages, and are continually propagated through the media, assuming fathers are bumbling fools who are being dragged to childbirth classes,  panic at the first contraction, don’t know their way around a newborn, just might “pass out” at the birth and who are easily excited and unable to contribute anything positive to the experience.  This is just not the truth.  Today’s father is often researching right along with the mother for best practices, exploring choices and celebrating each milestone in the pregnancy.  During labor and birth, many fathers want to be the main support and fully share the experience with their partners.

We want the professionals we have chosen to participate with us on this journey to recognize the unique roles and needs that each parent has.  Their very actions and choice of words can help fathers to feel more involved and respected or can marginalize the father to a spot on the edge of the process.  Welcome us as an equal player, celebrate what we bring to the table, share resources and information sources that are specific to our needs as fathers and partners in creating this life.  Have office and classroom spaces filled with diverse images celebrating the amazing role that we are honored to play as partners. Use posters, films and activities that highlight and honor the special place we hold.  Allow us to grow into the role of father, feeling secure, supported and respected by the professionals who are helping us to birth our baby.

As childbirth educators, do you often make light of the lack of information and experience that fathers bring to the birth experience.  Do you make assumptions about the dads in your classes?  Have you perpetuated any of the longstanding stereotypes by the media you use, activities you conduct or your choice of words?  Can you share what you are doing in your class to be as inclusive as possible and to help the couple to moving into parenting by setting them up for a labor and birth filled with connection and support?  Let us know in the comments. – Sharon Muza

References

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4. 

About David Goldman, MAEd, CD(DONA, PALS)

David P. Goldman, MAEd. CD(DONA, PALS), was trained as a birth doula six years ago at the Simkin Center, Bastyr University and has become one of the very few male certified birth doulas in North America. He has been an educator working with students of all ages for over fifteen years and has completed a Lamaze International approved childbirth educator workshop on the path to obtaining LCCE status. David works with the WISE Birth Doula Collective in Bellingham, WA as well as Open Arms Perinatal Services in Seattle, WA. David can be reached at douladavid@gmail.com

Babies, Childbirth Education, Guest Posts, Infant Attachment, Maternity Care, Newborns, Parenting an Infant, Series: Welcoming All Families, Uncategorized , , , , , , , ,

Book Review: Breastfeeding Solutions; Quick Tips for the Most Common Nursing Challenges

May 30th, 2013 by avatar

Breastfeeding Solutions; Quick Tips for the Most Common Nursing Challenges by Nancy Mohrbacher, IBCLC, FILCA is a recently published book, (April 2013) designed  for breastfeeding mothers.  This book is small and lightweight, measuring just 5 x 7 inches, with 202 pages, including appendices, which makes it practically pocket sized and easy to throw in a diaper bag or read while nursing a little one.  There is also an e-book version available as well.

The book is divided in to 7 chapters, and includes a short and concise resource list at the back, along with some brief citations referred to in the book.  The chapters have simple titles such as “Nipple Pain” or “Night Feedings” making it easy to find the information a mother might be looking for.  Each chapter is divided into the typical challenges that mothers might be dealing with under that particular topic.  With a clear, easy to read large font for each section,  the pages are well designed and simple, making it a breeze for a tired and sleep-deprived mother or partner to find exactly what information s/he needs. Occasional, basic, black and white line drawings reinforce the information provided in the text.  The language used throughout the book consists of common terms and is easy to read and understand. I really liked how Nancy reassures the reader with her writing style, that the while the mother or baby may be experiencing some struggles, that things can be fixed and will get better.   In many places throughout, the author lets us know that if things do not improve that the mother should seek out help from an appropriately skilled expert, with her first recommendation being an international board-certified lactation consultant (IBCLC).

Right from the start, Nancy encourages and explains laid back breastfeeding positions for the mother-baby dyad, sharing why these positions makes so much sense for the mother and baby who are just starting to breastfeed.  She even references and provides a link for a short video on this from Suzanne Colson. In several places in the text, Nancy encourages readers to refer to a linked video to reinforce the information provided in the book.

Nancy emphasizes throughout the book that mothers can follow their instincts and will know what to do, but problems can arise and that help is available. She uses some of the same vocabulary that I use when teaching breastfeeding classes, such as “breast sandwich” to help mothers understand getting a deep latch. When discussing weight gain in breastfed babies, Nancy references the WHO exclusively breastfed growth charts as the appropriate guide for how baby is doing.  This is good to know information when a mother will be discussing weight gain with the baby’s provider.

Important information is repeated throughout the book, so a mother who has opened the book to find specific information will not miss key points such as “drained breasts make milk faster, full breasts make milk slower” even if she never turns to the “Milk Supply Issues” chapter.

One of my favorite sections was Nancy’s accurate explanation of breastfeeding norms for the newborn.  Reassurance that cluster feedings, having night and day time mixed up, frequency and length of feedings in the first six weeks really go along way to reassure the new mother that her baby is normal and doing what normal newborns do.  She also shares information about the volume of milk a baby can expect to need as she grows. Every pregnant woman or new mom should read this section, so they don’t wonder if things are normal in their sleep-deprived state.

The old foremilk-hindmilk discussion is squashed as Nancy explains how fat molecules are released from the milk ducts as the feed progresses, but reassures mothers that this is not something to be concerned about.  When a mother feeds on demand and offers both breasts over the course of a day, the baby will be provided with adequate breastmilk that contains everything needed.

There is a great section on going back to work and maintaining supply, along with how to make a pumping session most effective. There are even tips on choosing the right pump for your pumping needs.  I loved the information and drawings included for making sure that your pump has the proper sized phalanges (or nipple tunnels as they are called in the book) for each woman’s nipples, as I frequently see women who have poor fitting phalanges, making pumping so much more uncomfortable.

Nancy shares several different strategies for solving the common problems, so women have many things to try and includes a section for each topic called “If these strategies don’t work” with even *more* information and other things to consider. There are also little sidebars with “Myth and Reality” nuggets scattered throughout the book.  Women are provided with current evidence based information for best breastfeeding practices.

The book closes with a lovely chapter on weaning, sharing ideas on how to decide when the time is right and how to make it easy on both mother and child.  The entire book is non-judgmental, acknowledges that there can be challenges and offers encouragement and information in a non-biased manner and easy to read style that will provide support and answers to the most common concerns facing breastfeeding mothers today.  This book would be a great accompaniment to a breastfeeding class, and lactation consultants,  childbirth educators, doulas, midwives and doctors that work with breastfeeding families will want a few copies to put in their lending libraries for new moms to borrow.

About Nancy Mohrbacher

Nancy Mohrbacher, IBCLC, FILCA, is author of the books for breastfeeding specialists, Breastfeeding Answers Made Simple (BAMS) and its BAMS Pocket Guide Edition.  She is co-author (with Julie Stock) of all three editions of  The Breastfeeding Answer Book, a research-based counseling guide for lactation professionals, which has sold more than 130,000 copies worldwide. She is also co-author (with Kathleen Kendall-Tackett) of the popular book for parents, Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers.  Nancy has written for many publications and speaks at breastfeeding conferences around the world. Contact Nancy by email: nancymohrbacher@gmail.com

 

 

 

Babies, Book Reviews, Breastfeeding, Childbirth Education, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Newborns, Parenting an Infant, Uncategorized , , , , , , , , , ,

Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part One

March 28th, 2013 by avatar

by Christine H. Morton, PhD and Monica Basile, PhD, CPM, CD(DONA), CCE (BWI)

Last month there were great discussions after a study was published by the University of Minnesota, examining the potential cost savings to Medicaid if doulas worked with Medicaid clients, helping to reduce interventions and cesareans.  Today and next Tuesday, regular contributor, Christine Morton and her colleague Monica Basile, take a look at that study and another from Oregon, and share thoughtful insight about topics that might still need to be addressed if costs savings were to be effectively realized in a two part blog post. – Sharon Muza, Community Manager, Science & Sensibility

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http://flic.kr/p/5eqPFL

How can doula supported births help reduce the cesarean rate and realize cost savings within Medicaid-funded births? Two studies published last month offer the opportunity to address this complex question.

We support the goal of increasing access to doula supported care to childbearing people of diverse racial/ethnic and class backgrounds, and we are pleased that discussions are taking place about how doulas may be able to help reduce racial disparities in maternal and infant health. We recognize that work toward these goals requires policy advocacy, which depends heavily on economic arguments for the benefits of doula care.

However, by limiting the discussion of benefits to the economic impacts of reduced cesareans, advocacy for Medicaid funding of doula supported births—without specifying the doula model of care and without according true value to the doula’s impact—may have unintended consequences for individual doulas, and the organizations that represent them.  One such consequence may be that the resulting system will continue to perpetuate a model of economic marginality and potential exploitation for the doulas who serve a low income population of childbearing people.

The AJPH study by Katy Kozhimannil and colleagues in Minnesota received a lot of media attention when it appeared last month, even live coverage in the Huffington Post.  This study compared 1,079 selected Medicaid doula patients in Minnesota to Medicaid patients nationwide for their total cesarean rates.  They found that doula clients of a community program in Minnesota had a rate of 22.3% while national Medicaid had 31.5%.  The authors reported three scenarios, all assuming that if states reduced cesarean rates, by offering doula services, there would be varying levels of cost savings, depending on the cesarean rate achieved, and by reimbursing doulas between $100-300 per birth.

In our view, the Minnesota study design raises several methodological questions, which are applicable to this study and to future research on doula-attended births. We outline those questions here, as well as raise several more substantive concerns about the implications of the study’s stated conclusions.

  1. Why did the researchers not compare Minnesota Medicaid doula clients to Minnesota Medicaid women who gave birth?  Minnesota has a much lower rate of total cesarean that the US as a whole (27.4% during this time period), and this would have been a better matched comparison.  A better comparison would be doula attended births vs. non-doula attended births at the same facility.  It is not clear from the study whether the doula program whose data was utilized served women at one or multiple hospitals in Minneapolis. 
  2. Why did the researchers not limit their investigation to primary cesareans?  Doulas typically support women in labor rather than women undergoing repeat cesareans.  The total cesarean rate includes repeat cesarean so it will be much higher than the primary cesarean rate, which is more applicable to doula clients.  Including total cesarean rates means that the researchers are comparing a limited universe (doula support of women in labor) to all births (thus including repeat and primary cesarean).   The data source for this study, (Nationwide Inpatient Sample), however, does not have this information.
  3. Cesarean rates are very dependent on the parity distribution of the birthing population, so first time mothers need to be compared to first time mothers and multiparous women to multiparous women. This information is not available in the data source used by the researchers, but in future studies of this type, it is critical to verify that the proportion of each is the same in the intervention and control populations.
  4. States are implementing a number of payment reform models to reduce cesareans among women covered by Medicaid, with limited success.  In part, that is because cesareans are influenced by a number of factors, with payment incentives only one.  (Many of these issues are covered in the CMQCC white paper on improvement opportunities to reduce cesareans, which argues that a multi-pronged strategy is necessary). 
  5. Because hospital rates of cesarean have been shown to have high geographic variation in a number of studies (Baicker 2006; Main et al 2011; Caceres 2013; Kozhimannil 2013), it may be more feasible to have comparison groups of hospitals with similar primary cesarean rates.  Until we understand what accounts for variation in cesarean rates between institutions (unit culture; facility policies and protocols), it may be premature to assess the independent effect of labor support by a trained doula.

While doula support is associated with fewer cesareans across the board (Hodnett 2012), the methodological issues described above are likely to over estimate the benefits of doula-attended births in terms of reducing the cesarean rate for Medicaid covered births.  This, in turn, raises questions about the purported cost savings.  In the Minnesota study, the cost breakpoint is no more than $300 dollars for the doula per birth.  In most cities, doulas charge well above this amount for fee-for service care.

A cost-benefit analysis by Oregon Health & Science University researchers for the Oregon State Legislature was presented at the Society for Maternal Fetal Medicine in February 2013, which found that doula care in labor provides a cost benefit to payers only when doula costs are below $159.73 per case.  In that study, data sources are not entirely clear, but do seem to come from the OHSU facility where a hospital-based doula program is in place.  In that program, doulas are on call on weekends only and come to assist in a labor when requested by the woman during her prenatal care or when she arrives at the hospital.  A case-control study claiming the benefits of this doula model at OHSU was published as an abstract, and although it claims “women receiving doula care were statistically less likely to have an epidural during labor (p = 0.03), have an episiotomy (p = .03), or cesarean delivery (p = .006) and on average, doula attended women had a shorter hospital stay compared to the control group (p = .002),” nowhere does it show what the actual rates were.  This is important, because, they are likely to be relatively low overall, given that OSHU is a teaching hospital, with midwives and family practice physicians providing maternity care.

There are several types of doula models; not all have the same components.  The community-based doula model, as exemplified by the HealthConnectOne approach has a solid evidence base. This model employs doulas who are trusted community members, and provides extensive prenatal and postpartum support in addition to continuous labor support.  Doulas work collaboratively with community organizations, have extensive training in experiential learning and cultural sensitivity, and are paid a wage commensurate with their value and expertise, serving an important workforce development and grassroots empowerment function. Some so-called community doula programs do not incorporate all these components.

Hospital-based programs usually assign or utilize an on-call doula, who has not met the mother in advance and is not likely to follow up postpartum.  Some advocates of Medicaid doula programs utilize the community health worker (CHW) model, which seems to mirror the community-based doula (CBD) model but with important differences.  The American Public Health Association has defined CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve.”  Yet, despite their widespread utilization in public health over the past several years, the conditions of their training, job opportunities, and even job description are idiosyncratic, and highly varied, and this “lack of CHW identity and standards of practice has led employers to contribute to the confusion about who CHWs are and what they do.” While the CHW and CBD models offer important job opportunities to members of under-resourced communities, their wages are often on the low side, with full time work paying $35,000 to $42,000 annually.  According to a health careers website, “CHWs often are hired to support a specific health initiative, which may depend on short-term funding sources. As a result, CHWs may have to move from job to job to obtain steady income.  This short-term categorical funding of health services is a challenge to the stability and sustainability of the CHW practice.”

In cost-benefit or cost effectiveness studies, it is critical to clearly specify the doula model of care on which the economic model is based.  It seems the doula model in the Minnesota study incorporates extensive pre and post partum contact and that there is an attempt to match doulas and clients in terms of race/ethnicity and language, but this is not always possible.   The study does not indicate what the doulas in the Minnesota program were paid, however, and that information was unavailable on their website.

Before we move to the topic of reimbursement, we want to note that the type of doula model is critical for assessing the benefits of doula-attended births.  The research clearly shows different outcomes for doulas who are affiliated with hospitals compared to those who work independently (Hodnett, 2012).  If a cost benefit model shows little gain in terms of outcomes, or yields a price point in the low hundreds of dollars, it may be that findings are affected by the assumptions embedded in the calculations.

More fundamentally, however, we argue that doula benefits cannot be captured solely through an economic model.  Neither should doulas be promoted as a primary means to reduce cesarean rates.  Both strategies (economic benefits and cesarean reduction) for promoting doulas have significant barrier.  In part two of this topic, running on Tuesday, April 2nd,  we discuss our concerns about reimbursement and program sustainability alongside a caution against relying too heavily on arguments that position the doula as primarily a money saver and cesarean reducer.

References

Baicker, K, Kasey S. Buckles, and Amitabh Chandra. Geographic Variation In The Appropriate Use Of Cesarean Delivery: Do higher usage rates reflect medically inappropriate use of this procedure? Health Affairs 25 (2006): w355–w367; doi: 10.1377/hlthaff.25.w355

Caceres, Isabel A., Mariana Arcaya, et al., Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact, PLoS ONE 8(3): e57817. doi:10.1371/journal.pone.0057817

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues, Health Affairs 32, NO. 3 (2013): 527535; doi: 10.1377/hlthaff.2012.1030

Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K and Gould JB. 2011.  Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality.  Palo Alto, CA: CMQCC.  (Available at http://www.cmqcc.org/white_paper)

Pilliod, Rachel; Leslie, Jennie; Tilden, Ellen; et al. Doula care in active labor: a cost benefit analysis. Abstract presented at 33rd Annual Meeting/Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM), San Francisco, CA, February 11-16, 2013, American Journal of Obstetrics and Gynecology, Volume: 208 (1); S348-S349.

About the authors

 

Monica Basile

Monica Basile has been an active birth doula, childbirth educator, and midwifery advocate for 17 years, and holds a PhD in Gender, Women’s and Sexuality Studies. Her 2012 doctoral dissertation, Reproductive Justice and Childbirth Reform: Doulas as Agents of Social Change, is an examination of emerging trends in doula care through the lens of intersectional feminist theory and the reproductive justice movement.

 

Christine Morton

Christine Morton

Regular contributor Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth, which will be published by Praeclarus Press in Fall 2013. For more on Christine, please see Science & Sensibility’s Contributor page.

Cesarean Birth, Doula Care, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Research, Uncategorized , , , , ,

Free Lamaze Webinar: Childbirth Education – A Collaborative Role for Nurses and Doctors

February 22nd, 2013 by avatar

 

Join us for a Webinar on Thursday, February 28,  from 12 p.m. to 1 p.m. EST.  

Lamaze International and OB Consult are collaborating on a joint education initiative to provide evidence-based and complimentary educational services to OB nursing staff and physicians on their role in supporting patient childbirth education and participation, resulting in enhanced physician-patient relationships, engaged mothers, and healthier babies.  This Webcast officially launches this new collaborative initiative.

Childbirth preparation has been an integral part of the birth experience for centuries, in the beginning as experiential learning when births occurred in the home and then in the 50s and 60s as part of a formal curriculum in physician offices, hospitals and the community.

Travel with us through time to see how the trends in childbirth and childbirth education can impact the care that pregnant women and their families experience in the 21st century.

  • Is childbirth education a passing fancy or an integral part of the childbirth experience?
  • How can physicians, nurse midwives and nurses work together to create a safe and satisfying birth experience for all involved?

Learn about evidence-based strategies that you can put into place now and in the future to educate all stakeholders in the experience of birth.

This presentation is open to all OB department staff, including OB-Gyns, OB department managers, OB nurses, lactation consultants, educators, doulas and the rest of the OB team.  This includes YOU!

This presentation features our own Michele Ondeck, RN, MEd, IBCLC, LCCE, FACCE,  Lamaze International President-Elect and Margaret “Peggy” M. DeZinno, BS, RN, LCCE, an OB-Gyn risk management specialist.

This is a great opportunity to learn more about the Lamaze International and OB Consult cooperative venture, and clarify the importance of your role in supporting families and babies as part of the OB team.

Find more information on the Lamaze International Webinar page. Register now by following this link.

For more info, questions about registration or webinar content, please contact OB Consult at 717.399.6658 or ceb@ob-consult.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Space is limited.
Reserve your Webinar seat now at:
https://www1.gotomeeting.com/register/245111544

 

Childbirth preparation has been an integral part of the birth experience for centuries, in the beginning as experiential learning when births occurred in the home and then in the 50s and 60s as part of a formal curriculum in physician offices, hospitals and the community.
Travel with us through time to see how the trends in childbirth and childbirth education can impact the care that pregnant women and their families experience in the 21st century.
•     Is childbirth education a passing fancy or an integral part of the childbirth experience?
•     How can physicians, nurse midwives and nurses work together to create a safe and satisfying birth experience for all involved?
Learn about evidence-based strategies that you can put into place now and in the future to educate all
stakeholders in the experience of birth.

 

Title:

Childbirth Education – A Collaborative Role for Nurses and Doctors

Date:

Thursday, February 28, 2013

Time:

12:00 PM – 1:00 PM EST

Babies, Childbirth Education, Continuing Education, Evidence Based Medicine, Lamaze International, Maternal Quality Improvement, Webinars , , , , , , , , , , ,