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Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

 Today, contributor Henci Goer reviews a recently published study in the journal Birth, that compared the outcomes of births in women who received non pharmacological pain management techniques with women who received the “usual care” treatment.  The researchers found that maternal and infant outcomes were improved.  Take a moment to read Henci’s review to get a glimpse at the results and her analysis.- Sharon Muza, Science & Sensibility Community Manager

© Patti Ramos Photography

© Patti Ramos Photography

In 2012,  the Cochrane Database published an overview of systematic reviews of forms of pain management that summarized the results of the Cochrane database’s suite of systematic reviews of randomized controlled trials (RCTs) of various pain management techniques. Reviewers reached the rather anemic conclusion that epidurals did best at relieving pain—no surprise there—but increased need for medical intervention—no surprise there either—while non-drug modalities (hypnosis, immersion in warm water, relaxation techniques, acupressure/acupuncture, hands on techniques such as massage or reflexology, and TENS) did equally well or better than their comparison groups (“standard care,” a placebo, or a different specific treatment) at relieving pain, at satisfaction with pain relief, or both, and they had no adverse effects (Jones 2012). Insofar as it went, this finding was helpful for advocating for use of non-drug strategies, but it didn’t go very far.

Fast forward two years, and we have a new, much more robust review: Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Its ingenious authors grouped trials of non-drug pain relief modalities according to mechanism of action, which increased the statistical power to determine their effects and avoided inappropriately pooling data from dissimilar studies in meta-analyses (Chaillet 2014). The three mechanisms were Gate Control Theory, which applies nonpainful stimuli to partially block pain transmission; Diffuse Noxious Inhibitory Control, which administers a painful stimulus elsewhere on the body, thereby blocking pain transmission from the uterine contraction and promoting endorphin release in the spinal cord and brain; and Central Nervous System Control, which affects perception and emotions and also releases endorphins within the brain.

Overall, 57 RCTs comparing non-drug strategies with usual care met eligibility criteria: 21 Gate Control (light massage, warm water immersion, positions/ambulation, birth ball, warm packs), 10 Diffuse Noxious Inhibitory Control (sterile water injections, acupressure, acupuncture, high intensity TENS), and 26 Central Nervous System Control (antenatal education, continuous support, attention deviation techniques, aromatherapy). Eleven of the Central Nervous System Control trials specifically added at least one other strategy to continuous support. More about the effect of that in a moment.

Now for the results…

Compared with Gate Control-based strategies, usual care was associated with increased use of epidurals (6 trials, 3369 women, odds ratio: 1.22), higher labor pain scores (3 trials, 278 women, mean difference 1 on a scoring range of 0-10), and more use of oxytocin (10 trials, 2672 women, odds ratio: 1.25). Usual care also increased likelihood of cesarean in studies of walking (3 trials, 1463 women, odds ratio: 1.64).

Compared with Diffuse Noxious Inhibitory Control strategies, usual care was associated with increased use of epidurals (6 trials, 920 women, odds ratio: 1.62), higher labor pain scores (1 trial, 142 women, mean difference 10 on a scoring range of 0-100), and decreased maternal satisfaction as measured in individual trials by feeling safe, relaxed, in control, and perception of experience.

We hit the jackpot with Central Nervous System Control strategies (probably because female labor support, which has numerous studies and strong evidence supporting it, dominate this category [19 labor support, 6 antenatal education, 1 aromatherapy]). As before, usual care is associated with more epidurals (11 trials, 11,957 women, odds ratio: 1.13), more use of oxytocin (19 trials, 14,293 women, odds ratio: 1.20), and decreased maternal satisfaction as measured in individual trials by perception of experience and anxiety. In addition, however, usual care is associated with increased likelihood of cesarean delivery (27 trials, 23,860 women, odds ratio: 1.60), instrumental delivery (21 trials, 15,591 women, odds ratio: 1.21), longer labor duration (13 trials, 4276 women, 30 min), and neonatal resuscitation (3 trials, 7069 women, odds ratio: 1.11).

© Breathtaking Photography http://flic.kr/p/3255VD

© Breathtaking Photography http://flic.kr/p/3255VD

The big winner, though, was continuous support combined with at least one other strategy. Usual care in these 11 trials was even more disadvantageous than in central nervous system trials overall with respect to cesareans (11 trials, 10,338 women): odds ratio 2.17 versus 1.6 for all central nervous system trials, and instrumental delivery (6 trials, 2281 women): odds ratio 1.78 versus 1.21 for all central nervous system trials.

The strength of the data is impressive. Altogether, Chaillet et al. report on 97 outcomes, of which 44 differences favoring non-drug strategies achieve statistical significance, meaning the difference is unlikely to be due to chance, while not one statistically significant difference favors usual care. And there’s still more: benefits of non-drug strategies are probably greater than they appear because on the one hand, “usual care” could include non-drug strategies for coping with labor pain and on the other, many institutions have policies and practices that make it difficult to cope using non-drug strategies alone, strongly encourage epidural use, or both.

The reviewers conclude that their findings showed that:

Nonpharmacologic approaches can contribute to reducing medical interventions, and thus represent an important part of intrapartum care, if not used routinely as the first method for pain relief…however, in some situations, nonpharmacologic approaches may become insufficient…the use of pharmacologic approaches could then be beneficial to reduce pain intensity to prevent suffering and help women cope with labor pain…birth settings and hospital policies . . . should facilitate a supportive birthing environment and should make readily available a broad spectrum of nonpharmacologic and pharmacologic pain relief approaches. (p. 133)

No one could argue with that, but a persuasive argument alone is unlikely to carry the day given the entrenched systemic barriers in many hospitals. States an anesthesiologist: “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go” (quoted in Leeman 2003). The Cochrane reviewers concur, writing that using non-drug strategies is “more realistic” (p. 4) outside of the typical hospital environs.

So long as this remains the case, attempts to introduce non-drug options are likely to make little headway. As Lamaze International’s own Judith Lothian trenchantly observes:

If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural because they’re unable to work through their pain. . . . I go wild with nurses and childbirth educators who say, . . . “[Women] just want to come in and have their epidural.” I say, “And even if they don’t . . ., they come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them.” (quoted in Block 2007, p. 175)

Success at integrating non-drug strategies will almost certainly depend on addressing underlying factors that maintain the status quo. Can it be done? You tell us. Does your hospital take a multifaceted approach to coping with labor pain? If so, how was it implemented and how is it sustained?

Resources

Block, Jennifer. (2007). Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press.

Chaillet, N., Belaid, L., Crochetiere, C., Roy, L., Gagne, G. P., Moutquin, J. M., . . . Bonapace, J. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137. doi: 10.1111/birt.12103 http://www.ncbi.nlm.nih.gov/pubmed/24761801

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. doi: 10.1002/14651858.CD009234.pub2 http://www.ncbi.nlm.nih.gov/pubmed/2241934

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). Management of labor pain: promoting patient choice. Am Fam Physician, 68(6), 1023, 1026, 1033 passim. http://www.ncbi.nlm.nih.gov/pubmed/14524393?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 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.  

Childbirth Education, Doula Care, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Newborns, Research , , , , ,

A Celebration of Midwifery – Supporting Safe, Healthy Birth!

July 1st, 2014 by avatar

In June, midwives were making news all around the world in person and in print.   Maternity care researcher Judith Lothian presented at the International Congress of Midwives conference in Prague, an enormous international gathering of thousands of midwives from all the corners of the globe that occurs every three years. Dr. Lothian shares her impressions of the Congress gathering today.  Additionally, the journal, The Lancet released its Series on Midwifery, long awaited and recognizing that if normal, safe birth is to be supported, midwifery care is the key to achieving that goal.  Dr Lothian summarizes this important series and shares what it means for women and their babies. – Sharon Muza, Community Manager, Science & Sensibility

@ Barbara Harper

@ Barbara Harper

In the US, where midwives attend around 10% of births and around 1% of women have planned out of hospital births, most women and many health care providers know little, if anything, about midwifery. Several decades ago, I began to write about midwifery and out of hospital birth as a way of promoting, protecting and supporting normal birth.  More recently, I’ve done research on women’s and midwives’ experiences of home birth. I’ve also spent a great deal of time with midwives, with my daughters during the births of my grandchildren, at two historic Home Birth Summits, at Normal Birth conferences and, in the last 2 years working with the American College of Nurse Midwives on their Normal Birth Initiative. I count many midwives among my most respected and cherished friends.

I’ve wanted to spread the good news about midwifery and women and babies for a very long time, but the last month has me wanting to ring bells, light candles, and shout from the rooftops to celebrate the tremendous accomplishments of midwives and midwifery, the courage of midwives, and the commitment of midwifery to women and children here in the United States and across the globe.

In early June I attended the International Congress of Midwives in Prague. Thirty eight hundred midwives (and a smaller group of nurses, sociologists, epidemiologists, birth advocates and researchers) came together as they do every three years to share what they know, learn what they don’t know, and recommit themselves to women and babies around the world.  Midwives from 85 countries, most often in the traditional dress of their country, paraded into the opening ceremony. The video and pictures from this event can’t begin to capture what it was like to be there, but it does give you a taste of the excitement and the pride.  It was truly amazing.

ICM.Frances_open

@ Barbara Harper

The number of sessions was mind boggling. In each time slot there were multiple sessions on normal birth. It was difficult to choose and impossible to get to even a small percentage of what was offered. I am sharing some of the standouts for me.

Lisa Kane Low, from the University of Michigan, and a champion of midwifery and evidence based maternity care, was a plenary speaker. Her talk on access to care highlighted the importance of meeting women where they are and putting their needs, not ours, first. Toyin Saraki is the newly appointed ICM Global Goodwill Ambassador. The former First Lady of Nigeria, she is the founder and director of the Wellbeing Foundation Africa. The work of the foundation has reduced maternal mortality in Nigeria by 20%.

Ms. Saraki shared a Nigerian saying with us: If you want to go fast, go alone. If you want to go far, go together.  I can’t stop thinking about that, and its implications for our work.  Cecily Begley, the Chair of Nursing and Midwifery at Trinity College Dublin, participated in a plenary panel, Education: The Bridge to Midwifery and Women’s Autonomy. Professor Begley talked about “communities of change” and she described education and research as necessary in crossing the bridge to change. Ray DeVries and Saras Vedam participated in a symposium on ethics related to birth place. Both Ray and Saras contributed to the Journal of Clinical Ethics Fall 2013 special issue on place of birth. The audience participation was lively.

© Barbara Harper

© Barbara Harper

The ethical issues related to pushing women to unassisted births when there is no real choice related to planned, assisted out of hospital birth and the ethical issues of hospitals and providers stonewalling efforts to make transfer seamless, safe, and without recrimination were discussed. Dr. Marianne Nieuwenhuijze from the Netherlands, presented her excellent work on shared decision making. Tanya Tanner from ACNMEllie Daniels from National Association of Certified Professional Midwives, and I presented the collaborative work of ACNM, MANA and NACPM developing a consensus statement on normal, physiologic birth, and more specifically, our work developing a consumer statement based on the consensus statement, Normal, Healthy Childbirth for Women and Families: What You Need to Know.

It was wonderful meeting midwives from Australia, Canada, Ghana, the UK, and Ireland. The challenges are not exactly the same as ours in the US, but we are all fighting uphill battles in support of normal birth.

On the heels of the ICM, The Lancet launched its eagerly awaited Lancet Series on Midwifery.  In Ireland for the summer, I was glued to my computer savoring every moment of the launch online on June 23.    The lead author of each of the four major papers provided a summary and there were comments from a wide array of noted scholars, researchers, practitioners and policy makers from around the world. There were many familiar faces from the International Congress of Midwives. Toyin Saraki gave a stirring speech applauding midwifery, noting that midwifery is not a job, but a passion, a vocation.  Holly Kennedy, who co-authored a paper, and is working on a follow up paper, brought congratulations from the ACNM.

Why did the Lancet do a series on midwifery? Richard Horton, who was involved in the project from the beginning , has this to say in his commentary, The Power of Midwifery:

“Midwifery is commonly misunderstood. The Series of four papers and five Comments we publish today sets out to correct that misunderstanding. One important conclusion is that application of the evidence presented in this Series could avert more than 80% of maternal and newborn deaths including stillbirths. Midwifery therefore has a pivotal, yet widely neglected, part to play in accelerating progress to end preventable mortality of women and children”.  Horton and Astudillo  go on to note that the work is based on a set of values and philosophy that are distinctive. “These values include respect, communication, community knowledge and understanding, and care tailored to a woman’s circumstances and needs. The philosophy is equally important—to optimise the normal biological, psychological, social, and cultural processes of childbirth, reducing the use of interventions to a minimum. “

The four papers include

  • Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care by Mary J Renfrew, Alison McFadden, Maria Helena Bastos, James Campbell, Andrew Amos Channon, Ngai Fen Cheung, Deborah Rachel Audebert Delage Silva, Soo Downe, Holly Powell Kennedy, Address Malata, Felicia McCormick, Laura Wick, Eugene Declercq
  • The projected effect of scaling up midwifery by Caroline S E Homer, Ingrid K Friberg, Marcos Augusto Bastos Dias, Petra ten Hoope-Bender, Jane Sandall, Anna Maria Speciale, Linda A Bartlett
  • Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality by Wim Van Lerberghe, Zoe Matthews, Endang Achadi, Chiara Ancona, James Campbell, Amos Channon, Luc de Bernis, Vincent De Brouwere, Vincent Fauveau, Helga Fogstad, Marge Koblinsky, Jerker Liljestrand, Abdelhay Mechbal, Susan F Murray, Tung Rathavay, Helen Rehr, Fabienne Richard, Petra ten Hoope-Bender, Sabera Turkmani
  • Improvement of maternal and newborn health through midwifery by Petra ten Hoope-Bender, Luc de Bernis, James Campbell, Soo Downe, Vincent Fauveau, Helga Fogstad, Caroline S E Homer, Holly Powell Kennedy, Zoe Matthews, Alison McFadden, Mary J Renfrew, Wim Van Lerberghe

The Lancet Series on Midwifery makes a major contribution to the literature bringing together the evidence basis for midwifery, its outcomes, and how to affect policy. We need to translate that evidence into action, into the education of the women we teach, and into our advocacy efforts on behalf of safe, healthy birth.

The Lancet Series on  Midwifery can be accessed at through this link. The series includes an executive summary, commentaries, and the four major papers. You need to register on the Lancet site but everything can be accessed for free.

The time has come to recognize and celebrate the incredible work that midwives do. In the US, it is time for women to know about midwifery, and to see the connection of midwifery and normal, physiologic birth.  It is time for childbirth educators to encourage women to choose midwifery care, and time to collaborate with midwives both in our communities and on organizational and governmental levels.  If we want to promote safe, healthy, normal physiologic birth, we need to promote and support midwifery. Healthy low risk women need to know that if they want the safest, healthiest birth for themselves and their babies that they need to find a midwife.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , , , ,

5 Business Practices of Successful Childbirth Educators

June 26th, 2014 by avatar

by Robin Elise Weiss, PhDc, MPH, LCCE, FACCE

Robin Weiss, childbirth educator and president-elect of Lamaze International shares some very smart business tips for being a successful childbirth educator, regardless of whether you work for a large hospital system or teach independent classes. Check out her advice below and share your own suggestions in our comments section. – Sharon Muza, Community Manager for Science & Sensibility

Being in childbirth education is an amazing profession. As a childbirth educator, we are privileged to be with families as they learn and prepare for one of the most exciting journeys of their lives, that of giving birth. Many childbirth educators began this path as a calling, and have had to stumble through the business aspects. It can be difficult to separate the calling from the business.

The good news is that there are five things that you can do that will greatly improve your business acumen and help you become successful in all facets of your profession.

1) Get educated

A formal education in childbirth prepares you to teach and for your certification examinations. However, other than quick mentions of finding clients and paperwork, there is often little information given towards having a business and running it well. There are many questions that you might have from settling on a business name, incorporating, taxes, license fees, or office space. These are questions that have widely varying answers, but that are very specific to where you live and how you practice. Finding a local resource for education is an imperative. Many groups that are willing to help small business owners, like SCORE. They offer free classes and counseling to help you get started.

2) Have back up

Back up in this case refers to your certifying organization. Having an international organization behind you will open many doors. While a hospital of doctor’s office may not know you, the name of an organization such as Lamaze International is well known. The people that you are applying to work with know of the high standards that Lamaze International sets forward in their educators.
There are also special benefits to being a member of a professional organization. This can include referrals for clients in your area, continuing education, conferences, and other things of professional interest. In addition to these benefits, there is also the satisfaction of being with like-minded people.

3) Give Referrals

Referrals may seem like something that does not fit in this list. But following the old adage of it being better to give than to receive is only partially true. I would amend it to be that when you give, you also receive. Keep a local resource list handy and feel free to give it away to anyone who would like it. Also be quick with personal referrals for those with complementary business practices. Think about lactation consultants, doulas, midwives, and doctors in your area. Be sure to ask the person to whom you give the referral to say that you sent them. This shows others in the area that you appreciate their services. Consider asking for their cards to pass out when asked for referrals.

4) Be present

Attend all of the local functions that you are invited to attend or that you can apply to attend. This can include baby fairs thrown by hospitals, guest speaking for various groups from nursing education to mothers’ groups. Being seen in public and having lots of people get to know you is beneficial. It has two benefits, 1) to get to know others in the community and to give back, and 2) to let people know about your services.

5) Be prepared

You should always be prepared with at least two things: your business cards and your elevator speech. Multiple business cards is a no brainer. Don’t be so thrilled with your cards that you are afraid to give them out. (I did this when I first started!) Give them out like candy. Need to give another mom your number for a play date? The back of your card works as a great white space!
Your elevator speech is a 1-2 minute long summary of what you do. Be prepared so that the next time someone asks you what you do for a living, you can quickly and confidently tell them. You can practice this after writing it out at home if that helps you. Some childbirth educators say that they’ve even made a video to watch themselves give this mini-speech to help make it more natural.

In the end, do not let the business side of your calling be a barrier. There are ways to build this side of your skill set and to be both a great childbirth educator and a great businessperson, with just a few steps.

About Robin Weiss

robin weiss head shotRobin Elise Weiss is a childbirth educator in Louisville, KY. She is also the President-Elect of Lamaze International. You can find her at pregnancy.about.com and robineliseweiss.com

Childbirth Education, Continuing Education, Guest Posts, Lamaze International , , ,

Series: Welcoming All Families – The Need for LGBTQ- Specific Childbirth Classes

June 24th, 2014 by avatar

By Kristin Kali, LM, CPM

© Kendra Quinn

© Kendra Quinn

Today on Science & Sensibility, as part of the occasional series, Welcoming All Families, midwife and educator Kristin Kali, LM, CPM shares information on holding a childbirth class that is designed specifically for LGBTQ families.  Kristin discusses the benefits of holding an LGBTQ class, provides some resources and offers additional information on content designed to meet the specific needs of LGBTQ families.  - Sharon Muza, Community Manager, Science & Sensibility

Take off your childbirth educator hat for a moment, and consider your own personal experience. If you are a member of a culturally marginalized group, (and if you do not identify as a member of a marginalized group – imagine) you know the difference between being in a space where you are welcomed and respected, versus being in a space with others who share a similar cultural experience, who speak a common language, and who have aspects of everyday life in common. In a space that is welcoming yet mixed, you may only discuss things you hold in common with those around you, unless you are willing to teach others around you in order for them to understand you and your experience. But if you are in a position of vulnerability, such as being pregnant, or in a class to prepare you for giving birth, you are not likely to discuss things that the people around you simply do not understand or do not have a context for.

Imagine being a lesbian, gay, bisexual, transgender or queer person who is going through pregnancy, with many of the same physiological concerns as any pregnant person, and with many of the same needs and desires, including the desire for a healthy baby, a positive birth experience, and a childbirth class to help assist in attaining that goal. Yet, although you have much in common, if you are in a class of primarily heterosexual couples, or even a class with many different types of families, some of the primary aspects of your experience of bringing this baby into the world and becoming a parent will not be shared.

© Firestone-Kahn 2013

© Firestone-Kahn 2013

Now put your childbirth educator hat back on again. As a childbirth educator, you might be thinking, “Well, there are many unique circumstances that people have when they come to a childbirth class – people may be coming from having dealt with infertility, military wives whose husbands are away at war, women who are giving birth as single moms. We are together to learn about giving birth, so that’s mostly what we talk about when the group comes together.” I invite childbirth educators to imagine any one of those unique scenarios, and envision if the class was full of people who had that scenario in common. How powerful would that be? What might be discussed in the safety of others who truly understand this experience? How might that affect the empowerment, strength and resolve of someone who is preparing for the prospect of giving birth and becoming a parent?

I can tell you, after 9 years of teaching specialized childbirth classes for LGBTQ families, that it is very powerful. When people live in a culture where their relationship may not be honored with the right to marry, when a child is born and a parent is not legally recognized as a parent and they have to prove themselves worthy to a social worker just to gain legal parentage (or perhaps legal parentage is not allowed in their state at all), when they didn’t simply have sex with their partner, rather they used all of their savings and maxed their credit cards just to get the funds for sperm so that they could conceive, it is such a relief to be in a group that has the same common denominator. More than that, it allows for camaraderie, and issues that are unique to families like theirs to be discussed.

In my childbirth classes, the families introduce themselves to each other with the “usual” information, such as name, due date and place of birth. However, before we get started with introductions, I briefly talk about the transformation of self that happens when a person becomes a parent, and as a person’s gender is so central to who they are, of course gender is central to that experience. I invite the introductions to include stating the pronoun that they prefer people to use in reference to them, and also what they plan for their baby to call them – maybe Mom or Dad, but perhaps a different word that more closely matches their gender such as Baba or Dadmom or anything else.

The second thing we do is share conception stories – I’ll bet this is not something discussed in heterosexual or mixed groups! But for the LGBTQ families in my class, the pregnancy experience started way before that little one was growing inside, and sharing these stories candidly establishes normalcy when the situation is not viewed as “the usual way” by society. Furthermore, families may be still be carrying emotional aspects of their conception process in a way that can impact the birth itself, or the partnership during the transition to new parenthood. Sharing conception stories brings me, as the instructor, up to date. It lets me know what happened for each family in the process of getting to this class, and anything important that I need to watch out for or hold space for with each parent-to-be.

Throughout the class, after setting the stage for open discussion and creating such a sense of safety, participants are likely to ask the important questions that they may not otherwise have asked. People feel free to be exactly who they are, not a guarded sense of “how much can I share about myself and not have the other parents look at me weird or be a spectacle”. We cover all the aspects of labor and birth that would be covered in any childbirth class. In fact, my class is based on a popular curriculum. I just bring together LGBTQ families and specifically discuss topics that are unique to this group within the context of the curriculum.

What makes an LGBTQ childbirth ed class so special? I will let the parents speak for themselves by sharing some of the feedback and comments I have received after class:

“There is something wonderfully supportive about being surrounded by other queer families. It created a truly safe and inclusive space where our LGBT experience was at the center, and not just touched on as an aside or an exception to the norm.”

“I am so grateful for this class. Going in as a queer family, not having to translate from everyone else’s ‘normal,’ not needing to explain our family was great.”

“As a gender variant pregnant woman, this class provided support and community that is often lacking in society at large.”

“I needed to voice fears and have time to ask questions in a non-judgmental space.”

“It’s not just about using neutral pronouns and terms (like “birth parent” instead of “mom”). It’s  great to be in a room full of queer folks who understand my experience, so I feel like my queer specific questions are adding to the group’s experience rather than distracting or pulling the class off on a tangent.”

As an educator, it is important to be able to inform people about what to expect, and to be able to hold people as they explore their thoughts and feelings in relation to the class material. While LGBTQ families may have a lot in common, each family is unique. There is a broad range of family structures, conception histories, gender issues, co-parenting strategies, and interpersonal dynamics to explore, all in relation to giving birth and caring for a newborn.

For those who are interested in teaching childbirth classes for LGBTQ families, there are a number of considerations. Are there enough families in your community to support an exclusive class? Even if you are an LGBTQ person, do you have experience working with a variety of LGBTQ people in the process of becoming parents? Are you able to name common birth and postpartum dynamics that come up in lesbian partnerships, for transgender parents, and extended co-parent families?

You can educate yourself by reading books about LGBTQ family- building:

The New Essential Guide to Lesbian Conception, Pregnancy and Birth
And Baby Makes More
Confessions of the Other Mother

Attend an LGBTQ cultural sensitivity training that is specific to birth and family-building:

MAIA Midwifery LGBTQ Cultural Sensitivity Trainings

Check out websites and blogs about LGBTQ parenting:

http://www.mombian.com/
http://www.lesbiandad.net/
http://itsconceivablenow.com/
http://www.milkjunkies.net/

I do not recommend that non-LGBTQ allies teach this specialized class. Instead, enthusiastically refer LGBTQ families to a specialized class if there is one in your area, explaining the value that so many families have found in attending a childbirth class with other queer families. (Read about ways to make your mixed class supportive for LGBTQ families here and a lesbian couple’s CBE class experience  here.)  The sense of safety that is created when a marginalized group gathers exclusively allows something to happen that would not happen in a mixed group. Being in “safe space” provides a sense of common understanding that goes way beyond welcome and acceptance. It allows for dialogue regarding a common lived experience and a shared cultural identity. There is a sense of knowing – not needing to explain the things that to an outsider could be explained, but would not truly be understood without direct, lived experience. Kind of like becoming a parent.

If you are interested in teaching childbirth classes for LGBTQ families in your community, please don’t hesitate to contact me.

Are there educators in your community who teach LGBTQ childbirth classes?  Maybe you are one of those educators?  Do you see the need for such classes in your community?  Share your experiences and observations with our readers on specialized classes such as this. – SM

About Kristin Kali

© Kristin Kali

© Kristin Kali

Kristin Kali, LM CPM is the owner of MAIA Midwifery and Fertility Services, a fertility-focused midwifery practice that provides holistic, individualized care. MAIA serves all families, with specific expertise in serving LGBTQ families, single parents by choice, transgender parents and those conceiving over 40. Fertility consultations, classes and support groups are available in Seattle, Oakland, and online.

Kristin is a Certified Professional Midwife through the North American Registry of Midwives. She is a Licensed Midwife in California and Washington. Kristin is a graduate of Seattle Midwifery School and a member of the Midwives Association of North America, National Association of Certified Professional Midwives, American Society for Reproductive Medicine, Gay and Lesbian Medical Association, California Association of Midwives, and Midwives Association of Washington State.

Childbirth Education, Guest Posts, Parenting an Infant, Series: Welcoming All Families , , , ,

One of a Kind: An Interview with Dr. Meltzer-Brody about UNC’s Inpatient Mother Baby Psych Unit

June 19th, 2014 by avatar

As Postpartum Support International’s 2014 Annual Conference kicks off this weekend in Chapel Hill, NC, regular contributor Kathy Morelli shares her interview with Dr. Samantha Melzter-Brody as Kathy learns more about the only inpatient psychiatric Mother-Baby Unit in the USA.  Perinatal mood and anxiety disorders affect up to 1 in 7 mothers, and at times, inpatient help is what is needed to properly serve the mother and her family.  This unique five bed unit is offering this inpatient care to help mothers get treatment for their perinatal mental health illnesses.  Learn more about this groundbreaking clinic in Kathy’s interview with Dr, Meltzer-Brody. – Sharon Muza, Community Manager, Science & Sensibility.

© Dr. Meltzer-Brody

© Dr. Meltzer-Brody

Dr. Samantha Meltzer-Brody has developed a substantial career as a psychiatrist in the areas of Reproductive/Maternal Mental Health. She is an Associate Professor and Director of the Perinatal Psychiatry Program at the University of North Carolina, Chapel Hill. It’s a comprehensive clinical and research program that includes a five bed inpatient psychiatric Mother-Baby Unit, the first and only of its kind in the United States. UNC’s unit is based on the standard of care psychiatric Mother-Baby Units in Europe and Australia.

In addition, Dr. Meltzer-Brody is scheduled to be the Keynote Speaker on Saturday, June 21st at the Postpartum Support International (PSI) 2014 Conference hosted at the University of North Carolina at Chapel Hill Center for Women’s Mood Disorders. At PSI, she’s speaking about the psychopharmacological treatment of perinatal mental illness.

As a mental health clinician, I admit it took me a while to feel comfortable with the idea that women who are pregnant or lactating who are in need of psycho-pharmaceuticals can do well on them. Now I know there’s a risk-benefit analysis that women should be empowered to employ. Many women in my practice are extremely opposed to taking any medications suggested for their mental health (even when not pregnant or not lactating), so this is a topic with many facets. Each woman is an individual and each woman should talk to her doctor about what’s best for her situation. I’m attending the PSI conference and looking forward to learning more.

Kathy Morelli: How did you become interested in your particular niche, Reproductive/Maternal Mental Health?

Dr. Samantha Meltzer-Brody: First of all, I want to say that I love being a part of the Reproductive Mental Health field.
There are many different roles in the area of Reproductive and Maternal Mental Health, not just one. There are many different types of people needed to work in this area and fill these many different roles. I love that we all can work together, helping each other.

When I began working at the University of North Carolina (UNC) at Chapel Hill, there was no formal women’s mental health program in place. Our women’s mental health outpatient clinic was created at a grassroots level, beginning in the clinics on Wednesday mornings. I was fortunate as UNC Chapel Hill functions with a wonderful collaborative and interdisciplinary atmosphere, so the psychiatry program and the obstetrics program were able to dovetail nicely. In addition, in 2006, our new chair of the psychiatric department arrived, Dr. David Rubinow, who is an international expert in women’s reproductive mood disorders, thus, the time was ripe to create our interdisciplinary Perinatal Outpatient Clinic.

KM: The Mother-Baby Unit at UNC Chapel Hill is the only Maternal-Baby Psychiatric Unit in the United States. I’d love to know more about how the idea came about to develop the Mother-Baby Unit at Chapel Hill. 

SM-B: At UNC, we found there was a high demand for reproductive psychiatry in our outpatient mental health clinics. We have clinic locations in a variety of settings and we found that there was a certain percentage of patients to whom we couldn’t deliver much needed proper care in the outpatient setting nor on a general inpatient psychiatry unit. The Mother-Baby Unit was developed to serve the needs of women experiencing severe perinatal mental illness in a safe and specialized setting to meet the needs of women at this vulnerable time.

As the collaborative team discovered and documented the needs of our patients, we were able to work together at UNC to engage hospital administration at higher levels. We were very fortunate to have a number of champions for this idea within the healthcare system. Initially, we piloted our inpatient program by designating two beds for perinatal patients on a geropsychiatry unit. We developed specialized programming for the perinatal patients and began to get an enormous number of referrals. Eventually, we were able to document that we needed an expanded and completely separate perinatal psychiatry inpatient unit and were able to obtain the support of hospital administration at UNC to launch a new program. And that’s how we became the only Mother-Baby inpatient unit in the United States.

At UNC, we feel it’s critical to have a unit to meet needs of mothers and babies. We feel you can’t mix all the different types of psychiatric populations together. We were able to remodel existing inpatient unit space to create the new unit on a relatively small budget. It’s extremely difficult for the family when a new mom becomes mentally ill and requires hospitalization. Our Mother-Baby Unit helps families through this difficult time by providing family care. It’s extremely rewarding to provide whole care that positively impacts the entire family. We are a state hospital committed to serving the population of the state. Indeed, there’s a state mandate to care for the people of the state, and we take that very seriously.

Keep in mind that our Mother-Baby Unit is a psychiatric care unit, not a respite or spa facility. To be admitted, the patient must meet the criteria for psychiatric inpatient hospitalization, such as suicidal ideation, a heightened bipolar episode or postpartum psychosis or inability to care for self. Most of our patients have suicidal ideation at the time of admission. The average length of stay (LOS) is seven days. Compare this average LOS in the US to the average LOS in a Mother-Baby Unit in Australia of 21 days. We also have a growing number of referrals for women presenting with postpartum psychosis.

When a mother and her baby comes to stay with us, it’s required that a family member, such as the grandmother or father or other identified care provider accompanies the baby on the unit. This is because the babies don’t stay overnight as the health insurance companies in the United States won’t pay for babies to stay overnight. But we work as best we can with the family, in order to preserve the mother’s sleep time for her mental health and also preserve the healthy attachment with her infant. Sleep is especially important when a person is suffering from a mental illness.

In the units, we have bassinets and breast pumps available for the patients and their babies. The nurses’ interaction with the babies vary based on the needs of the particular mother.

Our treatment plans focus on several psychosocial areas of concern. We focus on maternal mood, impaired mother-baby attachment issues, the relationship with the partner and on improving what the partner and family understands about what has happened. To serve these needs, we run several targeted groups: a maternal mental health group, a mother-infant attachment group and a partner group for fathers. But the treatment is individualized; it’s tailored to meet the needs of the family. Due to the typical short length of stay allowed by insurance companies in psychiatric units in the United States, the emphasis is on teaching self-help skills and tools to the patient and family. Such skills and tools are mindfulness, biofeedback, breathing, trigger identification, and post-discharge planning.

KM: There is so much stigma around the diagnosis of mental illness and perhaps more so around perinatal mental illness. Research shows that individuals suffer from both externalized and internalized stigma around a diagnosis of mental illness, much more so than a physical medical condition. So, there’s already stigma about depression and anxiety….it’s already difficult to come forward and then even more so for women to come forward about how they feel, as new mothers and with a baby. There’s shame associated with not coping and also fear about having the baby taken away.

Do you believe there is unconscious stigma around mental illness? Have you seen this phenomena in your work?

SM-B: Stigma is a huge and well documented issue in perinatal mood disorders. It’s very hard and terrifying for people to admit to having a mental illness, especially during the transition to motherhood. There are so many fears around hurting the baby. It’s documented that actual harm to the baby is quite rare, but when it happens, of course it’s a tragedy and the media sadly sensationalizes the event. Plus there is enormous personal shame. Research and clinical experience indicate this shame around feeling emotionally ill and then being diagnosed with a mental illness is exaggerated during the perinatal period. New mothers can feel so insecure and inadequate in their new roles. The stigma, shame and guilt issues are important and need to be part of the therapeutic sessions.

KM: There is so much contradictory information about how hormones, breastfeeding, formula feeding can affect a woman’s self-esteem and mood. Some studies suggest that breastfeeding is protective of depression, yet clinically, some women feel better when they choose to discontinue breastfeeding.

In layman terms, what are your thoughts about the relationship between breastfeeding and postpartum mood disorders? What are some of your guidelines for clinicians to follow regarding the choice of infant feeding method for a woman and her family?

SM-B: At the UNC Perinatal Psychiatry Program, we love to educate organizations that support new moms that women have psychiatric needs. We enjoy the opportunity to educate and influence breastfeeding groups with information about the unique needs of the perinatal population of women with mood disorders. Our feeling is that setting up breastfeeding as an all-or-nothing construct is a set up for feelings of failure for some new moms and can lead to exacerbation of psychiatric symptoms.
It would be great to see the prescription for sleep as a recognized treatment for new moms. And, for mothers with a perinatal mood disorder, to define successful breastfeeding to include one bottle nightly so that mom can sleep for an adequate block of time. This is important for the mom’s brain health.

We also want to emphasize that mothering is not a competitive sport. Our goal is a healthy mother and a healthy baby. Whether or not a woman breastfeeds shouldn’t be colored by judgment of right versus wrong or success versus failure. We need to keep in mind that the goal is that the baby must be fed, even when the mother is suffering from a severe perinatal mental illness.

One thing we do know is that sleep deprivation exacerbates depression anxiety and mood disorders. So we try to help women who wish to breastfeed increase the odds of successful lactation without significant sleep deprivation. We encourage women and families who wish to breastfeed to continue but also set up some guidelines to help the mothers heal mentally and emotionally. We don’t see breastfeeding as an all or nothing activity. At UNC, we say that there can be a combination of breastfeeding and formula feeding in order to support the needs of both mom and baby. We feel that breastfeeding has many benefits and that it’s not an all or nothing equation. We want to enable women with perinatal mood disorders to continue to breastfeed but also help them succeed at mothering, in a way that’s realistic and healthy for them.

KM: Dr. Meltzer-Brody, thank you so very much for your time! You’ve shared enlightened information and guidelines for perinatal clinicians and expanded the definition of mothering to be more inclusive. I look forward to seeing you at the conference at UNC!

What are the health care providers and clinics doing in your area to support the needs of women suffering from perinatal mental illness?  Do you think that your community would benefit from such an inpatient clinic?  How could this become a reality around the country, so all women are served as they should be, with the professional help and treatment they deserve?- SM

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