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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 , , , , , , , ,

Pelvic Exams Near Term: Benefit or Risk? Talking to Mothers About Informed Consent and Refusal

November 2nd, 2012 by avatar

Today, S&S contributor Jackie Levine discusses the potential risks of routine cervical checks near term and how to help your clients and students be prepared to have a discussion with their health care provider about the necessity of such exams. – SM

There are some studies that show a link between routine weekly pelvic exams in the last month or so of pregnancy and an increase in rupture of membranes (ROM) that occur well before labor was meant begin, meaning the membranes have ruptured prematurely, (adding a P to ROM, for premature rupture).   The natural onset of labor may be a week or perhaps only days away, but everything is not quite ready, and if effective labor does not begin induction frequently follows.  And when induction fails, as often it will, since the rupture was premature, and the body and the baby are not ready, cesarean is often the outcome.

photo credit: flickr (link below)

Many women find that their health care providers may start doing pelvic exams at about 37 weeks gestation.  Women should consider asking their doctor or midwife whether these exams are necessary to insure the health and safety of herself and her baby, before providing consent for this invasive procedure.  When I discuss these near term cervical exams with my childbirth class students and look at the studies, mothers-to-be have to ask themselves whether the benefits of weekly exams outweigh the other risks; potential PROM, induction and the increased possibility of cesarean section.

“How do I tell my health care provider that I don’t want an exam, and not have those uncomfortable moments when my doctor or midwife thinks I’m defying him or her and not letting them do what they always do?”  That’s the common and sensible worry, that our students may have, but if we provide an opportunity to role-play with our students and clients and also provide the studies, they will feel confident about having this discussion. They will know the facts and are informed health consumers who could consider saying “Oh, I just don’t want that exam today, so can we do it next week?” They might also share that they’ve researched this topic, mention the studies and ask how routine exams week after week will help insure good health.

An older study examining the relationship between late term pelvic exams and the incidence of PROM stated:

 In the 174 patients on whom pelvic examinations were done weekly starting at 37 weeks gestation, the incidence of PROM was 18%,   which was a significant increase (P=.001).  The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean rate when PROM occurred was found to be twice that of the remaining population. The study suggests that routine pelvic examinations may be (sic) a significant contributing factor to the incidence of PROM. Women with uncomplicated pregnancies were randomly assigned to one of two groups. The author theorizes that the probing finger carries up and deposits on the cervix bacteria and acidic vaginal secretions capable of penetrating the mucous plug and causing sufficient low-grade inflammation or sub-clinical infection to rupture membranes.“  “It would therefore seem prudent to recommend that no pelvic examinations be done routinely in the third trimester unless a valid medical indication [sic] exists to examine the cervix … especially since the information gained from these routine examinations is often of little or no benefit to either the physician or the patient.” (Lenahan, 1984.)

We have all been subtly bullied at one time or another by those in positions of authority, and it’s easy to understand the courage and confidence needed to question a caregiver. It’s a mother’s right and responsibility first to know and then to question, but confidence is the key.  We must make an effort to give real meaning to a women’s right to choose, and to the principle of informed refusal.  The American Congress of Obstetrics and Gynecology (ACOG) has addressed informed refusal several times with its membership since at least 19921, speaking powerfully  about the autonomy of the individual.  Although these writings and bulletins are aimed mainly at assuring legal protection for caregivers, they are a resounding affirmation of the legal and moral right of the patient to decide for herself.

Since the studies assert that routine exams are neither predictive nor probative, the doctor or midwife must be able to say something medically strong to counter the available studies.  When mothers have asked their providers for the reasons to do an exam, they bring a myriad of interesting answers back to class for discussion, but rarely any facts or science.  Remember, ACOG  itself published a study last year examining the basis for its care guidelines and found that “One third of the recommendations put forth by the Congress in its practice bulletins are based on good and consistent scientific evidence” ACOG, 2011) meaning Level A, and that gives us pause to consider the 70% of practices represented by Levels B and C . Care providers will often reconsider when an informed mother-to-be can ask politely and tactfully, about the science that recommends a weekly routine cervical assessment.

Again, women should be able to weigh the risks of routine exams against the possibility of that cascade of interventions that follow on with PROM, interventions that will, at the least, lead to an uncomfortable and harder-to-manage induction, and at worst, put our students and clients on that gurney ride into the operating room.

When a mother is motivated to discuss routine pelvic exams with her caregiver, it may be the first test of the mutual trust and respect she hopes for in that relationship.  Until that point in her pregnancy, she may not have had the opportunity, or the necessity to assert her rights as a maternity patient.  She may have refused to have a routine sonogram or two because her insurance policy would not cover extra routine assessments, but refusing pelvic exams unless there is a valid medical reason will tell her how little or much her HCP is willing to act on best evidence, give her individuated care and show respect for her informed refusal.

The first time she refuses the exam may not be an accurate opportunity for her to judge; many caregivers will let refusal ride that once, but as pregnancy nears term, most docs begin to be insistent about cervical assessment, even without medical indication. A mother-to-be can begin to learn her caregiver’s view of best-evidence care and his or her willingness to listen to her so that she will have an idea, going forward, of how best to assert her rights, with knowledge and confidence in herself, and can get support she may need in our classes.

In a Science & Sensibility post in May 2011, I talked about the importance of giving mothers the same studies that caregivers have access to.  What I said then about giving our classes the actual studies, along with discussion, still applies:

“…perhaps we need to give women a different kind of “evidence”, by giving them a look into the medical community.  If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment.  They feel a gravitas….Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes.  It expands their sense of control and choice. “  

Refusing to have routine pelvic exams in those last weeks of pregnancy is a real opportunity for our students and clients to learn how to ask for, even insist on, best-evidence care for themselves and their babies.  It’s certainly worth a try, and we can support them in the last weeks in a positive way with lots of opportunity for role-play and discussion as they report back to class and share their experiences with informed refusal.

How do you bring up the topic of regular cervical exams for women who are not in labor?  Do you talk about this with your clients and students?  What are your favorite resources for presenting this and facilitating discussions?  Have your students shared stories about their experiences.?  Are you a health care provider?  What are your feelings on routine pelvic exams at the end of pregnancy?  Share your thoughts in our comment section. – SM

References:

ACOG: Ethical dimensions of informed consent: a compendium of selected publications, ACOG Committee Opinion 108. Washington DC, 1992.

ACOG Committee opinion. Informed refusal. Number 166, December 1995. Committee on Professional Liability. American College of Obstetricians and Gynecologists. et al. Int J Gynaecol Obstet. (1996).

ACOG Committee Opinion No. 306. Informed refusal. ACOG Committee on Professional Liability, Obstet Gynecol. 2004 Dec;104(6):1465-6.

Lenahan, JP Jr., Relationship of antepartum pelvic examinations to premature rupture of the membranes. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37.

Levine, J. (May 31, 2011) A Lamaze Story. Retrieved from http://www.scienceandsensibility.org/?p=2954

Vayssière, C. Contre le toucher vaginal systématique en obstétrique Gynécologie Obstétrique & Fertilité, 2005, Volume 33, Issue 1, Pages 69-74.

Wright JD, Pawar N, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ, Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins, Obstet Gynecol. 2011 Sep;118(3):505-12.

photo credit: www.flickr.com/photos/nathansnostalgia/498100786/

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , , , , ,

Preconception and Women’s Healthcare: An Interview with Dr. Michael Lu (Part Two)

July 19th, 2011 by avatar

[Editor’s note:  This is part two of an interview series between Science & Sensibility’s Walker Karraa and OBGYN/researcher, Dr. Michael Lu.  To read this interview from the beginning, go here.For a list of resources pertaining to this interview series, go here: resources and bibliography_dr lu interview series. ]

Working Smarter: Preconception Care, Part II

 

Walker Karraa: You encourage your colleagues to follow the “every woman, every time” philosophy–to use every visit as an opportunity for pre-conception or inter-conception counseling.  Given the current system of medical care, how can a care provider manage to do preconception counseling, and get reimbursed?

 

Dr. Lu: I’ll give you a short answer and then maybe later on I’ll give the broader vision.  The short answer is that everything I read and learn from quality and systems improvement over the last several decades indicates that it’s not just about making individual doctors work harder, it’s really about making the systems work smarter. We’re always asking the OB to do this and do that–often they’re not trained for it.  They don’t necessarily have the time for it.  And they’re not reimbursed for it.

OBs should have an obligation to try to do their best in terms of promoting women’s health, but I think there’s a need to really rethink how we might redesign prenatal care, or how we might redesign women’s health care in general, so that the center of the universe doesn’t revolve around the OB office–which I think is presently poorly equipped to address the totality of the continuum of women’s health across the life course.

Currently the 1.0 system is that you get the OB in either a solo, or small group practice, who is supported by the office clerks, maybe a nurse manager who doubles as a health educator, and maybe an ultrasound tech.

All of the things we’ve been learning about the fetal origins of health –the importance of nutrition, mental health, environmental exposures in developmental and fetal programming, how much of that counseling do you think is actually going on in OB’s office?  And remember most of these OB’s didn’t sign up to be a health educator, to be a nutritional counselor, to be a teratogen information specialist, to do all the things that we know are important in terms of really promoting maternal and infant health.

The public health response over the last couple of decades has been if the OB’s aren’t doing all those things, then let’s create these “wrap-around services”– some kind of the enhanced prenatal care model: I call it the prenatal care 2.0 system.

Ideally it should work better than the 1.0 system, but we all know that there are a lot of holes, a lot of gaps:  If the providers don’t make the referrals, for example. There’s nothing more frustrating to me when I screen somebody positive for peripartum depression and there’s no one on the other end of the referral, or when we screen someone for intimate peripartum violence and there’s no infrastructure at all to help them.  And so the 2.0 system just doesn’t work very well either.

 

OB is not the center of the universe

Dr. Lu cont’d: Many of my colleagues around the country and I have been talking about the need to redesign prenatal care, to move it from the 1.0 or 2.0 system to the 3.0 system where the center of the universe is no longer the OB’s office.  It could be a medical home or better yet kind of a wellness home for women’s health– and let’s make sure all the things that need to get done, actually get done in that home.

For OBs who don’t want to run a medical home, they can be the specialists.  They can run an ultrasound center.  They can be a hospitalist and just do deliveries.  Let them do what they actually enjoy doing.  Don’t ask them to pretend to be a nutritional counselor or health educator –which they never really signed up to do.

We now know health education is critically important.  We know that nutritional counseling is critically important.  We know some component of mental health and social support, etc. is very important.  We know that environmental influences, both looking at the physical and social environment, also play a big role.  Let’s make sure that we actually have a system of supporting this, including reimbursement systems and so forth and actually support this more integrative, more comprehensive system of health care.  This doesn’t have to be just a medical home for prenatal care because now you can have preconception, inter-conception care, family planning, all the things that we know that make that continuum of women’s health care over the life course.  All of that can be happening in this medical home.

 

Walker Karraa: Where do you see childbirth education in the model?

 

Dr. Lu: I think certainly childbirth education needs to be an integral part of that model and that the review and the birth plan–discussing, creating the birthing plan would be important.  Many OBs maybe take 5-10 minutes to sit down with the women and go over some of the components about the birth plan.  They might take some time to explain what an episiotomy is, the risk and benefits and alternatives to analgesic use during labor, and they might talk about the different modes of delivery, the vaginal, versus instrumental, versus caesarean.  But that’s about it.  They may address some questions that the couple has, but I don’t think it usually goes any further than that.

And that’s what I’m saying in terms of we can’t just ask the OBs to work harder.  We’re training our OB residents about the importance of nutrition and mental health, etc. and we can ask them to screen for more and more…and I think we should do that; but on the other hand, the system just doesn’t work very well.  When they’re thrown into a private practice setting, or when they’re thrown into a clinic where they’re seeing two OB patients every fifteen minutes–it just doesn’t happen.

 

So we’ve got to work a lot smarter than that.

 

[Editor’s note:  In tomorrow’s installment of this interview series, you will read Dr. Lu’s thoughts on how childbirth educators can expand their curricula to include inter-conception information, as well as what our culture can do to better support fathers.]

Preconception Care, Research, Series: Preconception Care, Uncategorized , , , ,