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Series: Welcoming All Families; Working with Women of Color – Educator Information

February 27th, 2014 by avatar

By Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE

Today, contributor Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE finishes her two part post series “Welcoming All Families; Working With Families of Color” with a fantastic post on evaluating how well your classes are meeting the needs of Women of Color and tips and information to create a space that welcomes and celebrates WOC and their families.  While, February is Black History Month, educators have a responsibility to offer classes that are inviting and appropriate for WOC all year long. Find Tamara’s first post here. – Sharon Muza, Community Manager, Science & Sensibility. 

black mother and newborn

© David Blumenkrantz

Are your classes inviting and supportive for Women of Color? Or are WOC not your “target market”? I received a comment after sharing my post about Tuesday’s Welcoming All Families; Working with Women of Color blog post; “Sadly many of my (as you say) ‘women of color’ friends, associates and even just casual acquaintances have told me straight up ‘you don’t need to do all that!’,” referring to the belief that taking a childbirth class is not really a valuable or important part of preparing to have a baby for African American women. I believe that it will take more than a few focus groups to get to the bottom of why some WOC do not feel the need to take childbirth education. In today’s post, I would like to focus on childbirth educators! How can childbirth educators be sure their classes are appropriate and inviting to Women of Color?

Prior education experiences

The first thing childbirth educators have to be aware of is that people are more likely to connect with people of their own culture. An example of this; a vegan may be more likely to seek out health care from a provider who blogs about a vegan lifestyle. WOC and other ethnic communities will seek out education from a provider they can relate to culturally. At the least, the educator will have proven to be sensitive to their needs whether those needs are cultural, ethnic or economic. Vontress writes in the Journal of Multicultural Counseling and Development, “Members of minority groups bring an experience of consciously having to negotiate and even survive educational treatment of invisibility or negative ultra-visibility,[ultra-visibility; being singled out or made to be the “token” Black person], lower expectations, stereotyping, hostility and even abuse.” If an expectant mother or her partner has ever had this type of experience, why would they want to sit in yet another class and perhaps have those same feelings brought up all over again? What if they are presently feeling dismissed, their concerns ignored and rushed with their health care provider? Childbirth educators have the responsibility to understand this and make our classes welcoming by using language and images that subconsciously allude to our support and equal treatment and understanding of families of color.

I am guilty of saying “the baby’s mouth and lips should look pink to indicate great oxygenation.” A WOC in class raised her hand and said, “Even brown babies?” I responded “Well, yes, especially a newborn.” Be mindful that WOC have babies of all color hues. Some babies may be dark when born and others may be very light. Darker hued mothers who have not been around newborns may not know to expect their newborn to look light skinned.  A culturally sensitive childbirth educator should mention this fact, so that all families can be prepared. During early pregnancy class, talk about how WOC may experience expansion of the areola and that yes even though they may have dark areolas to start, the areolas can get darker. In discussions about nutrition, talk about soul food cooked in a healthy flair. Remember that the standard American diet is not a one size fit all solution. The Physician Committee for Responsible Medicine mentions 70 percent of African Americans are lactose intolerant (compared with only 25 percent of whites) and may suffer from cramping, diarrhea, and bloating after eating dairy products. Encouraging a WOC to have cheese and yogurt to get calcium and added protein may not be the best advice. Offer alternatives that are appropriate for everyone.

Marketing and teaching materials

Next, evaluate your marketing materials. Have you placed images of women of color on your website, brochures, and social media pages? Do you keep up with the health disparities and concerns for women of color? Do the images on your classroom walls or your teaching posters represent a wide variety of ethnicities?

Review your teaching materials. Do you show birth and breastfeeding images of WOC? Are there images of WOC exercising, eating well, and asking questions of their care providers? In order to effect behaviorial change, one has to be able to envision oneself doing something similar. A great example is a commercial from fatherhood.gov. This videos features an African American dad learning cheerleading moves with his daughter with the grandmother listening and approving of the interaction in the background. AA women love this commercial because we remember performing the same type of cheers when we were young. This type of imaging will promote interest in fatherhood and also plant a seed in the minds of some men that it’s okay to spend daddy-daughter time, maybe even doing something fun or a little silly. The commercial would not be as effective if it showed a Caucasian father doing the same thing. There would be no connection. And if there is no connection, there is no assimilation, and therefore no change in behavior. When expecting parents can see themselves in the “role models” then they can see themselves emulating this behavior with their own children, or their own birth or breastfeeding experience.

Be ready to make change

Once your evaluation is complete, make some changes. There are not many sources to purchase ready made childbirth class images of women and families of color. Don’t hesitate to create your own. Look for images of AA couples on sites such as Shutterstock, Corbis Images , iStockphoto, or Fotosearch. Then use some creativity to create posters and images you can use! Or better yet, have a contest in your classes, asking them to create a poster. Invest in videos that show women of color birthing and breastfeeding. I use Injoy’s products in my classes as I find their videos do a good job representing multicultural families.

In Injoy’s “Miracle of Birth 4″ video, Natasha’s birth shows a biracial couple experiencing a birth supported with analgesia. In “Understanding Labor 2″ and the “Miracle of Birth 3,” Chelsea’s birth follows a young African American couple as they have an epidural birth with augmentation. Daniela’s birth follows a bi-lingual Spanish speaking couple as they have a cesarean birth. Injoy offers an option to purchase these videos individually which is great for a limited budget. The Baby Center has a video of Samiyyah‘s birth center birth which can be imbedded in PowerPoint presentations or played on a monitor. Unlike the well edited and discreet videos Injoy offers, this Baby Center video feels raw and uncut. Be prepared with Kleenex. This birth is a great lead in into discussing orgasmic birth, normal birth emotions, vocalization for pain relief and the fetal ejection reflex during pushing.

Language used when addressing health concerns of African American women is important. As an instructor, you don’t want to talk about pre-eclampsia and preterm birth in a manner that assumes that AA women should already know they are at higher risk for these diseases, but rather frame it as health care workers and researchers are uncovering higher rates of pre-term birth, diabetes, cesareans and lower rates of breastfeeding in the AA community. Presenting these subjects in this fashion, as an awareness among health care providers, may remove any feelings of guilt or negative self-consciousness for those who may not know the information ahead of attending class. Sources to find information related to women of color include Office of Minority Health, March of Dimes, Womenshealth.gov and Women’s Health Guide to Breastfeeding.

Create an event

Consider bringing in guest speakers to your class. Is there a WOC birth advocate in your area that has a large following? Collaborate with her to spread the word. Can you host a Twitter chat or Facebook party discussing your intent to serve the needs of WOC and clarifying the wants and needs of your birth community. Have WHO code compliant corporations donate products for a baby shower or a baby fair. Ideas for a fair may include a pediatric dentist who discusses the important of infant oral care. Bring in a safety expert who will discuss and demonstrate car seat safety and installation. Have a prenatal fitness expert and/or nutritional counselor to discuss food and the connection to gestational diabetes. A community midwife or OB can discuss the impact of lifestyle choices on the risks of developing pre-eclampsia, diabetes related to induction and cesarean births and low birth weight babies. Conclude the event with a game show set up like Family Feud with topics covering medical options, comfort techniques and support strategies for breastfeeding families. Having a fun event always draw crowds.

Offer tiered pricing

Are your classes accessible on an economic level? Do you accept insurance or have a sliding scale for families. The National Health Service Corp has a great resource on how to set-up a discount fee schedule. Is your practice set up to accept social service coupons or Medicaid for childbirth class subsidies such as what Washington State offers? The Kaiser Family Foundation reports 27 states out of 44 that responded to their Medicaid Coverage of Prenatal Services Survey offer coverage for childbirth education. Independent instructors will have to research their own state Medicaid offices for specific information on provider eligibility and reimbursement rates. When receiving reduced fees or subsidies, it may be tempted to schedule classes during the day. Please remember even people on Medicaid or WIC have jobs. Let’s respect that and offer flexible schedules for classes in the evening and on weekends.

Can you set up scholarships? Human Resources and Services Administration has several large grants available to serve the maternal child health community. The March of Dimes has scholarships available for grants reducing disparities in birth outcomes. The What to Expect Foundation has a new program to teach practices that build a healthy pregnancy. The wonderful Kellogg Foundation is another resource to tap into for help building a program to be inclusive and inviting to women of color.

Community connections

Do you have local resources so you can connect AA women to WOC birth workers that share their ethnicity and culture? Sista Midwife Productions has a resource list by state of birth workers of color. If we have to refer out to help a mother feel more comfortable and get what she needs rather than what we have to offer, that’s a win-win situation.

Educators need to learn from the clients they serve. We have to ask the community what information is important to WOC. The Black Mothers Breastfeeding Association can serve as a template to build networks that educate and support pregnant WOC. Invite mothers and fathers of color to lead groups for expectant parents. Groups can cover topics such as how to have conversations about birth options, cultural expectations of birthing mothers and parenting styles and ethnic cooking with a healthy spin and specific topics related to controlling or preventing gestational diabetes and pre-eclampsia, reducing cesarean birth and increasing breastfeeding success.

In order to attract WOC to our classes, educators need to become culturally sensitive and appropriate. Evaluations of our marketing and teaching materials are in order to ensure inclusion of AA women. Educators have to be up to date on the statistics and health facts and challenges facing AA families. Our hospitals, birthing centers, birth support groups and networks should brainstorm ways to fund and provide scholarships and/or grants to make classes economically feasible. Lastly, if we are serious about supporting all mothers and helping them to have a safe and healthy birth, let’s build and support local birth support groups.

Change can be challenging. Start with small goals. The first step is self-evaluation. What had been working and what can be improved? Share your resources? Where do you find images and videos that are welcoming to women of color and all ethnicities? After you have evaluated your program, come back and let me know what worked and did not work. If you need some help, please contact me. I’m excited to try some of these resources myself. I’ll keep you posted on my Facebook page.

References

Vontress, C. “A Personal Retrospective on Cross Cultural Counseling.” Journal of Multicultural Counseling and Development, 1996, 24, 156-166

About Tamara Hawkins

tamara hawkins head shotTamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE is the director of Stork and Cradle, Inc offering Prenatal Education and Breastfeeding Support. She graduated with a BSN from New York University and a MSN from SUNY Downstate Medical Center. She is a Family Nurse Practitioner and has worked with mothers and babies for the past 16 years at various NYC medical centers and the Elizabeth Seton Childbearing Center. Tamara has been certified to teach childbirth classes since 1999 and in 2004 became a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant.  Follow Tamara on Twitter: @TamaraFNP_IBCLC

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Series: Welcoming All Families; Working with Women of Color

February 25th, 2014 by avatar

By Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE

In honor of Black History Month, and as part of Science & Sensibility’s occasional series on welcoming all families to our classrooms and practices, Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE writes a two part post for the series speaking to meeting the needs of families of color.  Today, Tamara shares some insights into the experiences of women of color and their families in childbirth classes and on Thursday, Tamara will discuss how educators can make their classes friendly to women of color and their partners, with information and resources for the educator as well as other birth professionals. – Sharon Muza, Community Manager, Science & Sensibility

© Williams Family

© Williams Family

In my second year of nursing school, I gave birth to my daughter. When pregnant with her, I faced the choice of taking a Lamaze class or completing my Biochemistry course. Both classes were on the same night.  I wanted to become a midwife and knew the benefits of birthing with the least amount of interventions. I also knew the stigma I would face as a single young Black mother so I prioritized and choose Biochemistry. I had to complete my semester before giving birth. I did not even think of taking a class other than what was offered at the hospital. I was not offered any alternatives either.  I thought to myself, “How difficult could labor be? It all seemed so simple.” In preparation, I read the book, Preparation for Birth: The Complete Guide to the Lamaze Method by Beverly Savage and Diana Simkin.  I was ready with the electric massager and my birth plan.

I never second thought the benefits of Lamaze class or thought it wasn’t something Black women did, however I clearly remembered people saying, “Why do you want to take that class?” “You don’t need that,” or just laughing because somehow I should’ve just known what to do and didn’t. Women in my neighborhood started having babies as teenagers.  In the prenatal clinic, there was limited information about birthing options and childbirth education other than the public education programs that played endlessly on a loop in the waiting room. Grandmothers, who were mostly the primary caretakers, would expect the girls to tough it out without pain relief as this could be seen as punishment for getting pregnant so early. Some mothers hoped it would serve as a deterrent to getting pregnant again. Childbirth education was not an expectation as past generations just knew to go to the hospital when the pain got too bad. I was just expected to know to move and breath and squat and groan with the contractions and to just deal with the pain. The baby would eventually come out.

A few months after the birth, I wished I had taken a class. I had a horrible birth and breastfeeding experience.  The book and “barely there” labor support was not enough to get me through the emotional challenges of labor. I needed more. I needed practice. I needed discussion. I needed to know the real deal and how to navigate the system. From my birth experience, I knew childbirth education was an essential path to have a beautiful normal birth experience.  I felt so passionate about this that I became a Lamaze certified childbirth educator.

The women I get to mentor in my childbirth classes come from different cultures and backgrounds than I do. They have different fears and concerns. What troubles me is the low attendance of women of color (WOC) in childbirth classes. Lamaze class is about learning healthy habits, building confidence and facing fears. Techniques shared in class help women create solutions for potential labor scenarios and manage labor pain while partners learn skills to comfort and protect moms in labor and to communicate effectively with care providers. This is especially important for African American (AA) women.

The Office of Minority Health reports AA women have 2.3 times the infant mortality rate as non-Hispanic whites.  AA women have twice the rate of sudden infant death syndrome and are 2.3 times more likely to begin prenatal care in the 3rd trimester than non-Hispanic white women. (Mathews, et al, 2013)  The cesarean birth rate amongst AA women is no better.  The rate of cesarean delivery declined among non-Hispanic white women for the third straight year to 32.3% in 2012. The 2012 cesarean rates rose, however, among non-Hispanic black (35.8%) and Hispanic (32.2%) women.  (Hamilton, et al, 2013)  Amnesty International 2010 report, Deadly Delivery: The Maternal Health Care Crisis in the USA revealed AA women are nearly four times more likely to die of pregnancy-related complications than white women. These rates and disparities have not improved in more than 20 years. (Amnesty International, 2010)

Attending childbirth class is a path, and some people may say, a Rite of Passage to achieve better health, better birth outcomes and better breastfeeding for African American Women.  For the past two years, R.O.S.E., Women E-News and MomsRising have hosted a twitter chat (#blkbfing) encouraging women of color to breastfeed. These organizations also have to emphasize breastfeeding success starts with a normal birth, minimal interventions and a healthy mother.  Skills and techniques learned in Lamaze classes support these outcomes.

So, if we know the health disparities that affect WOC during pregnancy and birth and the government knows, how can I and other educators reach and encourage more attendance in Lamaze class. Does the instructor need to look a certain way? Are childbirth classes just for white women?  I sat down with Domineque and her husband Davon who delivered in New York City, NY and Reese McGillie, who birthed in Seattle, WA to talk about their experience attending a childbirth classes as women of color.

Tamara: Tell me about your experience in childbirth class? Were you the only African American in class?

Domineque: Well to start off as a new mom and WOC, I was really unsure what to expect at a Lamaze class.  However, after discussing things with my husband and talking to others, we decided to give it a try.  I wanted to know what others thought of Lamaze class. No one I knew ever attended one. As a school teacher, I am always into learning new things. I was nervous and afraid as this was a surprised pregnancy. I wanted everything to go right. I searched websites constantly and read tons of books. I must say I had a great experience. I felt a warm welcome and was very comfortable there. I don’t remember now if we were the only AA couple. (chuckles) I think we were, but I wasn’t bothered by that.

© McGillie Family

© McGillie Family

Reese: I had a familiar feeling of being the only AA woman in the class. It did not bother me during class. I might call it being complacent. Typically, I expect to be the only AA woman in classes, conferences and trainings. I had a great learning experience in my childbirth class. In hindsight, it would have been nice to have other AA women in attendance to not feel alone even though I was in a class full of people. You know, sort of having the ability to meet and join up with some Sista friends. Perhaps it was a combination of my security as a AA woman but sitting in that room, I knew no matter what, my experience would be different. I’m sure the other mothers did not worry about arriving at the hospital and having someone question them about their level of education, adequate prenatal care, whether they were married or even had a partner or even their competency level to parent their child.

TH: Do you feel the class touched upon topics specific to African American women such as higher rates of preterm labor, pre-eclampsia and lower rates of breastfeeding?

Reese: No. I wish it did. Twice I faced pre-term labor.  My first baby was born at 34 weeks. I was sad and afraid especially because I could not get a clear answer as to why I was having pre-term labor. It would have been nice to know sometimes preterm births happen more in AA women and that the exact reasons why are unknown in most cases.

TH: Do you think learning about the risks associated with birthing and being AA would make a mother more or less anxious about the process?

Domineque: I believe it would make anyone more anxious when the topic is introduced.  Giving strategies to reduce preterm birth such as recognizing labor contractions, how to time contractions, how to rest and hydrate oneself was discussed in class but not in the context of this only happens or happens more to AA women. We discussed pre-eclampsia in class but again not geared towards AA women. If it was just discussed as something that AA women experience more than other ethnicities, I might have felt singled out and self conscious. I did not know AA women experienced higher rates of pre-term births and pre-eclampsia. I am not sure if learning that specifically in class would have changed my learning experience.

TH: Did friends or family try to talk you out of the class? If so, what were their reasons for suggesting you not to take a class?

Domineque:  I didn’t get persuaded or dissuaded from others. No one in my circle attended a childbirth class and really had no input into the decision. My husband and I talked about our fears of being young parents, newlyweds and my desire to have an unmedicated birth. We agreed to do it. Thank goodness no one tried to dissuade us.

Reese: I was encouraged to attend childbirth classes by my midwife. It was an expectation. I was excited to take a class with Penny Simkin.

TH: Did it make a difference to you whether your instructor  was African American?

Domineque: No. I wanted someone who was experienced and fun. My biggest concern about attending a Lamaze class is  whether or not it was going to be boring and just filled with breathing exercises.

Reese: No. I was already reading a book Penny Simkin authored and was excited to attend her class

TH: What were two skills you learned in class that you were able to apply in labor and/or after giving birth?

Domineque:  Lamaze classes prepared me for a safe, healthy birth. I also learned about breathing and relaxation. Most importantly, I learned coping strategies and movement techniques. The class also gave me practical advice on how to start breastfeeding such as holding the baby skin to skin. I was able to breastfeed Dyllan for a long time. I was even surprised how easy it was to nurse in public. During our childbirth class there was a video clip of an AA woman breastfeeding her baby immediately after birth and I thought “Wow, I want to do that.”

TH: Did seeing images of AA women in birth and breastfeeding change your feelings or make you more confident about what you would be able to do in your birth?

© McGillie Family

© McGillie Family

Reese: Yes. Absolutely. I remember clearly the AA couple’s birth story in class. She seemed powerful. She was not in a hospital and it influenced my belief that even AA women could have beautiful experiences. That having great births were not just reserved for Caucasian women or those with money.

TH: What would you tell another African American mother about taking a childbirth class?

Domineque: I would tell them that after leaving the Lamaze class, I felt comfortable with breathing strategies and more at ease and confident. It was definitely worth it. The class prepared me to have conservations with my care providers.  One of the best parts of class was practicing the use of the acronym B.R.A.I.N. I was learning how to assert myself in situations where I was taught the doctors knew everything and I shouldn’t question what was happening.

TH: Davon, what would you tell AA men about taking a childbirth class?

Davon: As a husband, I would tell all partners, not just AA men, to weigh out options on pain medication vs. no pain medication and be there to support your spouse every step of the way. I believe a lot couples choose not to attend a Lamaze class because they think all that’s needed is an epidural. I learned there is so much more to birth than just the physical pain of the contractions. A woman needs the most support during vulnerable times like deciding when to go to the hospital and help her to advocate for walking and changing positions in labor.  My wife and I worked hard together to get through labor.  Support is key.  My wife was able to have an unmedicated birth using the techniques we learned and practiced in class.

TH: I have a few questions for the readers:

Is the Millennial generation of AA woman easier to reach and educate through social media instead of traditional classes?  Are you an AA mother who attended a childbirth class? What was your experience? Were your needs met in class? If you did not take a class, how did you prepare for birth? Did friends and family support your decision or turn their nose up at you?

I am grateful these two women shared their experiences with me. They even gave me insight as an AA woman and instructor to become more sensitive to how I run my classes. I find myself wanting to be more inclusive and not make race an issue, at least not in birth. Is there any situation in life that race does not play a role? Stay tuned for my post on Thursday that will include resources on how to make classes culturally sensitive and welcoming to AA families.

References

Amnesty International. (2010). Deadly Delivery: The Maternal Health Care Crisis in the USA.

Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2012. National vital statistics reports; vol 62, no 3. Hyattsville, MD: National Center for Health Statistics. 2013.

Mathews TJ, MacDorman MF. Infant mortality statistics from the 2009 period linked birth/infant death data set. National vital statistics reports; vol 61 no 8. Hyattsville, MD: National Centers for Health Statistics. 2013.

About Tamara Hawkins

tamara hawkins head shotTamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE is the director of Stork and Cradle, Inc offering Prenatal Education and Breastfeeding Support. She graduated with a BSN from New York University and a MSN from SUNY Downstate Medical Center. She is a Family Nurse Practitioner and has worked with mothers and babies for the past 16 years at various NYC medical centers and the Elizabeth Seton Childbearing Center. Tamara has been certified to teach childbirth classes since 1999 and in 2004 became a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant.  Follow Tamara on Twitter: @TamaraFNP_IBCLC

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Series: Welcoming All Families; Working With Teen Parents

June 20th, 2013 by avatar

On Tuesday, I highlighted the news that teen birth rates have dropped significantly. Our occasional series on welcoming all families continues today by examining the issue of teaching childbirth education classes for teen parents.  Teenagers and very young adults may be part of your student population, or you may have considered running a class just for this special group.  Either way, today’s blog post by Serena O’Dwyer, Director of Education for the Pregnancy Resource Center, in Everett, WA is chock full of information you can use to better serve teen parents. – Sharon Muza, Community Manager

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© http://flic.kr/p/5L3wn7

Imagine being 16. Maybe that thought alone is painful? Now imagine you’re pregnant and your mother is dragging you to a childbirth class on the same night as “Pretty Little Liars.” Why are you going with your mother? There may be a really good chance that the baby’s daddy doesn’t want to be a part of your future, let alone go to class with you.  You might be secretly hoping that none of the other dads come to class because that might make you feel better since your own boyfriend is MIA. Or maybe you don’t mind going because your BFF is with you. Now you can sit in the back of the room together and giggle every time the instructor says “vagina.”  Your next thought is “Holy Crap, what is going to happen to my vagina?!…”

Childbirth educators, this may be your audience. 

I’ve been teaching childbirth classes for nearly 6 years and am the Education Director for a childbirth education program designed for teens, single mothers and families experiencing unplanned pregnancies. In my regular childbirth class series, the class attendees’ ages may range from 14-45. However, we recently started offering a teen series for the younger families who prefer to learn exclusively amongst their own peers. Though I had always gotten positive feedback from the young families who attended the original mixed demographic classes, I saw many teens censor themselves or reserve their questions for later, to be sent as an email, which they viewed as a “safer” method of communication.

I came to the class with the baby’s dad. He was kind of hesitant to go at first. He did not want to feel judged for being young. He didn’t feel judged though and he liked the information so we continued the course together. – Teen mother

Since separating these younger mothers from the older crowds, I have seen much more consistent attendance and class involvement. Asking questions and exploring options with other young women, who are also facing many of the same social and relational challenges, seems less intimidating for these young mothers.  One of the biggest benefits of an exclusively-teen audience is the opportunity to foster new relationships with other young mothers and fathers. I’m always amazed at how quick they are to connect with one another and form strong bonds. This is very critical,  considering that most of their friends are still living the lifestyle of a carefree teen rather than a young adult preparing for parenthood. 

Before I entered the class, childbirth and breastfeeding felt unreal. I was so scared about getting a cesarean section and the pain of birth. I felt SO much better after finding out about doulas and giving birth naturally and breastfeeding.  After the class I was  still a little scared, but much more confident.  Teen mother

© http://flic.kr/p/5JVBsD

Discussions amongst pregnant teens can be quite different than those held on the same subject conducted by their elder counterparts. One of the most powerful discussions I have facilitated concerned shame. During a postpartum recovery topic, I asked what their support systems looked like. The conversation went on to reveal a common struggle of most of the young mothers, regarding their friends and family accepting their pregnancies. Each young woman shared a very similar story about a family member or peer calling her a “whore” and telling the young women that they had no business having a baby. There were seven teen mothers in that classroom and all seven of them had been made to feel unclean and incapable of motherhood at one point or another.  While this was extremely disheartening to hear, it was a beautiful discussion: honest and raw and undeniably unifying. Most of these mothers have wonderful support from friends and family, but they also have to deal with the brutal judgments of others. 

I feel like now I know that I have rights and choices over myself and my baby.  Teen mother

How many times have you heard the phrase “babies having babies”? How many times have these young mothers been told that? Statements such as this don’t empower young families and they certainly don’t build confidence or encourage a new mother’s parental advocacy. As childbirth educators, we have the incredible honor of shattering that paradigmt! These are young women becoming young mothers and they need our encouragement and they need tools. It is our responsibility to set aside whatever biases we might have about teen pregnancy/parenting and strive to empower these mothers. This empowerment goes beyond just informing them that they have choices. They are often just learning that these choices are THEIRS to make. It’s common for childbirth class attendance to be mandated by parents, counselors or social workers. Many of these women haven’t even selected their own care provider but rather attend appointments made by their parents with a health care provider chosen without their input. Our challenge as educators is to turn a “required” class into a safe place where they CHOOSE to learn and engage.

Before the class I had NO idea about the choices I had in my birth. It really changed my birth plans. I ended up waiting longer to go into the hospital and labored in the birth tub. I went totally med-free!  Teen Mom

Teens Dj, Dre and their young son

I understand that not every educator may be able to host a “Teen Only” class, but any talented and compassionate instructor can welcome, educate and help empower a young mother and partner within a group of established, older students by always being conscious and courteous of the societal gap. Here are some tangible suggestions:  

  • Alienation is one of the biggest hurdles in a mixed-generation class and we can’t always avoid that as some mothers will choose to isolate themselves. Try and cater your icebreakers/get-to-know-you sessions to break through social and age barriers. Chances are they all watch those horrid baby shows on TLC, let them celebrate that common bond before you encourage them to turn it off. (Even though we know they won’t.)
  • Often the younger attendees are left to feel inadequate if they are not able to contribute their own experiences to discussions. Keep this in mind when topics such as work, money and relationships come up. Incorporate common teen scenarios into your problem solving sessions and role plays. For example: when discussing breastfeeding, don’t just talk about moms going back to work, acknowledge that some mothers may be going back to school and let them know that they can pump at school in the nurse’s office or other private location.
  • Tweak your terminology. Talking about breasts and vaginas can be difficult for any age group but for a teen it can be painfully awkward. Try making it less awkward by diffusing the tension with adjusted terminology. Here’s an idea for example: when defining the vagina and it’s function in birth, you can encourage everyone in the room to share as many names for vagina as they can come up with. Grab a marker, write out their brainstormed terms and be prepared to learn a couple new nicknames! This lets everyone know that it’s okay to laugh and it’s okay to use the words we are more comfortable saying. Afterwards, it will be safe to say, “Your girly-bits are going to be a bit sore for a few days.” once you’ve already defined the perineum.
  • Play to the strengths of youth throughout your class/series by incorporating relevant interests like technology, celebrities, music, TV and movies. Pregnancy and birth apps are a hit. Talking about which stars are breastfeeding/baby-wearing seems to appeal to all age groups. Consider utilizing modern music for ambience. Maybe also mention how Adele might be great for relaxing throughout labor, but a little AC/DC can help energize for 2nd stage. What movies are out there portraying childbirth? “How realistic was that pushing scene from Knocked Up?”
  • Provide safe, non-confrontational ways for students to ask questions. Write your cell phone number on the board and at certain points in class ask everyone to text you a question about the section you just taught. No one will be singled out and questions are anonymous.  You may purchase a cheap, “pay as you go” phone just for this purpose if you want to keep your cell number private.
  • Don’t dumb-down your class content. Teenagers don’t want to be treated like children so don’t pander to them with trite games and exercises. If they feel secure in your class environment they will participate and ask questions if something is not clear. Teen students engage very well with informed decision-making as it sparks their curiosity and sense of justice.
  • Teens will typically need to rely on more community resources than the rest of your parents. Seek out your local resources that cater to their age group:

               - Teen parent support groups (Teen MOPS, Young Lives for example)
               - Community resources for housing, education and parenting
               - Legal resources and attorneys for parenting plans
               - Mediators for parents and grandparents
               - Free/sliding scale lactation consultants and  doulas

Above all,  be sincere. If someone feels patronized they will disengage. These teens are not “babies having babies”, they are young women becoming mothers, just like everyone else in the room.  Let us highlight their capabilities, help build confidence and empower self-advocacy for  themselves and their children. 

Have you taught teen parents?  In specialized classes or as part of your regular offerings?  What has been your experiences with working with very young mothers and fathers?  How do you engage and welcome these unique families?  Please share your favorite resources, tips and activities so that we all may become better educators and work more effectively with teen families. – Sharon Muza

About Serena O’Dwyer

Serena O’Dwyer is the Director of Education for Pregnancy Resource Center in Everett, Washington.  As a  volunteer instructor, she has taught free childbirth classes to hundreds of families in her community. She is currently teaching the class series, Expecting Your Miracle for Teens and is passionate about empowering young families. Serena received her first childbirth educator training through ICEA in 2007 and then from Lamaze International/Passion for Birth, in 2011.  She is currently working on certification through Lamaze.  Serena is also a birth doula at Serene Doulas.  She can be reached at serena@expectingmiracles.com

Childbirth Education, Guest Posts, informed Consent, Newborns, Parenting an Infant, Push for Your Baby, Series: Welcoming All Families , , , , , , ,

Series: Welcoming All Families; Working with Gender Variant (Transgendered) Families

January 24th, 2013 by avatar

In the occasional series on Welcoming All Families, we have explored how to make our classes and practices welcoming for women of size and lesbians.  Today on Science & Sensibility, Certified Nurse Midwife Simon Adriane Ellis shares how to offer care and classes that are sensitive to gender variant families. Recently the American College of Nurse-Midwives (ACNM) released a position statement on Transgender/Transexual/Gender Variant Health Care. The ACNM stated that they “support efforts to provide transgender, transsexual, and gender variant individuals with access to safe, comprehensive, culturally competent health care and therefore endorses the 2011 World Professional Association for Transgender Health (WPATH) Standards of Care.”  Simon Ellis served on the task force and played a significant role in writing and advocating for this recently released position paper and worked with ACNM to see it through Board of Director approval in December 2012. – Sharon Muza, Science & Sensibility Community Manager

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Note: The term “gender variant” is used throughout this post to describe individuals whose gender identity is in some way different than the sex they were assigned at birth. Other related words you may have heard before include transgender, gender non-conforming, and gender non-binary. In this post, I specifically address the needs of gender variant people who undertake pregnancy. The needs of gender variant partners and family members also warrant deep consideration, but will not be the focus of this piece. 

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

When asked, many birth professionals will tell you that they’ve never cared for a gender variant patient. Many of us claim that we don’t have the skills or the knowledge to do so. Turns out we’re usually wrong, on two fronts. First, chances are many of us have served gender variant people, without knowing it. And second, we are competent, compassionate, and well-trained professionals who already have what we need to provide excellent care and services to our gender variant patients. This post will provide a basic framework for approaching care, as well as some specific resources and suggestions to make your practice more inviting. I write it from both my perspective as a practicing Certified Nurse Midwife, and my perspective as a gender variant person (female-to-male).

Focus on What You Bring to the Table

We all bring ourselves – rich in beauty and flaws and experience – to each client encounter. We are our own building blocks of clinical or professional practice. Accordingly, when striving to provide care or services across difference, the first place to start is within ourselves. What do we bring? Among other things, we bring skills and biases.

Skills

As professionals who serve families in pregnancy and birth, the core of what we provide is compassion; we are incredibly dexterous at meeting people where they are at. We offer a strong and loving presence even in the intense terrain of labor, which takes a whole lot of humanity and skill. This is your number one asset for providing culturally responsive care to gender variant patients and clients. So keep doing what you do best! 

Biases

If someone asks you why you choose to do birth work, what do you say? Many of us would say that we are passionate about serving women, that we value women’s bodies and autonomy and we honor the journey to motherhood. Which is fantastic! We should! But what if your pregnant client doesn’t happen to identify as a woman? Does that change anything about the importance of their journey to parenthood? Does it make their birth experience less authentic and worthy of support? Of course not. Birth is birth, regardless of gender identity. And birth is our specialty. But many of us have a very hard time imagining pregnancy outside the concept of “woman,” which casts doubt on gender variant people who choose to carry a pregnancy. Being aware of and challenging your own biases and personal attachments to the concept of gender will help you prepare yourself for working with a more diverse client base. 

Don’t Pass the Buck

It is convenient to fall back on the idea that we, as birth professionals, are only trained to work with women and therefore are simply not qualified to work with gender variant people. In saying this, we falsely join two separate concepts – sex and gender – and we falsely absolve ourselves from responsibility. The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s wellbeing. But the truth is: with very few exceptions, there is no one with more experience.

In my work with gender variant parents, every single one of their doulas, childbirth educators, midwives, and OBs stated they had never before worked with a gender variant patient. There was no research these providers could review on the physical and emotional health needs of this population, no information on best practices. Each provider had to rely on the skills and knowledge base they already had, and do the best they could. And with compassion and clinical/professional acumen as their guide, it turns out they usually did an awesome job. The lesson to take from this is that 1) you are capable of doing a good job, and 2) a suggestion that the patient see “someone who has more experience” is usually little more than a referral to nowhere. 

Make Your Practice More Inviting

While there is no simple list of do’s and don’ts that you can follow (and the golden rule is, as always, to cater your approach to the needs of the specific client), I do think there are some basic principles that can be helpful in adapting your practice to meet the needs of gender variant patients and clients.

1. Build trust and offer accommodations

Fear of discrimination by providers and fellow patients or class participants presents a huge barrier to care for gender variant people. It is a source of great emotional and physiological stress. I can tell you that it is truly a terrible feeling. Take time to build trust, and to assess your client’s need for accommodations. Some clients will desire as much anonymity as possible, in which case you can offer one-on-one class sessions or facility tours, appointments at the beginning or end of the clinic day, assurances of privacy, and continuity of care. Other clients will desire facilitated integration, in which case you can offer assurance that you will address problems proactively, be available to address questions raised by other clients, and make a point to check in regularly on how things are going. If you need to refer the client to another provider, be sure to offer to call ahead and provide the patient’s background. Taking over the burden of explanation can be an enormous weight off your client’s shoulders.

2. Plan to offer additional emotional support

We all know that pregnancy is an intense and vulnerable time. Gender variant parents-to-be often have the additional struggle of profound isolation, coupled with the likelihood of heightened gender dysphoria during the course of pregnancy. With these things in mind, make yourself available to provide additional emotional support as necessary. Research LGBTQ friendly mental health providers in your area so you are able to make appropriate referrals if needed.

3. Keep your wording flexible

The language of birth work is extremely gendered. This can be isolating for gender variant clients. Work to make your language more inclusive by incorporating terms such as “pregnant parents,” “parents-to-be,” “new parents,” and “gestational parents.” Ask your clients what name, pronoun, and parenting term they would like to be addressed by, then respect their wishes in both individual and group settings. If you slip up and use the wrong name or pronoun, acknowledge it promptly and succinctly, then move on. If you work with a staff, make sure that all staff members are addressing the patient or client appropriately as well. Including fields asking for “preferred name” and “pronoun” on your intake or registration forms will send a clear (and very relieving!) signal to potential clients.

4. Don’t let curiosity get the best of you

I can tell you from personal experience that gender variant people are constantly asked about our gender identities. Regardless of the context or topic of discussion, we are expected to be willing and able to explain our innermost sense of self (or defend our right to exist!) at all times. This is stressful! While your curiosity may stem from a desire to better understand your client’s gender experience, and you should be open to hearing about their experience, focus on the pertinent issues at hand. Maintain your professional integrity and ask only what you need to know in order to provide excellent care.

5. Address issues proactively, especially in group settings

If you see clients in a group setting, consider a handout or brief talk at the beginning of each class (regardless of who is in attendance) affirming that there are many different types of families and that intolerance will not be allowed. Name behavior firmly but gracefully when someone acts inappropriately, and follow up with them individually outside of the class setting. Do not place the burden on your gender variant clients to defend themselves – instead, show them that you are a dependable professional who has their back and is willing to help other clients grow and become more accepting.

Thank you so much for your commitment to serving gender varient people!

Creating a class or practice that is welcoming to all families can involve sharing stories of all different families.  Choosing your media, handouts, posters and class material that includes all the different ways that families can look is important.  Please share your favorite resources for these types of supplies.  There is not a lot to choose from and we can all benefit from sharing information.  What do you do (or what have you done) to welcome gender variant families into your classes and practices?  Please share your experiences in the comments section.- Sharon Muza

Resources

Resources on this issue are few and far between, unfortunately, but here are some good places to start:

Basic vocabulary and introduction to the issue of gender variance: http://srlp.org/trans-101

2010 healthcare discriminatory survey: http://www.thetaskforce.org/downloads/resources_and_tools/ntds_report_on_health.pdf

Blog by a transgender dad who breastfeeds his son – lots of good information as well as personal reflections: http://www.milkjunkies.net/

Resources for gender variant parents – includes legal resources and family support resources: http://www.transparentcy.org/Resources.htm

Gender and the Childbirth Professional Facebook group – connect with other providers who work with gender variant clients, ask questions, post resources, etc.: https://www.facebook.com/groups/265359336861854/?fref=ts

My personal blog – occasional updates on midwifery, sexual health, and what’s it’s like to be a gender variant midwife: www.boimidwife.wordpress.com

It’s My Body, My Baby. My Birth – DVD for use in class that shows 7 natural births and interviews the couples.  One couple is gender variant.  http://www.itsmybodymybabymybirth.com/Home.html

Additionally, the ACNM Position Statement contains additional resources on this topic.

Thank you so much for your commitment to serving gender varient people!

 About Simon Adriane Ellis

Simon Adriane Ellis is a Certified Nurse Midwife, trained doula, and queer and gender variant person. He has a long history of social justice organizing around issues of racial and economic justice and LGBTQ rights, and brings these values to his work as a midwife. His practice is focused on providing empowering sexual and reproductive health services across the lifespan for people of all gender identities. He is currently working to publish his original qualitative research on the conception, pregnancy, and birth experiences of gender variant gestational parents. He hopes that this work will provide a broad call to challenge conventional assumptions about what pregnancy looks and feels like for all of our clients, regardless of gender identity. Simon can be reached through his midwifery practice, Essential Healthcare + Midwifery Services.

Childbirth Education, Guest Posts, Legal Issues, Midwifery, Series: Welcoming All Families , , , , , , , , , ,

Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

November 8th, 2012 by avatar

Continuing along in our occasional series on “Welcoming All Families” to our childbirth classes, this two part guest post is written by Pam Vireday,  creator of the Well-Rounded Mama blog.  Today, Pam shares how to promote optimum outcomes at the births of plus sized mothers. Click here to read the first post in the series, where Pam shared how to create childbirth education classes with women of size in mind. – Sharon Muza, S&S Community Manager

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In part one of the series,  we discussed how birth professionals can make women of size feel more welcome by creating a size-friendly space, by addressing special needs, by finding size-positive images and birth stories, and by addressing potential risks in a proactive, non-judgmental way.  Today, in part two, let’s discuss ways to promote optimal outcome in women of size.

Nutrition and Exercise

photo courtesy of Pamela Vireday

Many women of size find they feel better and have more stable blood sugar when they combine carbohydrates with protein instead of consuming carbohydrates by themselves. Modestly limiting carbohydrates at meals, eating smaller and more frequent meals, and using whole grains instead of refined carbs may also help promote euglycemia.

An even more powerful tool for optimizing blood sugar is exercise. Intensity of exercise is far less important than regularity of exercise, with daily exercise being optimal. Many women of size find walking, swimming, prenatal yoga, and water aerobics particularly friendly to larger bodies.

Nutrition Diaries

One of the most trying things for some fat women is the pregnancy nutrition diary. If used, these must be done with care.

After years of having every bite nit-picked, pregnancy food diaries can be very triggering for women with long histories of dieting or eating disorders. In addition, many providers don’t believe women of size no matter what they say. As one mom shared, “[My midwife] refused to believe what I recorded. She flat-out accused me of lying, telling me that I ‘must be living on ice cream and donuts.’”  This can be very disillusioning.

If you decide to use food diaries, question your assumptions about what fat women “must” be eating.  Some people eat normally and are still fat, while some thin women have terrible habits and yet are thin. Leave out assumptions, scolding, and lecturing, and find a way to neutrally help women analyze their own intake and gently adjust if needed.

Prenatal Weight Gain

Current weight gain recommendations from the Institute of Medicine are 11-20 lbs. for obese women, and 15-25 lbs. for overweight women.  However, many care providers these days are strongly pressuring obese women to diet to restrict weight gain, or even to deliberately lose weight during pregnancy.

This is a dilemma for women of size, because research suggests that very low gain or gestational weight loss may actually increase the risk of small-for-gestational-age or premature babies. Some research suggests differing weight gain recommendations for differing classes of obesity, but studies on limiting weight gain have many design flaws, so providers must tread carefully to balance potential benefits and risks.

Another alternative is to take a Health At Every Size® approach. Good nutrition and regular exercise is promoted, but without the scale as a goal.  The finger-wagging, shaming approach of most dietary intervention is absent, and although particular weight gain goal ranges can be encouraged, good nutrition is put ahead of rigid goals. Many women with a long history of dieting find a Health At Every Size® approach very freeing because it still emphasizes healthy behaviors, but without the scale as judge and jury.

Weight gain among women of size is extremely variable. A lot depends on the woman’s individual circumstances. Differing amounts can be normal as long as you are eating nutritiously.

As one big mom notes:

Talk about weight gain, but explain that every body is different. Some people gain lots and have healthy babies. Some people gain very little or even lose and have healthy babies. Don’t focus on the scale, but on healthy eating and assure people their bodies will then do what they need to do.

Another mom agrees, saying, “Providers can get across the point that excellent nutrition is key to a healthy pregnancy and birth without making mom stress over it.”

Finding a Size-Friendly Caregiver

Finding a size-friendly caregiver is critical to having a positive birth experience. Unfortunately, bias and mistreatment are not uncommon. Some of it is egregious mistreatment, while other examples show a more subtle bias.  In particular, many well-meaning care providers overutilize interventions in the labors of women of size.

Research shows that obese women are induced at much higher rates, experience a higher rate of interventions, and that caregivers have a lower threshold for surgical intervention in their labors. Although it is commonly believed that obesity predisposes to a cesarean, recent research suggests that cesarean rates can vary dramatically within the same weight class, depending on how the labor is managed.  This suggests that labor management and attitudes may be more of a factor in c-section rates than obesity itself.

High-BMI women need to ask careful questions about special protocols they may be pressured into (like early inductions for suspected macrosomia, early amniotomy, internal monitoring, or early epidurals) and how much wiggle room there is for working around these.

 One plus-sized postpartum nurse states bluntly:

As far as labor, the best advice I could give another [plus-sized] mom is to STAY MOBILE!!!!! Staying in bed, getting an epidural too soon, not being able to change positions frequently [equals] dysfunctional labor and c-section.

Other tips for lowering an obese woman’s chances for a cesarean can be found here and here.

Like other women, women of size need information on patient rights, how to advocate for themselves, their right to decline procedures, and information on filing a complaint if needed.  Knowing that they have the right to stand up for themselves and say “no” is a new concept to far too many plus-sized women.

Pay Attention to Fetal Position

There is some research and anecdotal evidence that suggests that women of size have a higher rate of malpositioned babies, and that this may play a role in their increased cesarean rate. Talk with women about fetal position, discuss ways to promote optimal fetal positions, and mention the possibility of chiropractic adjustments for those who are interested.

Since some very heavy women have pendulous bellies which may make it harder for the baby to engage in the pelvis, include some information about the “abdominal lift and tuck” exercise, as well as other positions that can help babies to engage during labor.

Birthing Positions for Women of Size

Encourage women of size to experiment with finding useful laboring and birthing positions that work with their bodies. Remember that like all women, women of size will vary in how athletic and flexible they are. Explore each position without judgment.

Many women of size find the all-fours position or a forward-leaning kneeling position useful. If the woman has an epidural, side-lying can be extremely helpful. Although “soft tissue dystocia” is an unproven concept, if there is any question of pelvic capacity frequent position changes and asymmetric positions like lunging may be helpful.  A birth ball (appropriate for height and weight) can also help relax the perineum, open the pelvis, and allow easier rotation among positions.

Many women of size report loving laboring in water. The buoyancy of the water allows position changes with greater ease, and eases pressure on the knees. The pain-relieving effect of water is another bonus, since epidurals can be harder to place in larger women.

Further information (and pictures) on birthing positions for women of size can be found here and here. Some care providers actively discourage mobility in women of size, so having a supportive caregiver is key. Practice multiple positions beforehand, emphasize the importance of frequent position changes, and promote having a labor support person who can help women utilize position changes more easily.

Summary

Although women of size are more at risk for certain complications, remember that women of all sizes can experience complications. All women benefit from the same basic advice for excellent nutrition, regular exercise, reasonable weight gain, choosing good providers, attention to fetal position, and use of flexible birthing positions. Emphasize proactive health behavior across the board.

What has been your experience in helping prepare women of size for birth?  How have the women you might have had in your classes or practice found the experience of pregnancy and birth as a large sized woman?  Do you have suggestions to add about your observations and favorite resources? Please share with our community.- SM

Plus-Sized Resources

Finding Size-Friendly Care

http://www.cat-and-dragon.com/stef/Fat/ffp.html – size-friendly providers of all types
http://plussizebirth.com/plussizedoulaconnections – size-friendly doulas
http://plussizebirth.com/midwife-ob-gyn-connections – size-friendly midwives and OBs
http://www.aafp.org/afp/2002/0101/p81.html – guidelines from the American Academy of Family Practitioners for improving care for obese patients
www.amplestuff.com – catalogue with products sized for larger people, such as larger blood pressure cuffs, scales that go to higher weights, larger exam gowns, etc.

General Size Acceptance and Health At Every Size® Resources

http://www.jonrobison.net/Health_Every_Size.pdf – pamphlet on Health At Every Size®
http://healthateverysizeblog.org/ – blog about Health At Every Size® issues
www.sizediversityandhealth.org – Association for Size Diversity and Health
www.cswd.org – Council on Size and Weight Discrimination
http://www.lindabacon.org/HAESbook/excerpts.html – info on Health At Every Size®
http://danceswithfat.wordpress.com/blog/ – size acceptance and Health At Every Size®
http://www.healthyweight.net/cntrovsy.htm – Healthy Weight Network
www.naafa.org – National Association to Advance Fat Acceptance
http://www.cat-and-dragon.com/stef/Fat/ffp2.html – tips on obtaining good health care
http://www.fwhc.org/health/fatfem.htm – Large Women’s Healthcare Experiences

Books on Health At Every Size®

• Bacon, Linda. Health at Every Size: The Surprising Truth About Your Weight. BenBella Books, 2010.
• Campos, Paul. The Obesity Myth: Why America’s Obsession With Weight is Hazardous To Your Health, Gotham Books, 2004.

 About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, informed Consent, Maternal Obesity, Series: Welcoming All Families, Uncategorized , , , , , ,