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“Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth”, Part Three, Interview with Walker Karraa

March 17th, 2015 by avatar

By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

© Walker Karraa

© Walker Karraa

Last week, Cynthia Good Mojab provided Science & Sensibility readers with the first two parts of her three-part series on the book “Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth” by Dr. Walker Karraa. Today on the blog, Cynthia shares her recent interview with Karraa. Dr. Karraa provides additional insights on her research and discusses her thoughts on how the book has been received and can be beneficial to professionals and families alike. I recommend that you go back and read Part One and Part Two as well as today’s interview. – Sharon Muza, Community Manager, Science & Sensibility.

Cynthia Good Mojab: First, Walker, let me start with congratulations! I found your book to be a page-turner. I think what you’ve uncovered is very important. I’m so grateful that your book is now a resource for perinatal care providers, lay supporters, and new parents. Have you gotten reader feedback yet? 

Walker Karraa: I have gotten feedback. The feedback I’ve gotten has been very much like what you’ve just shared. People have said that it reads very quickly. I like that feedback because it says that it reads for clinicians and for lay people. It reads from the stories. I didn’t want to take out the literature review—I believe that it’s important for individuals and families that experience perinatal mood and anxiety disorders to have access to that information. I struggled with how to put context in and not have it be heavy. So, I’m glad to hear this. I did have one reader tell me that it was hard to read emotionally because the stories hit home. I think that it is a hard read. It certainly was hard to research. I didn’t see that coming. It was hard to hear the stories and be touched in my own experience of postpartum depression. I was so surprised by the stark, universal level of suicidal ideation. That was one of the most surprising things.

CGM: I think that the structure of the book, the writing style, and how statistics have been combined with real life experiences are very effective. That it’s a painful read is actually helpful because we need many more people to grasp postpartum depression at a deeper level so we can change whether we screen, how we screen, and what kind of services, support, and treatment we’re providing.

WK: I think that is what is different about my work—both in the approach I took to the research question and how I went in asking. I got answers that are that deep and that reveal a picture of postpartum depression experienced as trauma. And, that’s why it’s a hard read. I will always be thankful on a deep, profound, personal level to the twenty women who sat with me in those initial interviews and the women, another ten after, who shared the most difficult parts of their lives. So, I’m so thankful that they had that courage because it revealed that there’s more to the paradigm of postpartum depression than, how we think of it right now anyway, a form of depression with a pervasive sadness.

And, you know we all have social constructs of depression as lack of energy, sadness, incredible fatigue, sleeping too much, these kinds of general symptoms. There’s no diagnosis for postpartum depression [in the DSM-5]. It’s an onset specifier for major depression. So, we all look at these symptoms as depression. And, what the women in the study showed us is that their symptoms go beyond the symptoms of major depression. And that there’s something that happens within the context of having a major depressive episode and a new baby that is shattering to all that women have known prior to that to be things that they could count on in the world—all of those preconceived assumptions about what was predictable in the world were completely decimated. So, that collision and deconstruction of the self that they all shared is a trauma to witness, and they see it themselves; they watched themselves almost from a dissociative place. So, I do think and I hope that it offers the opportunity for everybody to have a larger conversation about how the effect of a mood disorder after the birth of a child can be traumatic.

CGM: Another thing that really struck me in your book, Walker, was how unprepared the women were when they experienced the onset of symptoms of postpartum depression. Tell me more about that.

WK: Even the women who had a history of mental health challenges were completely unprepared for the physical and psychological symptoms of postpartum depression. Their providers had not prepared them and their social world had not prepared them. So, when those symptoms hit, they had no context for being able to articulate to anyone what was happening. As a result, the “During” aspect of experiencing postpartum depression was unbelievable invisibility as the symptoms got worse and worse and worse because they had been so unprepared. Because perinatal care providers were not offering the feedback—I see you and you are feeling this way—the situation reached critical mass for all of them. And, what was so interesting to me is that every single participant was responsible for her own recovery. She alone found her way to help. They had all been asking for help….They weren’t shy—which was different than what we see in the literature. What we see in the literature is that stigma keeps women from talking. But, these women were saying “Hi, I want to die and you don’t see me.” Often a provider would say something like, “You’re telling me you want to die. Why don’t you try putting your iPod on when your baby cries.” And, what was it that made them decide to stay? I would say it was the love of their baby. And, that, no one has looked at in the research. All these women had a plan when they were nearest death. They all had suicidal ideation. They all had thoughts of harming themselves or others. They all were at that quintessential existential end of the rope when they then reached out to someone that they hadn’t yet reached out to, all on their own. And, they didn’t want to die. They wanted the symptoms to end. That is very important. And for some, treatment meant going to hospital. For some it meant getting medication. For some it meant both.

CGM: My clients also tell me that very few providers are screening them for perinatal mental health challenges or even asking a casual “How are you doing with this?” Or they tell me how they start trying to tell care providers how they feel and they will get the same kind of discounting response like what you’re describing. We have other research that shows how undetected perinatal mental health challenges are. It’s just so clear that we are collectively failing.

© CC Smoochi: http://flickr.com/photos/smadars/4758708634

© CC Smoochi: flickr.com/photos/smadars/4758708634

WK: I have a tremendous amount of respect for providers. I don’t think it’s their fault. I think that there is such stigma around mental illness—and in particular around mental illness in new mothers—that we’re blind. We are not receiving training to look at our own biases—to see that the elephant in the room is the belief that new mothers with mental illness are going to harm their babies. And we have Greek mythology and modern media to help support that belief. So, yes, it’s the primary responsibility of a care provider and that’s why women go to care providers because that’s who you go to when you say that you’re sick and you need help. But, the care providers themselves, including OBs, general doctors, ER doctors, psychiatrists, the whole realm of childbirth professionals…they haven’t been given the opportunity or the mandate to look at their own internalized and institutionalized stigma.

CGM: Like you said earlier, the stigma taps into our own fears. We’re afraid. It tugs on our own internal memories and experiences of when we’ve been vulnerable or someone significant in our life has been vulnerable.

WK: Yes. We are afraid. But women have been doing this for millennia. Most women get through it. And, this is what we need to help women know. The women in my book are just a tiny little window into the millions of women throughout the ages who have the fortitude, the skill, the strength, to be dragged through hell and survive. And not only survive, but be transformed. It’s beyond recovery. This is the trauma literature. This is the incredible literature from Tedeschi and Calhoun regarding posttraumatic growth that needs to be brought into the birth world. And, Viktor Frankl—the famous Viktor Frankl, Auschwitz survivor…. He endured that process. Every human being does that and women will do that. So we’re talking about what obstacles and paradigms are set against women. What I learned in the book is that women are more resourceful because of their attachment to their children—because of their unbelievable strength of love for their infant—than we know. I would even go so far as to say that, if I had a huge funding source, I would do a study on my hypothesis that women who have perinatal mood and anxiety disorders are more attached. We’re not less attached. We may have periods where we are less attached, but staying present while experiencing that makes us more connected.

CGM: Look at the love that it takes to feel so bad inside and still go and do these attachment building behaviors over and over and over again. The attachment is still being built even if parents can’t see it. And, the other thing I really appreciate about your work is that it’s such a refreshing focus on growth. Attending to growth is very effective and links well with cognitive behavioral therapy and solution-focused brief therapy. And, it makes me wonder, instead of what are all the risk factors, can we do some research on resiliency factors and on growth factors? What is it that helps parents grow through this and how can we nurture that?

WK: I hope more clinicians will read the book and think about these things. You know Tedeschi and Calhoun have a wonderful model for clinical intervention that’s growth based. And it’s only been used in situations that have already been identified as traumatic. But they have a really strong model for how to work with people who experience trauma, clinically, to develop more growth. And, I’m not a clinician. If I were, I would be interested in doing that kind of work. They were kind enough to let me use their scale. I found off the chart suicidal ideation. So, I asked them if I could use their posttraumatic growth inventory with the original sample and they obliged. And my wonderful original 20 women all took it. And they scored off the charts for growth. So then I interviewed somebody who is an expert in posttraumatic growth. And I also sent my result to Richard Tedeschi. I wanted some feedback: is this growth? And, they both said, well, it’s a small sample—it’s only 20—but yes. And, furthermore, they said that the level that I was getting off those scales is much higher than in other populations that they had looked at, such as people who had been through terrorist attacks or rape or surviving cancer. So, again, if I had money for research, applying that posttraumatic growth inventory to women who had been through a perinatal mood disorder would be really valuable on a larger scale.

CGM: I know it’s a small qualitative study, but what is your sense of how generalizable your findings might be?

WK: You know, generalizability in qualitative research is not necessarily a concern. Grounded theory would say that the generalizability of the findings has to do with if you’ve sampled well. And, theoretical sampling is about getting a condensed understanding. It’s like essential oil—you want the essence of it. I tell my doctoral students, who are just learning about the difference between qualitative and quantitative research, that quantitative research is like a fisherman casting a really wide net—huge—and you gather as much data in that net as far as you can go. And, that gives you information about the nature of the farthest reach of the ocean. Qualitative research goes straight down, plumbs straight down into the ocean—you know, a core area where the essence of that part of the ocean is. And, then you can take that and ask the same questions in other parts of the ocean. And, that would be the next part of the research.

CGM: Exactly. I know the whole purpose of your study was not to answer the question how generalizable transformation is but to explore the phenomenon of transformation. Your study design allowed you to do that. The question I have is: who do you think the women in your study are? Do you think they had characteristics that make them different than the big broad ocean? What did you notice about their membership in different social groups even though that was not the focus of your study?

WK: I have a couple of responses to that. First, it would be definitely an indication of the need for future research. In the demographics that I got, I would say that it was pretty diverse regarding race. And, socioeconomic status was all over the place. It was very diverse in terms of educational status. I had women with professional degrees and women with a high school education. But they were all English speakers. And when I say racially diverse, I will say that they identified as “American.” So, I didn’t have folks who were immigrants and that’s definitely something that should be looked at. Regarding whether there is some different quality in women who transform through postpartum depression, again I look at the research done by Tedeschi and Calhoun. They’re looking at that very issue. Are there personality characteristics that lend themselves more toward being able to grow through a traumatic event? What they have found is that people who are more optimistic are slightly more likely to experience growth through trauma than those who are not. But, it’s not set in stone. In other words, the numbers aren’t so high that we can go out and say that if you’re an optimistic person you’re going to have this amazing growth. There are so many variables involved with the quality of the growth, the characteristics of the person, access to time, and the circumstances. I think that there are probably shades of growth—that anybody who has ever been through a clinical mood disorder following the birth of a child probably experiences some amount of growth. And, this is just me shooting from the hip. I think there’s something inherent in being a parent. All of the research about having a child in the NICU, losing a baby, losing a baby in pregnancy…these are all traumas. Anything that’s a life or death experience is a trauma. And every human being grows. That’s just my personal belief. It’s just the human experience that we have the ability to grow—because we need to make meaning about these horrible things that happen. And, that meaning usually comes from making choices to believe in our ability as a parent. 

CGM: What is your number one take away? How do you think your findings can be applied by childbirth educators, doulas, midwives, and other perinatal care providers?

WK: I think that the take away is that it’s a call to action. At the very least 1 in 7 of your clients or your students is going to have this experience. What are you going to do about it? What kinds of information do you need to be able to help them? And then ask your organizations to give you that.

CGM: In my work as a clinician and an educator, I need tools and resources that I can point people to that I think are useful. So, I’m really excited about your book. I think it’s going to have a lot of ripple effect in terms of new research but also in supporting a shift in broadening our worldview of postpartum depression to include growth. So, I think your work is great. I’m so delighted that you did the research and you published it.

WK: Thank you so much for spending this time. It’s been a pleasure and a gift. I so appreciate it.

About Cynthia Good Mojab

cynthia good mojab headshot 2015Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website

Book Reviews, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,

Book Review: Traumatic Childbirth and an Interview with the Author – Cheryl Beck

January 9th, 2014 by avatar

By Walker Karraa, PhD

It is thought that traumatic childbirth affects up to 34% of all birthing women, but frequently there is inadequate prenatal preparation for what to do if an individual woman has this experiences and scant resources for women seeking support and help.  The experiences are minimized and our society creates a fence of isolation that women with birth trauma are surrounded by.  Today, Walker Karraa, PhD reviews a new book geared for professionals and interviews the author, Cheryl Beck, DNSc, CNM, FAAN,  so that we can be better prepared to recognize trauma, support women and provide resources. What are you doing as a birth professional and childbirth educator to help women who may be at risk or or who have experienced birth trauma? – Sharon Muza, Science & Sensibility Community Manager

 …a fascinating and full-bodied presentation of the emerging understanding of the impact of traumatic childbirth on mothers, fathers/partners, and providers.

Traumatic Childbirth1 should be required reading for any birth professional. The trifecta of midwife, pre-eminent researcher and Distinguished Professor at the School of Nursing, University of Connecticut, Cheryl Tatano Beck, clinical nurse specialist in psychiatry, psychotherapist and author Jeanne Watson Driscoll, and survivor, activist and founder of TABS Sue Watson, provides the most comprehensive resource on traumatic childbirth for health professionals to date.

© Cheryl Beck

© Cheryl Beck

Since Cheryl Beck’s ground-breaking research, Birth trauma: in the eye of the beholder2 (2004a), health providers, researchers, and birth professionals have applauded the relevance and strength of Cheryl Beck’s research regarding traumatic childbirth. Her research has covered PTSD following traumatic childbirth3-4, the experience of the anniversary of birth trauma5, breastfeeding after a traumatic birth6, subsequent birth after a previous traumatic birth7, secondary trauma experienced by labor and delivery nurses exposed to traumatic birth8, and multiple publications on research methods and birth trauma 9-12.

In 2006, Cheryl and Jeanne Watson Driscoll (co-author of the landmark Women’s moods: What every woman must know about hormones, the brain, and emotional health13) collaborated on what is still considered a clinical tour de force in perinatal mood and anxiety disorders, Postpartum mood and anxiety disorders: a clinician’s guide14.

TABS (Trauma and Birth Stress) was founded by Sue Watson and colleagues in 1998 and continues to offer current resources and support regarding traumatic childbirth.

In Traumatic Childbirth, Cheryl, Jeanne, and Sue offer their individual expertise as researcher, clinician, and activist and combined wisdom of nearly two decades of work in the field. The result is a compelling read and review of current literature. The case studies are profound examples of the lived experiences of traumatic childbirth. Additionally, after each case Jeanne and Sue offer their own perspectives. It is a fascinating and full-bodied presentation of the emerging understanding of the impact of traumatic childbirth on mothers, fathers/partners, and providers.

I am honored to have had the opportunity to ask Cheryl some questions for Science and Sensibility regarding how childbirth professionals might use Traumatic Childbirth in practice. I know that you will find her insights both useful and encouraging.

Walker Karraa: How has the definition of traumatic childbirth evolved since you began your work?

Cheryl Beck: In the beginning of my research traumatic childbirth was viewed as an event that occurs during labor and delivery that involved actual or threatened serious injury or death to the mother and or her infant. After my first 2 studies on birth trauma and its resulting PTSD what I learned was that traumatic childbirth can also occur even if a woman does not perceive that she or her infant is at risk for serious injury or death. Women can perceive their birth as traumatic if they perceive that they were stripped of their dignity during the birthing process.

WK: How does loss of dignity play a role in the traumatic birth?

CB: One of the most frequent phrases I hear mothers using to describe their traumatic their birth to me was “I felt raped on the delivery table with everyone watching and nobody offering to help me.” Some women shared that they felt like a piece of meat on an assembly line. Women did not feel cared for by the obstetrical team. To me this lack of caring stripped women of a protective layer during their labor and delivery and left them prime to perceive their birth as traumatic.

WK: How important is it for childbirth professionals to understand the subjective experience of childbirth trauma when working with clients?

CB: It is essential for childbirth professionals to hear and really listen to the voices of mothers as they describe what it was about their labor and delivery that was so traumatic. As the title of my first research study tried to impress upon health care providers, birth trauma is in the eye of the beholder. What one woman perceives as a traumatic birth may be viewed quite differently through the eyes of obstetric staff that may see it as a routine birth.

WK: What are some of the ways childbirth educators, doulas, and lactation consultants might use Traumatic Childbirth in developing curriculum or direct service to clients?

CB: Childbirth educators, doulas, and lactation consultants can use the various chapters in Traumatic Childbirth to develop a series of classes for education. Examples of some of these chapters in the book include:

  • Risk factors for postpartum posttraumatic stress
  • Assessment and diagnosis
  • Instruments to screen for PTSD
  • Impact of traumatic childbirth on breastfeeding
  • Anniversary of birth trauma
  • Subsequent childbirth after a previous traumatic birth
  • Treatment methods for PTSD
  • Fathers and traumatic childbirth

WK: As doulas are increasingly becoming a part of birth team, they too are exposed to traumatic births that may lead to distress, impairment and disability in their work. Given the findings in your recent study11 regarding secondary traumatic stress for labor and delivery nurses, I wonder what your thoughts are regarding how doulas might prepare, or even prevent secondary trauma for themselves using Traumatic Childbirth?

 

© Cheryl Beck

© Cheryl Beck

CB: In 1989 Charles Figley15  first wrote about the “cost of caring” for supporters of traumatized victims. He called it secondary traumatic stress or compassion fatigue. Doulas who have built up such a close relationship with the women they are supporting through labor and delivery certainly are at risk of developing secondary traumatic stress. Continuing education is a must for doulas to learn about their risk of secondary traumatic stress and the symptoms they should be watching. Self-awareness of these symptoms is essential so that doulas can get the help they need. Doulas need to learn how to nourish their mind-body-spirit. Debriefing sessions, support groups, and opportunities for doulas to share the traumatic childbirths they have been present for are necessary.

WK: I so appreciate the inclusion of fathers in your book. When I was practicing as a doula I had several fathers who they themselves had risk factors for traumatic stress due to experiences in military or law enforcement. Knowing that upfront, we were able to strategize labor and birth in ways to mitigate exposure to triggers (i.e. < seeing too much blood, not being able to see an open door, etc.). How could Traumatic Childbirth help childbirth educators include partners in the conversation about traumatic childbirth?

CB: Researchers are finding that fathers can also develop posttraumatic stress symptoms as a result of being present at their partner’s traumatic childbirth. This possibility for fathers should be address in one of the childbirth classes. As one father in a research study of mine and Sue Watson’s shared “I am on an island watching my wife drown and I don’t know how to swim! I not only do not know how to swim but I was drowning myself. But I am a man, I do not need help-John Wayne, you know. I was fooling myself at the expense of my wife and myself.” This quote impresses on childbirth educators their responsibility to also be helping the fathers and support them if he and his partner have experienced a birth trauma.

WK: One of the things I note is that we don’t yet have support systems within childbirth organizations to help our childbirth educators and doulas seek support for themselves, or colleagues who suffer extreme distress after attending traumatic births. This is particularly devastating for new doulas who may not know their own risk factors, or the signs and symptoms of traumatic stress following exposure to traumatic childbirth. What are some ways childbirth organizations such as Lamaze can use Traumatic Childbirth to inform policy and prevent secondary traumatic stress in doulas and childbirth educators?

CB: At the annual conferences of these organizations, workshops, sessions, or keynotes on secondary traumatic stress due to traumatic childbirth are a must. The first step in helping to prevent this or minimize secondary traumatic stress is education. Breakout sessions at the conferences could be offered by a mental health care professional for doulas, lactation consultants, and childbirth educators to provide an opportunity for them to share their traumatic experiences.

Conclusion

For those who have followed the research on traumatic birth, this book has been a long time coming! Traumatic Childbirth is a highly readable, compelling and comprehensive collection of research, practice, and perspective that speaks to the birth professional’s sensibilities. I highly encourage the discussion of implementing this material as required reading, and instituting the suggestions of debriefing workshops for professionals. I look forward to hearing your thoughts on this, as well as the book!

I know I speak for so many in thanking Cheryl Beck for her input, and to both Jeanne Driscoll and Sue Watson for their tremendous contributions in Traumatic Childbirth, and their dedication to the prevention and treatment of traumatic birth.

References

  1. Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic childbirth. New York, NY: Routledge.
  2. Beck, C. T. (2004). Birth trauma: in the eye of the beholder. Nursing research, 53(1), 28-35.
  3. Beck, C. T. (2004). Post-traumatic stress disorder due to childbirth: the aftermath. Nursing Research, 53(4), 216-224.
  4. Beck, C. T. (2011). A metaethnography of traumatic childbirth and its aftermath: Amplifying causal looping. Qualitative Health Research, 21(3), 301-311.
  5. Beck, C. T. (2006). The anniversary of birth trauma: failure to rescue. Nursing research, 55(6), 381-390.
  6. Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding: a tale of two pathways. Nursing Research, 57(4), 228-236.
  7. Beck, C. T., & Watson, S. (2010). Subsequent childbirth after a previous traumatic birth. Nursing research, 59(4), 241-249.
  8. Beck, CT, & Gable, RK (2012). A mixed methods study of secondary traumatic stress in labor and delivery nurses. Journal of Obstetric Gynecological and Neonatal Nursing, 41, 747-760. doi:10.1111/j.1552-6909.2012.01386.x
  9. Beck, C. T. (2005). Benefits of participating in Internet interviews: Women helping women. Qualitative health research, 15(3), 411-422.
  10. Beck, C. T. (2006). Pentadic cartography: Mapping birth trauma narratives. Qualitative Health Research, 16(4), 453-466.
  11. Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic Stress Disorder in New Mothers: Results from a Two‐Stage US National Survey. Birth, 38(3), 216-227.
  12. Beck, C. T. (2009). Critiquing qualitative research. AORN journal, 90(4), 543-554.
  13. Sichel, D., & Driscoll, J. W. (1999). Women’s moods: What every woman must know about hormones, the brain, and emotional health. New York: William Morrow.
  14. Beck, C. T., & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Jones & Bartlett Learning.
  15. Figley, C. R. (Ed.). (1989). Treating stress in families (No. 13). Psychology Press.

 

 

 

Birth Trauma, Book Reviews, Childbirth Education, Guest Posts, Trauma work , , , , , ,

Book Review: Cut It Out: The C-Section Epidemic in America

November 7th, 2013 by avatar

By Christine Morton, PhD

What accounts for the dramatic rise in cesarean delivery in the United States over the past two decades? In her new book, Cut it Out: The C-Section Epidemic in America, sociologist Theresa Morris addresses this question by going to the source: she interviewed maternity clinicians (obstetricians, midwives and labor and delivery nurses) as well as women who had recently given birth. She examines guidelines from the major professional group of obstetricians and gynecologists. Morris goes beyond simply documenting the rise in C-sections, the health risks they pose to women and their babies, although she does that very well. To explain how we got to an epidemic of c-sections in the U.S, she applies an organizational lens, making it clear how “organizational changes constrain the decisions and behaviors of maternity providers and women.”

This way of looking at c-sections will be useful for childbirth educators, doulas and childbearing women because it goes one step farther than most research on c-sections, which demonstrate trends and possible associations between clinical causal factors, or characteristics of women. It is also different from advocacy around c-sections that largely frames the issue as one of individual agency or rights (“women must advocate and prepare for vaginal birth,” or “women have right to informed choice”). And although we have some research on how organizational structure impacts c-section rates, such as teaching hospitals and health maintenance organizations (HMOS), absent from these studies are explanations as to why this is so. Morris argues that the research on c-section epidemic is missing an “understanding that is rooted in the experience of maternity care providers and pregnant women” (p. 21).

While most childbirth educators and doulas have a good understanding of pregnant women’s experience, Morris takes the reader into the perspectives of a range of maternity clinicians, arguing that organizational policies and procedures constrain their actions. We can’t blame individual clinicians for the high c-section rate, she argues, nor can we hold them responsible for reducing it. Social constraints on individual behavior are very powerful and need to be understood if they are to be changed. As many sociologists have observed, deviance from social norms has real consequences for individuals. Imagine yourself riding in an elevator filled with people you don’t know, with your back to the doors. It’s not easy to do. Morris notes, “Maternity providers may face professional consequences for deviance—for example, being informally scolded by colleagues, formally reprimanded by a supervisor, or having a malpractice insurer deny coverage in a case of a bad outcome” (p. 22). By talking to maternity clinicians about how they see the problems, and what they do about them, Morris is able to show how obstetricians are also caught in systems not of their own making.

“Hospitals are organizations with fixed rules to guide individual behavior” (p. 22) and this applies to all individuals within organizations. Morris has provided a nuanced and rich picture of what she calls the “organizational paradox, in which the increasing rates of c-section do not protect the health of women or babies or make birth safer or good outcomes more likely,” and argues that if we look at the c-section rate as the result of how health care organizations respond to their legal, political and economic environments, we can understand, and hopefully change, the system.

I found one of the most compelling sections of her argument in her discussion of the patient safety movement and its emphasis on standardized protocols, language and peer review. Until very recently, c-section rates were not considered part of the patient safety movement in obstetrics. Morris shows that when a hospital embarks on patient safety initiatives, with the goal of malpractice claims due to a bad baby outcome, these initiatives often result in an increase, or at best, no change in c-section rates.

Morris also reviews how doctors frame risks of VBAC vs. repeat c-section in ways that foreground the statistically rare risk of uterine rupture (indeed, the more dangerous rupture vs. the more common, but still rare, occurrence of uterine dehiscence). The more common risk to women of repeat c-section is often not included. Here we see how possible risks for the baby (and to the physician in the event of a bad outcome) are prioritized over risks to women’s health. Organization pressures influence how these risks are defined and described to women, says Morris.

“Any effort to resolve the c-section epidemic requires organizational solutions” (p. 153).

The stakes are high, and unless there is concerted and coordinated effort to reduce the c-section rate through organizational and policy change, we are unlikely to see a downward trend. Morris concludes, however, by listing what individual women and maternity clinicians can do to help solve the c-section epidemic. For women, this includes learning about and advocating for evidence-based care, with the assistance of independent childbirth educators and birth doulas, and finding maternity physicians and hospitals with low rates of c-section. Maternity providers, she notes, may find it helpful to be up front with women about the risks of childbirth, and that even with best of care, sometimes things go wrong. The policy and social changes Morris recommends are quite sweeping and it’s not clear where political will for these will come, but happily, there are some efforts being made on the organizational solutions she proposes. In particular reporting of c-sections as a quality measure will be required by The Joint Commission as of January 2014 for hospitals with more than 1100 births/year. A recent publication on Preventing the first cesarean delivery summarized the evidence from a joint workshop held by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists.

In this YouTube video, author Theresa Morris shares why she wrote Cut It Out: The C-Section Epidemic in America. 

Here are several more videos in the video series, where Theresa talks about the cesarean epidemic

This book is highly recommended for all childbirth educators, doulas and other maternity care professionals who wish to help pregnant women understand how the organization in which they are giving birth will likely shape both they, and their maternity clinicians’ actions. Yet, it also holds out the promise of hopeful change, especially when it is clear that many of these efforts are underway. With states seeking ways to drive down costs and with support from national government action focusing on maternal health, more pressure from payers, women and maternity care advocates, we can look forward to reducing c-sections and turning the tide of this epidemic. Let’s discuss what we can do to bring down the c-section rate.

About Christine Morton

Christine Morton

Christine Morton

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

Babies, Book Reviews, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Quality Improvement, Maternity Care , , , , , , ,

The Complete Illustrated Birthing Companion: A Book Review

September 10th, 2013 by avatar

I recently had the opportunity to review a book published in January, 2013, written for birthing families. The Complete Illustrated Birthing Companion; A Step-by-Step Guide to Creating the Best Birthing Plan for a Safe, Less Painful, and Successful Delivery for You and Your Baby.  This book is authored by a diverse team of experts, Amanda French, M.D., an OB/Gyn, Susan Thomforde, CNM, Jeanne Faulkner, RN and Dana Rousmaniere, author of pregnancy and birth topics. I wanted to share my review with Science & Sensibility readers so you can consider if you want to add this book to your recommended reading list for expecting families. The book is available on Amazon for 14.29 and a Kindle version is available as well.

This book is marketed as a large 8 1/2 by 11 inch paperback with an attractive cover.  Inside is easy to read print, a pleasant amount of white space on semi-glossy paper, along with full color photographs and illustrations.  There are some beautiful photographs in there, clearly taken by talented photographers, but some of the photos seemed too unnatural, women posed in the perfect position, wearing make-up with hair just so.  The pictures are all completely modest, with the exception of just one woman in a birth tub, which surprised me in a book about birth.  In my experience, birth is a bit more “gritty” than represented by the pictures chosen for this book.  I really appreciated the diversity of images of the women and their families, women of color and their families are well represented throughout. I also appreciated the choice of language, women have partners and those partners can be men or women.

Who is this book for?

This book for is for women who are still deciding on a birth along the spectrum of options, from a home birth to a planned cesarean. It also makes sense for women who are not quite sure what type of birth they want; they can read about all the choices as they settle on what feels good to themselves and their families.  The book is written in easy to understand language, and when medical vocabulary is introduced, a definition is provided so that readers can be clearly understand what is being discussed.  The book is best used for determining what type of birth a woman is interested in having.  If the mother has already determined where and how she would like to birth,  then this book, which is in large part a comparison of the different options, would be less useful.

Jeanne Faulkner, RN

What will families find inside?

The book starts off by asking women to imagine their perfect birth, encouraging them to hold this in their minds, but to also remember that birth requires flexibility as things can change during a pregnancy or labor that will require a deviation from what a mother was planning.  A brief but accurate overview of provider types (and a good list of questions to ask providers to determine who is right for each mother) and childbirth education options are covered, and states Lamaze includes a “good, comprehensive overview of childbirth.”  The chapters are then divided into options by birth location as well as pain medication choices, and then goes on to cover induction, planned and unplanned cesarean. Natural coping techniques and pharmacological pain medication options are covered in a chapter toward the end, along with a guideline for writing a birth plan.

“Unmedicated Vaginal Birth at Home” or “Epidural, Vaginal Birth in the Hospital” are some of the chapter titles and for each section the authors take the time to explain what this option is, why it may or may not be right for any particular woman (in the case of home birth, why a woman  might risk out of this option prenatally or in labor), the pros and cons of each option and how to best prepare if this is the choice a woman has made.  Throughout the book, the authors take care to state that women should be flexible and things may change. Desiring an epidural but not having time for one is a possibility that women need to consider.  I really appreciate this gentle reminder throughout the book, as I too believe that being flexible and being able to deviate from what a woman originally planned will help as the labor unfolds.

For each type of birth, women are given suggestions to help them achieve the birth they want and are encouraged to have a variety of coping techniques lined up for dealing with labor pain if they are choosing to go unmedicated.  Realistic and useful advice is given, even when the birth is highly managed, so that the mother and her partner can have a positive experience.

Amanda French, M.D.

What families won’t find inside?

This is not a book about pregnancy, breastfeeding, postpartum care or newborn care and it doesn’t claim to be.  This is a book about birth and the choices surrounding birth.  Families who want to read about prenatal testing, or learn about breastfeeding techniques will want to have other books in their collection that cover those topics.  While this book does a nice job covering the different options, birth locations and provider choices available to them,  it does so in a very matter of fact way.  There is not a lot of “rah-rah you can do it” language or encouragement for women to stretch for a low intervention option.  On one hand, it is nice to have the facts. On the other hand, evidence shows that for normal, low risk women, the less interventions the better for both mother and baby.  I am not sure that parents will walk away with that message after reading this book.

Would I recommend this book?

While providing a nice general overview of birth choices, I felt like there were several times that the authors wrote that women should trust their care provider’s expert recommendations versus becoming more informed and discussing all options, including the right to informed refusal.

For example, in the small section on episiotomy, it reads “How do I decide whether I want an episiotomy or a tear?  The short answer is this: You don’t make that decision, your provider does…If your provider decides an episiotomy is absolutely necessary, for example, to get the baby out more quickly, then so be it.  Your provider makes that decision based on the medical situation at hand.”  No mention of informing the woman, seeking consent or alternatives to cutting, for example changing position or waiting.

One of the authors, Dr. Amanda French also states several times that she stands with ACOG’s statement on homebirth (which is that birth should occur in a hospital or birth center attached to a hospital) and does not believe that having a baby at home is safe. She does acknowledge a woman’s right to make the decision on birth location for herself.  In reading the chapter on home birth, this bias does come through.

Dana Rousmaniere

In my opinion, the book is written through the health care provider’s lens.  Doulas are promoted- but readers are warned to watch out for those doulas who may have a “strong personal agenda” and parents are encouraged to work with experienced doulas, instead of doulas-in-training or those just starting out.  Birthing women are asked to let the anesthesiologist attempt two epidural placements, (if the first one does not work due to the mother having a “challenging back” or “not being in the ideal position”) before asking for another doctor to try.  Women are told to follow the recommendations of health staff in several places in the book.  Families are told that their newborn will have antibiotic eye ointment and hepatitis B vaccines administered.

In the chapter on VBACs, women are told that a con of VBAC-ing is that “Vaginal delivery can result in tears in the vagina, which can be repaired immediately after delivery but may result in pain for several weeks after birth.”  Isn’t this a risk of any vaginal delivery?  For the families that I work with, I try to have mothers (and their partners) view themselves as a more equal partner in the decisions that are being made during labor and birth.

In summary

Overall, this book does a fair job of representing what to expect in eight different labor and birth scenarios, who might be a good candidate for each option and how best to be prepared.  Women can read and get assistance in choosing what might be the best option for them. Information on coping techniques and even pictures of good labor positions to try are well organized for easy reference.  For a woman who is undecided about where she wants to birth, this book will help her to understand the differences and the pros and cons of each location and type of birth, along with who attends births in each location.  For women who are have more clarity on what type of birth they want, I might make a different birth book recommendation.

Have you read this book?  Can you share your thoughts and opinion in our comments section?

 

Book Reviews, Epidural Analgesia, Home Birth, informed Consent, Maternity Care, Medical Interventions, Midwifery, Pain Management, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,

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

May 30th, 2013 by avatar

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

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

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

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

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

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

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

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

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

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

About Nancy Mohrbacher

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

 

 

 

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