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Care Model Innovations – Changing The Way Maternity Care Is Provided

February 17th, 2015 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

Amy Romano was the original community manager, editor and writer of Science & Sensibility back when this blog was first established by Lamaze International in 2009.  After a healthy stint in that role, Amy has since moved on to other positions and most recently can be found in the position of Vice President of Health Ecosystems at Maternity Neighborhood, a technology company providing digital tools and apps to maternity health care providers around the world.  Additionally, Amy has been focused on finishing up her MBA at the same time.  (Talk about multitasking!)

While moving on to other things, Amy has not stopped blogging and I have been enjoying her most recent series on care model innovation in maternity care in particular and healthcare in general.  The series started in October of 2014, and Amy just published the seventh post in her ten post series. The entire series is part of Amy’s school work toward receiving her MBA.  That is a great blend of combining her degree program with her work, with her passion and interest.

Amy decided to look at four care models in particular: Nurse-Family Partnership, community-based doulas, midwife-led maternity services, and CenteringPregnancy. In talking with Amy, she shared that one of the things that really struck her is that these evidence-based care models are all very much relationship-based. She is more convinced than ever that trusting relationships are the “secret sauce” of good birth outcomes.

The posts available in the series so far include:

  1. What is care model innovation?
  2. The case for care model innovation in U.S. maternity care
  3. Care models that work: Nurse-Family Partnership
  4. Care models that work: Doulas as community health workers
  5. Care models that work: Midwife-led maternity services
  6. Care models that work: Group Prenatal Care
  7. Early examples of payment innovation in maternity care

And those posts yet to come:

8.  More mature payment reform models: An overview
9.  Driving community-based care through payment reform
10. The data infrastructure required for care model transformation

Particularly helpful are the references and learning resources that Amy includes in each of her posts, where the reader can go for more information and to dig deeper into the programs and research that Amy used to substantiate her research.

Changing the maternity care model currently in place is a critical piece for helping to improve the current status of both maternal morbidity and mortality as well as neonatal morbidity and mortality in the USA, which despite our abundance of resources, still has our world ranking in these categories shamefully at the bottom of the list.

According to Amy:

We’re in the midst of a “perfect storm” right now, with implementation of health care reform and lots of forces changing healthcare to be more patient-centered and integrated with community services. If ever there was a time when midwifery care, doulas, physiologic birth practices, etc., were going to take hold, that time is now.

As I have been reading Amy’s series, I have been struck by how some of her posts have reinforced the Lamaze Six Healthy Birth Practices themes, in particular #3 – Bring a friend, loved one or doula for continuous support, and #4 – Avoid interventions that are not medically necessary.

I asked Amy to share what her thoughts on what the role of the childbirth educator was in this time of transition.  Her response:

I think childbirth educators have lots of opportunities in the new healthcare landscape, but it will require a shift in thinking for some. New payment models will reward team-based care and CBEs have an important potential role as valued members of these teams, helping to implement shared decision making, help with care navigation/coordination, and extending educational offerings to postpartum/parenting, special conditions (e.g. gestational diabetes), etc. 

Amy Romano

Amy Romano

We need innovative ideas, forward thinking, and the ability to examine what we are currently doing with a critical eye, if we are to design and implement maternity care programs that improve outcomes and utilize resources more effectively to help mothers and babies.  As Amy highlights, there are existing programs that have shown great results and deserve the opportunity to be implemented on a wider scale.

Take some time to read the seven posts and come back to the Maternity Neighborhood blog to catch the final three when they become available.  Share your thoughts about what Amy is discussing as she rolls out the entire series.  And, consider what your role will be in the changing landscape of care that women receive during their childbearing year.

Babies, Childbirth Education, Doula Care, Healthcare Reform, Healthy Birth Practices, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, New Research, Newborns, Research , , , , , , ,

New Lamaze Infographic on Labor Support and Doulas!

December 23rd, 2014 by avatar

Lamaze International has been periodically releasing a comprehensive series of infographics designed to help consumers understand maternal infant best practices.  These easy to read, evidence based infographics can help families to know the facts and supports the “Push for Your Baby” campaign that can help improve birth outcomes.

doula info 1

The newest infographic covering the topic of labor support helps families to understand that building a great support team, including adding a professional doula, can reduce the risk of unwanted interventions and non-medically needed cesareans.  “Who Says Three’s A Crowd”  lets families know that while health care providers can offer emotional support and physiological comfort measures, their responsibilities and patient load may prevent them from offering the continuous support that has been shown to reduce cesareans, need for pitocin, epidurals and improve satisfaction with the birth experience.

Lamaze International’s Healthy Birth Practice #3 “Bring a loved one, friend or doula for continuous support” goes into further detail about the benefits of having good labor support, and includes a short but informative video that supports the third birth practice.  The labor support infographic is a very simple and attractive learning tool that educators can use to teach from or make available in handouts or on the classroom wall for passive learning.

doula info 2

Available infographics include:

Lamaze International provides links to specific infographics for viewing online and makes them available in downloadable “pdf” or “jpeg” formats. Check out the Lamaze International Professionals website here, specifically the infographics page, to see all the infographics.  Parents can find them at the “Push for Your Baby” website.

Have you checked out the infographics?  Have you shared them with your students and clients?  Which one is your favorite?  How do you use them for teaching?  We’d love to hear from you!

Childbirth Education, Doula Care, Evidence Based Medicine, Healthy Birth Practices, Lamaze International , , , , , ,

Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

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

© Patti Ramos Photography

© Patti Ramos Photography

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

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

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

Now for the results…

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

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

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

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

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

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

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

The reviewers conclude that their findings showed that:

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

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

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

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

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

Resources

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

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

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

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

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach winner of the American College of Nurse-Midwives “Best Book of the Year” award.An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

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

Evidence Supports Celebrating the Doula! Happy International Doula Month!

May 15th, 2014 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

May is International Doula Month and I am delighted to recognize and celebrate this important member of the birth team today on Science & Sensibility.  A birth doula is a trained person (both men and women can be and are doulas) who supports a birthing person and their family during labor and birth with information, physical and emotional support and assistance in women finding their voice and making choices for their maternity care. A postpartum doula is a trained professional who supports the family during the “fourth trimester” with emotional support, breastfeeding assistance, newborn care and information along with light household tasks as postpartum families make adjustments to caring for a newborn in the house.  Birthing families  traditionally have received support from family and community going back hundreds of generations.  In the early to mid 20th century, as birthed moved from home to hospital, the birthing woman was removed from her support. In 1989, the first doula organization, PALS Doulas was established in Seattle, WA, and then in 1992, DONA International was founded by by leaders in the childbirth and maternal infant health field.  Since then, many other training and professional doula organizations have been created around the world and the number of doulas trained and available to serve birthing and postpartum families has grown substantially.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Doulas and childbirth educators have similar goals and objectives – to help birthing families to feel supported, informed , strong and ready to push for the best care for themselves and their babies.  Some childbirth educators have trained as doulas as well, and may work in both capacities.  It can be a wonderful partnership of mutual trust and collaboration.  In fact, Lamaze International, the premier childbirth education organization and DONA International, the gold standard of doula organizations have joined together to offer a confluence (conference) jointly hosted by both organizations in Kansas City, MO in September, 2014. An exciting time for networking, continuing education, learning and fun with members of both organizations.

© Sarah Sweetmans

© Sarah Sweetmans

While the profession has grown considerably since those early days, the most recent Listening to Mothers III survey published in 2013, indicates that only 6 percent of birthing families had a trained labor support person/doula in attendance at their birth. (Declercq, 2013)  The most recent systematic review on the impact of doulas on a woman’s birth experience found that birthing women supported by a doula were:

  • more likely to have spontaneous vaginal births
  • less likely to have intrapartum analgesia or regional analgesia
  • less likely to report dissatisfaction
  • more likely to have shorter labors
  • less likely to have a cesarean
  • less likely to have an instrumental vaginal birth
  • less likely to have a baby with a low five minute Apgar score

There were no adverse effects reported. (Hodnett, 2013)

When the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal- Fetal Medicine (SMFM) released their groundbreaking “Safe Prevention of the Primary Cesarean Delivery” Obstetric Care Consensus Statement in February 2014, one of their key recommendations to reduce the primary cesarean rate in the USA was the continuous presence of a doula at a birth. (Caughey, 2014)

Continuous Labor and Delivery Support

Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Given that there are no associated measurable harms, this resource is probably underutilized. – ACOG/SMFM

dianne hamre doula

© Dianne Hamre by Kristen Self Photography

Doulas do a great job of supporting mothers, partners and families during the childbearing year and helping to improve outcomes for mothers and babies. The research shows it, the experiences of families confirms it and now ACOG recognizes the important role that a trained doula has in reducing the cesarean rate in the United States.  Childbirth educators can share this with students and maybe the next time birthing families are surveyed, the number of families choosing to birth with a doula with have risen significantly!

Doulas, thank you for all you do to support families!  You are providing a much needed service and improving the birth experience for families around the world.  We salute you!

How do you discuss doulas with the families you teach and work with?  Do any educators have doulas come in to help during class time?  Please share your experiences and let us know how it works out for you and your students and clients.

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth; Report of the Third National US Survey of Women’s Childbearing Experiences. New York, NY: Childbirth Connection.

Dekker, Rebecca. “The Evidence for Doulas.” Evidence Based Birth. N.p., 27 Mar. 2013. Web. 14 May 2-14.

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.

 

 

 

2014 Confluence, Childbirth Education, Confluence 2014, Doula Care, Healthy Birth Practices, Lamaze International, Maternity Care, Newborns, Push for Your Baby, Research, Uncategorized , , , , , , , , ,

Remembering Dr. John Kennell and His Great Contributions to Mothers and Babies Worldwide

September 5th, 2013 by avatar

It was with great sadness that I read about the death of Dr. John Kennell on August 27, 2013 in Cleveland, OH.  Dr. Kennell, a pediatrician and researcher, had a long history of contributions to the field of maternal infant bonding and attachment, especially at birth and in the early postpartum period  

Every time a mother opens her arms to receive her newborn baby on her chest (in line with Lamaze Healthy Care Practice #6) at the moment of birth it is a credit to the work of Dr. Kennell and his colleagues, especially his longtime collaborator,  Dr. Marshall Klaus.  Dr. Kennell examined and researched the connection (both physiological and emotional) of the newborn and its mother.  As a result of his research, the practice of separating mothers from their babies for hours or even days after birth has all but disappeared in the USA and many places around the world. Prior to Dr. Kennell’s work, little was understood about the newborn’s innate need to be close to and kept with its mother as it made the transition to life on the outside.

Our results reveal suggestive evidence of species-specific behavior in human mothers at the first contact with their full-term infants and suggest that a re-evaluation is required of the present hospital policies which regulate care of the mother and infant. (Klaus, 1970)

Additionally, Dr. Kennell helped clarify the importance of families connecting with their babies who did not survive or died shortly after birth.  Suggesting that time to hold, examine, and say goodby to a baby who passed away was helpful in processing grief and coming to terms with their loss,  has changed how stillbirth and neonatal death is handled in our hospitals.  For babies who are in the neonatal intensive care unit, the importance of promoting mother-infant bonding and attachment is now recognized as a critical part of the care plan.

Dr Kennell’s research has caused hospitals to completely change the methodology of the birth and postpartum experiences for the babies born in there facilities, supporting contact during the first hours and instituting a “rooming-in” policy that allowed mothers and babies to stay together during the postpartum stay.  Even NICU facilities are accommodating parents with couches that turn into beds right on the units, near the babies needing care special care.

These observations suggest that there may be major perinatal benefits of constant human support during labor. (Rosa et.al. 1980)

Dr. Kennell was one of the very first scientists to research and investigate the benefits of continuous labor support for birthing women, and along with Dr Klaus, Penny Simkin, Annie Kennedy and Phyllis Klaus, founded Doulas of North America, which later became DONA International, a well respected, worldwide doula organization committed to training both birth and postpartum doulas and providing a doula for every woman who wants one.  Since being established in 1992, DONA International has certified over 8000 birth and postpartum doulas and has members in over 50 countries around the world.  Many, many thousands of women have birthed with the support of doula, enjoying the benefits observed by Drs. Kennell and Klaus when they first started their research, and documented again and again since then; shorter labors, lower cesarean rates and reduced interventions. (Kennell, et. al. 1991)

If a doula were a drug, it would be unethical not to use it. – John Kennell, M.D.

 

© http://flic.kr/p/tvZYD

Dr. Kennell was the co-author of several books, including “Bonding: Building the Foundations of Secure Attachment and Independence” and “The Doula Book: How a Trained Labor Companion Can Help You Have A Shorter, Easier and Healthier Birth.” as well as a goldmine of research papers.  He was known for his gentle, caring and compassionate nature as well as his brilliant mind and wonderful sense of humor.

Please join me in extending the deepest sympathies of birth professionals everywhere, to Dr. Kennell’s wife, children and their families during this time of loss.  The memory of this esteemed doctor will live on in the work we all do to improve the childbirth experiences of women everywhere.  I am grateful that I have the chance to continue in some small way, the legacy of the brilliant contribution that Dr. Kennell made to women and babies worldwide.  Dr. Kennell’s family has requested that in lieu of flowers,  donations be made to DONA International or HealthConnect One. Dr. Kennell’s full obituary can be found here.

Please share  in the comments section, the impact that Dr. Kennell’s work has had on you.  He was very important to all of us.

References

Kennell, J., Klaus, M., McGrath, S., Robertson, S., & Hinkley, C. (1991). Continuous emotional support during labor in a US hospital. JAMA: the journal of the American Medical Association265(17), 2197-2201.

Klaus, M. H., Kennell, J. H., Plumb, N., & Zuehlke, S. (1970). Human maternal behavior at the first contact with her young. Pediatrics46(2), 187-192.

Sosa, R., Kennell, J., Klaus, M., Robertson, S., & Urrutia, J. (1980). The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine303(11), 597-600.

 

 

He is a featured speaker on this DONA International video. In it, Dr. Kennell

“If a doula were a drug, it would be unethical not to use it.” 1998
The Essential Ingredient: Doula

shares his great respect for the doula’s role in establishing a strong foundation for mothers and babies.

 

Our hearts go out to Dr. Kennell’s family, especially his wife Peggy. The family has asked that in lieu of flowers, donations be made to DONA International or HealthConnect One, which were his passions. Further details about how to make donations in his honor will be available on our website soon.

 

Rest in peace, Dr. Kennell. Thank you for all of the gifts you offered up to the world. Our lives are transformed because of you.

Babies, Breastfeeding, Childbirth Education, Doula Care, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Maternal Quality Improvement, Maternity Care, Newborns, Transforming Maternity Care , , , , , , , , ,