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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 , , , , , , ,

Congenital Heart Defect Awareness Week – Are You Up to Date?

February 10th, 2015 by avatar

 By Elias Kass, ND, CPM, LM

© Tammi Johnson

© Tammi Johnson

This week is Congenital Heart Defect Awareness week.  Critical Congenital Heart Defect screening can help identify and save the lives of newborns born with previously undetected but serious malformations of the heart that can significantly impact them as they transition to life on the outside.  Families can learn about the simple screening procedure in a childbirth education class and be prepared to discuss the screening with their health care providers.  Dr. Elias Kass, naturopath and midwife, shares 2015 information and updates on screening, stats on the incidence of CCHDs and how you can help spread the word on the importance of all newborns being screened. – Sharon Muza, Community Manager, Science & Sensibility 

There’s a new newborn screening being implemented in many birth settings – critical congenital heart defect screening, or CCHD. What is this screening? What does it look for, and how can you educate and prepare your childbirth education students for the screening and possible results?

Critical congenital heart defects refer to heart defects that babies are born with and that require surgical intervention within the first month (or year, depending on the defining organization). About 1 in 100 babies have heart defects (1%), and about 1 in 4 of those with a heart defect have a defect so severe that it needs to be corrected immediately (0.25% of all babies) Only some of these defects will be picked up by prenatal ultrasound, and they may not show up on exam before the baby goes home (or the midwife leaves in the case of a home birth). Depending on the defect, some babies may be able to compensate with structures that were in place during the fetal period but begin to go away after the baby is born.

Fetal circulation and changes after birth

By KellyPhD (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

By KellyPhD (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

Because a fetus receives oxygen through the placenta and umbilical cord, there’s no need for him to send a significant amount of blood to the lungs, so a fetus has very different heart and lung circulation than they will after making the transition to life on the outside. One of the big differences (simplified for this article) is the ductus arteriosis – this is a bypass that takes blood from the pulmonary artery and provides a shortcut to the aorta, instead of continuing on to the lungs. Another big difference is the foramen ovale – this is an oval-shaped window between the right atrium and left atrium, which allows blood to bypass being pumped out to the lungs entirely. After birth, pressure changes cause massive changes in flow. Pressure increases in the left atrium cause a flap to slam shut across the foramen ovale. Blood also finds it easier to flow to the lungs, so less blood flows through the ductus arteriosus. Over the course of days and weeks, the foramen ovale seals shut and the ductus arteriosus starts to shrivel.

Typically blood being pumped out to the body is loaded with oxygen. If there are structural problems, it’s possible that this blood would be a mix of oxygenated and deoxygenated blood – there would be less oxygen available in this blood, but at least it’s getting out to the body. Sometimes those fetal structures are what allows that mixed blood to circulate. So what if the baby was really depending on those shortcuts and bypasses? And then the shortcuts and bypasses go away? These babies may look well and do fine, until the fetal structures start to go away.

This March of Dimes article describes seven conditions considered to be part of CCHD:

  1. Hypoplastic left heart syndrome (also called HLHS)
  2. Pulmonary atresia (also called PA)
  3. Tetralogy of Fallot (also called TOF)
  4. Total anomalous pulmonary venous return (also called TAPV or TAPVR)
  5. Transposition of the great arteries (also called TGA)
  6. Tricuspid atresia (also called TA)
  7. Truncus arteriosis

See page for author [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

Circulation after birth [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

CCHD screening of the newborn is intended to catch babies who might need intervention, before they decompensate and their heart defects are made obvious.

The screening process

CCHD screening involves using a pulse oximeter at two locations — the right hand (or wrist), and either foot. The right arm receives its blood supply before the ductus arteriosus enters the aorta, so it’s known as “pre-ductal.” The left hand and the lower body receive “post-ductal” blood.

The pulse oximeter senses oxygen saturation by shining light through the skin. Red blood cells that are loaded with oxygen deflect light differently than red blood cells without oxygen. The opposite sensor collects the light and calculates how much was lost. By using multiple wavelengths of light, the unit can isolate arterial flow and disregard venous flow (veins return blood to the heart after the tissues have ‘used’ the oxygen the blood was carrying). For babies, an adhesive probe is typically wrapped around the hand or wrist, and then around a foot. The thin strip might be covered with a foam band to help block out the room light. Some facilities use reusable probes that are more like clips. Not all pulse oximeters are well suited for this purpose – they need to be able to sense low saturations and not be confused by an infant’s constant motion.

There are three possible results from the screening – pass, fail, and an in between, or “try again.”

If a baby’s oxygen saturation is ≥ 95% in the right hand or foot, and there is less than a 3% difference between the two readings, then she passes the screening.

For a baby whose saturations are between 90-95%, or has a greater than 3% difference between the right hand and foot, the screening test is repeated in an hour. If she still doesn’t pass or fail, she can have one more chance. If she still doesn’t pass after three tries (one initial and two retries), that’s considered a fail, and she should be evaluated.

If a baby’s oxygen saturation is under 90% in either the right hand or foot, or she didn’t pass in three tries, this is considered a fail, or a positive screening. This baby should be referred to a pediatric cardiologist who can assess her and do an echocardiogram (ultrasound of the heart), and/or other workup. Depending on her health at the time, that might mean an immediate consult, or it might mean having her scheduled for a visit soon.

In Washington state, Seattle Children’s Hospital and the other regional pediatric cardiology groups are available to talk with the clinician who has a patient with a problematic screening and help figure out when and where the baby should be seen. If there is no local pediatric cardiology group, some cardiology groups can do telemetry or read studies remotely. Before implementing screening in their practice or facility, there should be a clear process for how to obtain consultation and referral (who should be called, how to contact them, how to transmit images if able, etc). Evaluation should be arranged before the baby is discharged because a baby’s condition can deteriorate rapidly.

There are tools available to help with this algorithm. The Center for Disease Control and Prevention (CDC) has a flow chart to help guide the screening process, and Children’s Health Care of Atlanta has a web site and Pulse Ox Tool app to help guide providers.

When should the screening be done?

The screening should be done between 24-48 hours after birth. Before 24 hours, there is an increased incidence of false positives, but a baby who passes before 24 hours is still considered to have passed (i.e., it still “counts”). If a baby is being discharged before 24 hours, the recommendation is to do it as close to discharge as possible. For babies born at home, this screening should be done at the 24-48 hour home visit, along with the metabolic screening. For the screening to be most accurate, baby should be awake and calm, but not feeding. (Feeding causes some decrease in oxygen saturation even in normal term newborns.)

What about a failed screen?

It’s helpful to know that not all babies with a failed screen have a critical congenital heart defect. Like all screening tools, this screening has false positives. The false positive rate overall is about 1/200 (0.5%), but it falls to 1/2000 (.05%) when the screening is performed after 24 hours of age according to the FAQ on the Seattle Children’s Hospital Pulse Oximetry Screening for Newborns resource page for providers. About a quarter of the babies who fail the screening truly have a Critical Congenital Heart Defect(true positive), while half have condition that causes low blood oxygen, like pneumonia and sepsis, and a quarter are well (false positive).

Who should be screened?

All babies should be screened, unless the baby is already known to have a critical congenital heart defect, identified during ultrasounds done during the pregnancy or immediately after birth. Most states mandate screening, either by legislation or regulatory guidance. One state has an executive order. Several states, including Washington, have introduced legislation that is currently being voted on. In states without mandated screenings, most birth settings have adopted the screening, but not all. For some settings there are logistical challenges in terms of purchasing equipment (particularly independent midwives who might not have other use for the pulse oximeter, although since it was recommended to be used as part of neonatal resuscitation that has begun to change), arranging for consultation (particularly in rural areas or regions without adequate pediatric cardiology support), or logistical challenges in terms of who will do the screening and when. The Secretary of Health and Human Services (HHS) has recommended that CCHD screening be added to the newborn screening panel (like metabolic screening and hearing screening). The American Academy of Pediatrics also supports the universal adoption of this screening.

Cost can be a barrier in offering this screening. There is currently no procedure (CPT) code for this screening, and insurance companies are generally bundling it into the general newborn care (and not reimbursing for it as a separate service), though there are groups working to change this, since there is significant up-front investment and on-going costs in terms of probes and staff time to provide the screening. Most appropriate pulse oximeters start at $500 and the disposable probes around $3-5. Using reusable probes can decrease the cost of providing this screening.

If the hospital or midwife doesn’t provide this screening, parents can ask their pediatric provider to perform the screening at the baby’s first office visit. The goal is to catch these conditions as quickly as possible, ideally before the baby’s condition decompensates. Getting a screening a little later is better than not getting it at all.The screening is no less accurate later on.

The childbirth educator perspective

As a childbirth educator, you can share information about this quick screening test, when you discuss other newborn care procedures. You can encourage your students to ask their midwife or doctor about the screening, or ask on the hospital tour. If the hospital or health care provider hasn’t yet implemented this screening, families can ask why not, and if there’s anyone they can talk to encourage implementation. Facilities and providers should hear from families that they know about this screening and expect it as part of their newborn’s care.  Universal screening will go a long way to identifying those children who were not previously diagnosed with a Critical Congenital Heart Defect and who can begin to receive care for the CCHD as soon as possible by pediatric cardiologists.  Your childbirth class may be the only opportunity for these families to hear about and understand the importance of the CCHD screening test.

Are you already talking about this screening test for CCHD in your classes? If not, might you begin to share this information as a result of what you learned today?  Are providers and facilities in your area already offering this test as part of normal newborn screening? Do you know any families who have had this screening and their baby was diagnosed with an heart defect? Share your experiences in our comments and let’s discuss.- SM

References and Resources

March of Dimes, with general information about CCHD screening targeted towards families
American Academy of Pediatrics – detailed information about screening and implementation, targeted towards providers and facilities
Dr. Amy Schultz (a pediatric cardiologist at Seattle Children’s) frequently presents on CCHD screening – this presentation, with detailed information about critical congenital heart defects and screening, was recorded and can be streamed online

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, focusing on pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

Childbirth Education, Evidence Based Medicine, Guest Posts, Neonatology, Newborns , , , ,

Series: Building Your Birth Business – Free Website Content for Your Site from NIH

February 3rd, 2015 by avatar

HSS NIH

Having a blog or articles of interest on your website that are available to your students, clients and potential customers is a win-win situation for a birth professional. A win for your clientele because they are provided useful information and news important to them on the topics of pregnancy, birth and postpartum. A win for you, because providing this information creates engagement and positions you as an expert and a source of evidence based information.  Having useful content also increases traffic to your site. But writing this content takes time, requires research and can be very intimidating for some of us.

As part of our occasional series on building your birth business, I wanted to share a great service that the National Institutes of Health (NIH) Health and Human Services Division provides that can be a valuable time saver and help you to grow your business by increasing visits to your website and offering useful information to those who stop by.

NIH HSS exampleThe National Institutes of Health provides free web content that is up to date, accurate and easy to read. Even better, NIH provides a simple system that allows you to embed (place inside your website) content that you decide is important to your customer base.

Benefits of using the NIH Content Syndication Service

  • Material presented has the look and feel of your website
  • Content is updated automatically as new information or research is available, without any effort on your part
  • Time saving because you do not have to write personalized content
  • You can add your own thoughts and commentary
  • You control the topics, selecting only those you want to appear
  • You control the placement of the material on your site
  • Engagement and interaction occurs on your site, in the form of comments and dialogue
  • You can choose infographics, videos, podcasts and other multimedia offerings
  • Material is available in Spanish and in English

If you don’t find a topic you are looking for, you can request that specific information be provided for future use.

Step by step instructions are provided on the NIH website

How to Add Free Web Content from NIH to Your Website will provide everything you need to know to get started. After you register, you can browse all the topics that are offered or search for a subset of topics relevant to you and your business. You copy and paste a small snippet of code into your website and after you publish, the new material is exactly where you want it. The options are endless, you can use this material on your resource page or even drip it out slowly as part of your blog. Best of all, this material is designed for you to use in this way.  There are restrictions on using material from other sources, but this content provided by NIH is meant to be used in this way – and all the sourcing and credit appear automatically. You are also able to search for and use material from other sources in using the advanced search options.

Here is a topic I have embedded on toxoplasmosis and pregnancy for you to see how it works:

Why don’t you give it a try! Place something of interest on your website  using the NIH Content Syndication Service and then share the link in our comments section! Let us see how it looks! If you allow comments on your embedded article, I will try and leave a comment!

Babies, Breastfeeding, Childbirth Education, Maternity Care, New Research, Newborns, Series: Building Your Birth Business , , ,

“Pathway to a Healthy Birth” – Using Consumer Materials from Hormonal Physiology of Childbearing Report in Your Classes.

January 22nd, 2015 by avatar

Screen Shot 2015-01-21 at 6.01.46 PMLast week, Dr. Sarah Buckley in coordination with Childbirth Connection released a new research report, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care.”  This massive tome gathers in one place, all the current information available on the role of various hormones on pregnancy, labor, birth, breastfeeding and postpartum and provides information on what happens to the processes when interventions are introduced.  Well known childbirth educator Penny Simkin reviewed the report on Science & Sensibility on January 13th and then Michele Ondeck followed up with an exclusive Science & Sensibility interview with Sarah Buckley later in the week.

I think that everyone will acknowledge that this report is a remarkable and valuable piece of work, but at over 400 pages if you take into account all accompanying documents and with a bibliography consisting of over 1100 sources, the typical pregnant woman is hardly going to be keeping a copy on their bedside table for some light reading before drifting off to sleep.  Today on Science & Sensibility, I would like to highlight the resources and tools that Childbirth Connection has thoughtfully provided that are geared specifically for the consumer.  Childbirth educators, doulas and health care providers can access and share these materials with their students, clients and patients.

Pathway to a Healthy Birth – How to Help Your Hormones to Do Their Wonderful Work – consumer booklet

This 17 page colorful consumer booklet is written in easy to comprehend language and illustrated with attractive photographs that show a diverse collection of families.  Families are introduced to the hormones of birth and postpartum; oxytocin, beta-endorphins, catecholamines and endorphins.  Each hormone has a brief description and a short explanation about the role it plays in childbearing.

Families are told that events can interfere with the intended actions of the childbearing hormones.  Birthing women are encourage to think about how activities around them during their labor and birth may interfere with hormones and prevent the hormones from working effectively.

Women learn that hormones prepare her body for an efficient labor and birth.  The booklet addresses how women’s bodies are prepared by some hormones to handle the pain and stress that may accompany labor. They also find out that the hormones help prepare their babies for the newborn transition.  Infant attachment and maternal behaviors are also supported by the role of the hormones.

Follow Angela’s Birth Story

Families are introduced to “Angela” and read about her labor and birth story.  The story shows how the hormones allow the labor and birth to unfold in support of the normal processes and how small things can have a big impact and disrupt the process.  For example, The transition from home to hospital reduces the intensity and frequency of Angela’s contractions as a result of interference with the normal hormonal process.  The story is filled with lots of strategies to encourage and allow the hormonal effects as they are intended to occur.

It is easy to see from Angela’s story, that while labor and birth are hard and do involve pain, with the right support and environment, along with best practices that endorse physiological birth, Angela is able let her body do the work it is designed to do, and have a birth that is very satisfying to her.

“What’s Happening”

Accompanying the story is an easy to read guide that demonstrates exactly what the hormones of childbearing are doing at each particular point in Angela’s story.  Explanations of the role of each hormone as things unfold help families to understand how what happens in their own birth can affect their own birth story and outcome.

What Can You Do

The next portion of the brochure offers steps that families can take to help them identify providers and facilities that support physiologic birth.  Lists of questions to ask, tips for making a hospital room comfortable and private, interview questions for their doctor or midwife, how to pick a childbirth class, find a doula, how to determine if medical procedures are necessary and explore less interventive alternatives and more are all there in an easy to digest format. Included are valuable links in the final section that makes the booklet resource rich.  There are many web links to get more information about all the topics covered above.  This makes the booklet an ideal handout for a childbirth class, doula consultation or meet and greet with potential health care providers.

Infographic

Screen Shot 2015-01-21 at 6.03.49 PMThere is a consumer infographic that can be printed in a size suitable for hanging in a classroom or office, or provided in a smaller format that makes a great accompaniment to the above booklet.  The infographic identifies things that can keep a woman on the “pathway” to a physiological birth and what can steer her away from the pathway.  There is a lot of similarity between the points made in this infographic and the Lamaze Six Healthy Birth Practices.

One teaching idea

After discussing the role of hormones in labor and sharing the infographic as a visual aid, I can easily see how an educator can play a game with her class – making and distributing cards to class members with scenarios on them, and asking families to share if those scenarios and activities are making it easier for the mother to stay on the physiological pathway or what steers her further away and having the students identify which hormones are affected.

We have a responsibility as childbirth educators to share the important role the hormones of childbearing play in supporting healthy mothers, healthy births and healthy babies.  Using the Pathway to a Healthy Birth consumer booklet and accompanying infographic as part of your teaching materials provides a simple to understand but effective tool for conveying this information to the families you interact with.

How do you see yourself using these consumer products in your childbirth classes?  With your doula clients?  Please share your ideas for teaching, discussing and using this material and covering these topics with the families you work with.  I would love to hear your thoughts.

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns, Research, Transforming Maternity Care , , , , , ,

An Interview with Sarah Buckley: Discussing Her New Report – “Hormonal Physiology of Childbearing”

January 15th, 2015 by avatar

By Michele Ondeck,RN, MEd, IBCLC, LCCE

© Sarah Buckley

© Sarah Buckley

Sarah Buckley is a family doctor, mother of four, and author of the bestselling book Gentle Birth, Gentle Mothering. She has been writing and lecturing about the hormones of birth, among other topics, since 2001. Mothering Magazine published her article “Ecstatic Birth, Nature’s Hormonal Blueprint of Labor” in 2002.  She lives with her family near Brisbane, Australia.  On Tuesday, January 13th, 2015, Dr, Buckley released a comprehensive report entitled “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” in cooperation with Childbirth Connection.  Two days ago, Penny Simkin reviewed the report and shared valuable information on how birth professionals will be able to use this report in their classes or practices.  Today, Lamaze International Past President, Michele Ondeck, shares her recent interview with Dr. Buckley.  In this interview, they discuss Sarah’s thoughts on what this report means for both families and professionals. Sarah speaks to how it we are just beginning to recognize the downstream effects of disturbing the normal hormonal process that occurs during labor, birth and postpartum and what this disturbance might mean for future generations. – Sharon Muza, Community Manager, Science & Sensibility.

Michele Ondeck: Sarah, thank you for the in-depth review of the hormones of labor in the Hormonal Physiology of Childbearing (HPOC) report. I am thankful for the support you received for this project from the Childbirth Connection programs with the National Partnership for Women & Families. As a board member of Lamaze International, I am proud that we were able to also provide some support to make this report possible. How are you celebrating the report’s release?

Sarah Buckley: Finishing the report has been a big milestone, not just for me but also for my family who have been very involved and supportive. We’ll be celebrating with champagne and, as its summer down here, with an Aussie barbeque.

MO: Sarah, I have been sharing orchestration of the hormones of birth: oxytocin, beta endorphins, epinephrine and nor-epinephrine and prolactin from Ecstatic Birth with parents and professionals since its publication. You have expanded, clarified, and synthesized that basic information in your report. I know that you have been working on this report since 2011. What was your inspiration to keep at it? How did you find time to review more than 1,100 publications?

SB: Yes, it’s been a long gestation! What has kept me engaged is the practical relevance of the material for mothers, babies, fathers, and families, and my own lived experiences. For me, its much more than an academic body of knowledge, it’s a paradigm that recognizes the superb design of our female bodies, and describes the smoothest, safest, easiest, and most pleasurable path to parenting. I am also lucky to receive much support and positive feedback about this material, both from maternity care providers, who gain a scientific understanding of what they are seeing every day in the birth room, and from women themselves, who realize that there are positive ways to support their hormones and increase safety, ease, and pleasure for themselves and their babies.

Screen Shot 2015-01-13 at 6.38.16 PMMO: Now with the publication of the Hormonal Physiology of Childbearing, there is the potential to educate so many more professionals in the maternity and newborn care community. How does the timing of the report fit with the changes that you see happening today that can influence professionals?

SB: I have been writing and lecturing about the hormonal physiology for more than 10 years and I have seen a significant shift in receptiveness to this perspective, especially in the last 2 to 3 years. I think we are maturing as birth professionals and beginning to think more widely about the perinatal period. The microbiome paradigm, for example, which looks at the effects of birth on the transfer of healthy bacteria from mother to newborn, is giving us solid evidence that what happens at birth can have long-term consequences.

It is also a very exciting time to launch the report because this material is very much aligned with other initiatives, including ACNM’s Physiologic Birth Initiative and the ACOG/SMFM Safe Prevention of the Primary Cesarean Delivery statement. It’s also a pleasure to me that the Hormonal Physiology of Childbearing supports and extends other current models including the Lamaze Healthy Birth Practices.

MO: You refer to the growing recognition of the significance of the Developmental Origins of Health and Disease (DOHaD) in the report. Midwives, childbirth educators and doulas among others have long discussed the unintended consequences of interventions in childbirth. Now with more recognition of the importance of the perinatal period as a sensitive period that potentially affects long term health, how do you simply explain this fascinating concept and others like epigenetic programming for childbearing families?

SB: The perspective of Hormonal Physiology is very much aligned with these big-picture models including DOHaD, epigenetics, and Lifecourse Health Development, which is a multi-system model looking at the potential for early events to change the trajectory of long-term health and development.

Epigenetics refers to the biochemical processes that switch genes on or off, which helps organisms to adapt to their environment and circumstances. We know that epigenetic changes give critical adaptations (“programming”) in early life that increase the chance of survival in the environment they have come into.

In relation to DOHaD, it is now scientifically established, and widely accepted — e.g., you read this research in the media and online — that the baby’s exposures in the womb can have long-term health effects. We also know from animal studies (with a growing interest in human research also) that early life events can have long-term programming effects, and we have even identified the associated epigenetic changes in some animal studies.

What the HPOC perspective adds to these models is the possibility that these long-term programming effects may occur not only before and after birth but also during birth, and it provides possible mechanisms for such effects. In other words, changing the hormonal experiences around the time of birth could have far-reaching effects.

In fact, we would expect very significant epigenetic effects at this time, as part of the enormous shifts involved with adapting to life outside the womb and, for the mother, optimally adapting her to the essential tasks of nurturing and nourishing her young. We have substantial animal research showing long-term effects from perinatal hormone exposures, including exposure to high doses of synthetic oxytocin.

MO: When you were doing this in-depth research on the hormones of labor. What finding(s) were most meaningful to you as a mother?

SB: As we describe in the report, this is a “consistent and coherent mosaic coming into view,” so we don’t have all the gaps filled in. However, what strikes me as a mother, and in relation to my own experiences of birth and mothering, is evidence that the hormonal processes of labor and birth, including mother-newborn contact in the first hour after birth, might switch on maternal reward systems in the brain at this powerful time, so that the new mother finds her offspring rewarding into the future. This is a critical mechanism for species survival, and ensures that mammalian mothers give the dedicated care that their newborns need- without going to a prenatal class! And after birth, these systems are reinforced for the mother by rewarding hormones including oxytocin and beta-endorphins released with breastfeeding and also with close infant contact.

© Sarah Buckley

© Sarah Buckley

I wonder if some of the problems we have with parenting in our culture, that it seems like hard work, that we can find caring for our young children boring, are because we can miss all of these sources of rewarding hormones.

MO: The forward to the report was written by leaders in medicine, midwifery, nursing, obstetrics, and pediatrics urging maternity care to support physiologic birth in order to uphold the Precautionary Principle of “do no harm.” What do you want to say to us on where to start in changing the current environment?

SB: I think one of the most powerful things we can do is to share the information in this report, including the knowledge gaps, with professionals and with expectant parents, so that we can shift our cultural understanding towards appreciating how superbly designed women’s bodies are for childbearing, how these hormonal systems can be disrupted, and that we actually don’t know the long-term effects for our children, so we should be applying precaution.

I especially want to reach high-technology settings, so that we can begin to recognize the gap between physiology and current practice and work to bridge it. In situations where interventions are genuinely needed, I want care providers to be asking “How can we safely add more hormonal physiology?” and take actions. This could be as simple as supporting skin-to-skin after cesarean, or promoting doula care for women with pregnancy complications.

I also want this report to get the attention of policy makers and funders. Physiologic childbearing is a low-technology approach that is generally inexpensive compared to our current high-technology models of care. The hormonal physiology perspective also suggests significant longer-term and public health benefits, for example through support for breastfeeding. This could give even greater benefits and cost-effectiveness in the longer-term, making it an excellent investment of health-care funds

About Michele Ondeck

michele ondeck head shot 2015Michele Ondeck,RN, MEd, IBCLC, LCCE serves the Lamaze International Board of Directors as its immediate past president. She was employed by Magee-Womens Hospital of University of Pittsburgh Medical Center for more than thirty years in a number of positions including education and research in the pursuit of improving women’s health and maternity care. She is the mother and grandmother of four. Currently, she is a director of a Lamaze International Accredited Childbirth Educator Program and self-employed as a perinatal education consultant.

 

 

 

 

 

 

 

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