Archive for the ‘Preconception Care’ Category

Food for Thought! Covering Nutrition in Your Childbirth Classes

April 25th, 2013 by avatar

The topic of nutrition in pregnancy (and for breastfeeding moms) is an important one to cover, but may not get a lot of attention during your childbirth classes.  Women may also be “squeezing in” birth classes late in their third trimester, so the opportunity to make dietary changes during their pregnancy may not be feeling quite as “urgent” and they are very focused on preparing for labor and birth, as well as the postpartum period.  Hopefully, pregnant women are having an evidence based conversation about nutrition with their doctor or midwife during one of their early prenatals (or even better, during a preconception appointment, if they have had the opportunity to have one) at the start of their pregnancy.

Resources for Parents

Lamaze International’s “Giving Birth With Confidence” blog has several fantastic articles written by nutrition experts that you may want to review.  After reading these nutrition themed articles, you may very well want to consider sharing them with your class students as between class homework, highlighting them in a newsletter or just directing your students to the links.

Cara Terreri, the Community Manager at Giving Birth With Confidence states “Pregnant moms encounter so much conflicting advice on nutrition — from family, friends, doctors, the internet. First-time moms especially are known to stress over getting their nutrition just right. Educators can be an excellent resource to help moms find the most credible information.”

GBWC articles available include:

Choose My Plate

Additionally, the United States Department of Agriculture (USDA) has a very user-friendly, easy to read section on nutrition for pregnant and breastfeeding women in the “Choose My Plate” website.  Included in this section, is a “Daily Food Plan” personalized for each woman.  By creating a customized profile, using the SuperTracker tool,  a mother enters information, including her prepregnancy weight, her height and her due date.  The program creates a Daily Food Plan personalized for her pregnancy progress.  There is also a place to track foods eaten and the ability to produce reports to see how a mother is meeting suggested requirements.

I created a sample profile, as a pregnant woman, and found it very easy to move around and find useful information designed just for me. I suggest you take a few minutes to play around with it also, so you can share your experience with your classes.

Learning Activities

I teach nutrition in a variety of ways during my childbirth classes.  One of my favorite activities is to ask each family to bring in a food that is good for pregnant and breastfeeding women to eat.  We go around and have each family share what they brought, what nutrients, vitamins and benefits that item provides, how much makes up a single serving and finally I ask them to share their favorite way to eat it.

 I teaching method I use to share the nutritional needs of a pregnant or breastfeeding woman is to pass around my “lunch box” filled with laminated or plastic/fake food item.  Each family draws something from the lunch box and has a few minutes to look up information about that particular food, (see above) before sharing with the class.  I have some nutritional handouts and books in class and of course, the families all seem to have smart phones.

How do you teach nutrition?

Sharing nutritional information for pregnancy and breastfeeding is an important component of childbirth classes that often gets short shrift or overlooked all together.  If you are a childbirth educator, please share how YOU teach this important topic in your classes so that we all can create a diverse group of teaching tools to keep things lively for our students and ourselves.  If you are a provider, how do you talk about your client or patient’s nutritional needs during the childbearing year?  I look forward to reading your comments, suggestions and thoughts!  Thanks for participating.

Breastfeeding, Childbirth Education, Giving Birth with Confidence, Newborns, News about Pregnancy, Preconception Care , , , , ,

On Our Radar

November 9th, 2011 by avatar

** The March of Dimes, in collaboration with the American College of Nurse-Midwives, American Academy of Pediatrics, American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, Association of Women’s Health, Obstetric and Neonatal Nurses, and the Centers for Disease Control and Prevention, is organizing a Prematurity Prevention Symposium scheduled to take place on January 19-20, 2012, at the Omni Shoreham Hotel in Washington, DC.

The Symposium will provide a forum to share and review lessons learned from various collaboratives, prematurity prevention efforts and intervention programs.  This Symposium will also launch the Prematurity Prevention Network where those interested in the health of women and infants can continue the discussions started at the Symposium, to share ideas and help each other address the important problem of prematurity.

For more information, and to register for the symposium, click here.


** New Research out of the Canadian Medical Association is re-examining the association between NSAID use in early pregnancy and risk of spontaneous abortion (SAB).  The odds ratios from this study (statistics that demonstrate the likelihood of exposure to a risky substance or event for “cases” versus “controls”) was quite high—suggesting a strong link between NSAID use and SAB.  One interesting postulation the study authors make is the potential linkage between use of NSAIDS to treat cramping, and subsequent miscarriage.

My addition to this postulation:  Many women will experience some mild to moderate implantation cramping when a newly fertilized egg finds its way to the uterine wall and subsequently burrows into the endometriumPerhaps the use of NSAIDS to treat this cramping can result in a miscarriage that might not have otherwise happened.  For women who are concertedly trying for pregnancy (recalling that only 50% of pregnancies are statistically planned): advice from a woman’s care provider to avoid NSAID use if possible, during the last two weeks of their cycle (ovulation, onward) may serve this population well.

** The San Francisco Gate recently reported on a new study out of the NYU School of Medicine which looked at risk for emotional and behavioral problems in children ages 5-17 when one or both of their parents exhibited depressive symptoms.  Much research up until now has appropriately focused on maternal depressive disorders, including postpartum depression and other related perinatal mood disorders, and their implication on children’s mental health wellness.  This significant study, including 22,000 study subjects, suggests that while their seems to be a greater down-stream effect when a mother exhibits (untreated) depressive symptoms, paternal depression is also a risk factor for childhood development of behavioral problems, as exemplified in this summary from the SF Gate article:

The findings also indicate that the risks of child emotional or behavioral problems are much greater if mothers, rather than fathers, have such problems. Paternal mental health problems are independently associated with a 33 percent to 70 percent increased risk, depending on how assessed, whereas maternal mental health problems are associated with a 50 percent to 350 percent increased risk. Most striking, we believe, is the increase in child emotional or behavioral problems when both parents have such problems, with 25 percent of children living in such homes having behavioral or emotional problems.”

For the childbirth educator, this information that suggests the importance of recognizing mood disorders in mothers and fathers can be easily incorporated into discussions pertaining to postpartum topics when (hopefully!) perinatal mood disorders are covered.


** And lastly, huge congratulations go out to Dr. Michael Lu who was recently interviewed by S&S contributor, Walker Karraa.  Dr. Lu has been appointed the position of Associate Administrator of the Maternal & Child Health Bureau (MCHB).  The MCHB is an office within the Health Resources and Services Administration, which is a branch of the U.S. Department of Health and Human Services.  MCHB oversees the Block Grant Program of Title V of the Social Security Act, the Healthy Start Program, Universal Newborn Hearing Screening, Emergency Medical Services for Children,  Sickle Cell Services and Family to Family Information Centers.

In recent years there has been increasingly wide-spread concern over Maternal & Child Health being so focused on the child…that the mothers in the equation are receiving less attention than they deserve.  Perhaps then, with an OBGYN whose career has been dedicated to both maternal and child wellness, we will see some changes rolling out to equalize the distribution of research and programming efforts.



Posted by:  Kimmelin Hull, PA, LCCE, FACCE


New Research, News about Pregnancy, On Our Radar, Perinatal Mood Disorders, Preconception Care, Series: Preconception Care , , , , , , , , ,

The preconception care paradigm in US public health: An Interview Between Christine Morton and Miranda Waggoner

November 4th, 2011 by avatar

[Editor’s note:  in this post, Dr. Christine Morton interviews public health researcher Miranda Waggoner, PhD, on her work with Princeton University’s Office of Population Research.  Dr. Waggoner’s particular research interests lie in maternal, women’s and infant’s health.]


CM:  Please briefly describe your research on preconception/interconception for the Science & Sensibility readership


MW:  My current research focuses on the emergence of the preconception care paradigm in the U.S. and what it means for contemporary public health and clinical strategies that aim to improve maternal and child health. Advocacy for prenatal care began in the early part of the 20th century, and prenatal care utilization increased throughout the century. The problem, though, was that adverse birth outcomes, such as low birthweight and infant mortality, persisted despite increasing numbers of women getting early prenatal care. So, experts started to look for other approaches to tackle these problems, and a preconception care (PCC) framework emerged as a potential solution. In 2004, The Centers for Disease Control and Prevention (CDC) launched its Preconception Health and Health Care Initiative. The basic idea was that a new focus on clinical care prior to pregnancy would improve birth outcomes. This new focus on the preconception period was seen by many in the maternal and child health field as a paradigm shift. I study the evidence base for PCC and how the United States moved from focusing on the expansion of prenatal care services to what is now essentially a prenatal care model that includes the period prior to pregnancy. I am also interested in what this new paradigm means for how we think about women’s bodies, reproduction, and population health in our society.


CM:  What do you think is important for childbirth educators to consider when they provide information to expectant women (and their partners) about preconception/interconception issues?


MW:  As any childbirth educator will know from experience working with women and couples, many conceptions are unplanned or unintended. So, a good number of women will enter pregnancy without active knowledge about, or preparation for, “preconception health.” Discussing preconception health during pregnancy is too late and potentially induces undue stress on the pregnant woman.

A motto of the preconception care paradigm is “every woman, every time.” This is the idea that clinicians should address women’s preconception health at every clinical encounter. I have learned in my research that clinicians do not always find this to be a successful strategy. Clinicians reported that often when a patient is not planning to get pregnant, she usually does not want to be asked about how her behaviors will influence a pregnancy. The preconception care framework sees women’s bodies as inherently risky to future fetuses if women are not preparing for pregnancy and changing their health behaviors to prepare for a pregnancy. We have to worry about this kind of rhetoric if it makes women feel uncomfortable or guilty about their reproductive behaviors or lives. The New York Times and Washington Post both published pieces about PCC after the CDC launched its initiative, and they suggested that women now will be treated as forever “pre-pregnant.” I think we do have to worry about viewing women as pregnancy vessels, but the CDC’s initiative was more complex than what was captured in these news outlets. The PCC initiative outlines improvements to a woman’s health irrespective of whether or not she plans to have a baby. I’m writing right now about how this public health strategy impacts the way we think about women’s health and women as potential mothers.

If you are talking to a woman who is already pregnant about preconception care, you are really addressing her health for a future pregnancy. This is known as interconception care (ICC). However, not every woman wants a subsequent pregnancy. If a woman does not want another pregnancy, part of this care would include information on how to avoid future pregnancies. CBEs should include ICC in their curriculum to the extent that the patient wants to discuss, plan, or prevent a subsequent pregnancy.


CM:  What does a sociological perspective add to the public health vision of Preconception/Interconception health?  For example, in an earlier S&S post, Dr. Michael Lu of UCLA outlines a vision of “Prenatal Care 3.0” which puts the “Medical Home” in the center (not the OB, as in Prenatal Care 2.0).  Although he doesn’t include midwifery in his vision of the Medical Home, are there other components you think are important to consider?

MW:  It is important to distinguish between preconception health and preconception care. Preconception health refers to a woman’s health status, whereas preconception care focuses on the clinical context. The public health vision of preconception care and prenatal care currently highlights individual health behaviors of women, and prenatal care 3.0 is still very much focused on clinical interventions toward individual women. Not everything related to health is best addressed by individual behavior change or clinical interventions. That is, we need to attend to population health at the social level too, making sure that underlying factors related to health are addressed. The National Children’s Study, which Dr. Lu is involved in, hopes to shed light on some of these factors, such as environmental influences on child development. I hope that we turn attention to the social determinants of health and not simply focus on clinical interventions and telling women to change their behavior.  Health status is influenced by so much more than what an individual woman does or does not do. If we want to improve population health, we have to focus on the social factors related to health for all people, not just women.


Additionally, I think some of these frameworks could better consider women’s health for women’s health sake and not just focus on women’s health behaviors in terms of how they will impact a future pregnancy. What people are really talking about in the preconception care paradigm is improving women’s health overall and improving birth outcomes in particular.  Most of a contemporary woman’s life, though, is spent not pregnant. I think the term “preconception care” is sometimes misleading as people are increasingly adopting a life course perspective, as Dr. Lu and others have. The basic idea of “Prenatal Care 3.0” is expanding care to the entire reproductive life course, not just focusing on pregnancy. If we highlight a woman’s general well-being over her life course, and not just focus on her as a future mother, we would see the inclusion of midwives, doulas, and other women’s health support mechanisms in a broader vision of health care.








Posted by:  Christine Morton, PhD


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Childhood Asthma and Maternal Factors: Have We Hit a Goldmine?

October 11th, 2011 by avatar

At two-years-old, our middle son underwent what would end up being a non-conclusive colonoscopy, in our attempts to diagnose the cause of his chronic diarrhea.  Around the same time, he suffered from eczema—an itchy, red skin rash that made him miserable, and sometimes kept him awake at night.  A year after all that, he was diagnosed with asthma—a condition that still plagues him, today.  Our youngest son, born at the same hospital as his older brother, also suffered from eczema.  His allergic skin rash was so severe that he was literally covered in itchy, red plaques from head to toe.

What Do Asthma and Birth Have in Common?
As we work to get our asthmatic son through the final weeks of allergy season—his breathing compromised by the mold spores currently in the air— I read with interest this article, recently published on Reuter’s Health web site.  The article discusses a new study by John Penders, et al out of the Netherlands which suggests a link between mode and location of birth, and a child’s subsequent risk of developing allergies and asthma later in life.  More specifically, the study looked at colonization of an infant’s gut with particular bacteria—E  coli and C difficile—and found a greater association with colonization of C diff. at birth, and subsequent atopy  later in life.

A soon-to-be published cohort study (in the same journal) by Adrian Lowe, et al. looked at another possible predictor of childhood asthma:  maternal obesity.  189,783 children born to 129,239 mothers in Stockholm Sweden between 1998 and 2009 were included in this study.  The study’s primary goal was to assess the relationship between early pregnancy maternal BMI and subsequent asthma later in life of the children—as judged by prescriptive asthma medication purchase and hospital admissions for asthma.

Statistical regression models revealed a linear relationship between increasing maternal BMI and incidence of offspring asthma—although from my reading of the study, the relationship appeared to be modest, according to the odds ratios provided in the study’s data.  Study authors conclude that, “If the association between maternal BMI and asthma risk in the child is causal in nature, it might explain between 11% and 13% of childhood asthma.”  (Emphasis, mine.)

Another recent cohort study, published in the Journal of Pediatrics (Tollånes, et al, 2008) looked at the association between cesarean delivery and incidence of childhood asthma.  This large (1,756,700 singletons) study out of Norway revealed a 52% increase in asthma incidence among children born via c-section, compared to vaginal delivery.

Application to Childbirth Education and Maternity Care
What do these studies and numbers mean for those of us working with expectant families?  Is it realistic to pin the burden of potentially “causing” her child’s subsequent asthma on a pregnant woman of size?  Is it realistic to think a laboring woman will contemplate her child’s possible risk of asthma, when faced with the potential of delivering via c-section?  No, I would argue, neither of those scenarios are terribly realistic.  But what I think these studies do point to is the importance of preconception counseling and guidance:  in the form of impressing upon people of childbearing age the importance of preconception good health (including a reasonable BMI for height, build and activity levels) and the continued importance of decreasing the overall cesarean section rate.

More and more studies continue to emerge—not just out of the maternity care research industry, but out of several research fields (pediatrics and asthma/immunology being two)—that point out the importance of normalizing birth practices whenever possible.  Ask any family who deals with the frightening circumstance of childhood asthma, and they will tell you:  if there had been something we could do ahead of time to prevent our (son/daughter) from developing respiratory disease…we would have done it.  Perhaps, we have landed upon a couple of significant opportunities within our own industry to decrease asthma prevalence and incidence.  I, for one, would be more than happy to aid in the decrease of childhood respiratory disease.  And my son, I think, would be happy about that, too.



Posted by:  Kimmelin Hull, PA, LCCE, FACCE


Cesarean Birth, Maternal Obesity, New Research, News about Pregnancy, Preconception Care, Research , , , , ,

On Our Radar…Tocophobia and its Consequences

September 26th, 2011 by avatar

The Research
Several interesting studies have recently been published in the Scandinavian journal, Acta Obstetricia et Gynecologica Scandinavica (some of which I will cover in a subsequent post)The greatest one of interest, which has garnered much media attention lately is the study about fear of childbirth which, according to researchers, has a drastic affect on increasing instrumental deliveries (51%), labor inductions (17%), and requests for elective cesarean deliveries (30%) when compared to women not suffering from this intense form of childbirth-based fear termed “tocophobia.”

The results of this relatively small study (cases=353, controls =579) out of  University Hospital in Linköping, Central Sweden, are not necessarily surprising to many of us, but reiterate what many having been talking about for decades: fear has a very real affect on the process of labor and birth.  In fact,  in the most extreme cases, tocophobia may result in avoidance of pregnancy all together.  But for our purposes, as childbirth professionals, we need to be thinking about how we approach the topic of fear pertaining to birth in our interactions with our students/patients/clients.

Take the cascade of interventions, for example: For the woman who is increasingly anxious about what will happen during labor and birth–who asks for an elective labor induction to “just get it over with,” some of the difficulties she may be most afraid of, become a self-fulfilling prophecy when her labor is complicated by the effects of labor induction (increased pain, intensity and frequency of contractions…potential negative effects of epidural analgesia when assistance with her intense pain is requested…fetal heart rate concerns…maternal blood pressure concerns…potential advancement to cesarean surgery).

Application for Childbirth Educators
Carefully and sensitively bringing up the topic of fear related to childbirth is imperative for childbirth educators:  it gives our students the opportunity to express concerns which they might otherwise keep to themselves–thinking they are “the only ones” harboring such anxiety.   It is not about inducing or encouraging fear, rather it is about presenting the opportunity and encouraging dialogue on this topic–offering positive perspectives and coping strategies that the woman/couple may not have come up with on their own.

Don’t be Afraid to Refer
In the event we find ourselves interacting with a woman whose fear pertaining to pregnancy and/or birth is deeper than that which we feel poised to handle in class (or in clinic), referring the woman locally to a trained professional adept at counseling her through this challenge becomes a must.  Tocophobia is a very real phenomena.  This study published in Clinical Obstetrics and Gynecology, 2004 (47:3) describes tocophobia as occurring in 20% of pregnancies with disabling fear occurring in 6%.

As childbirth educators and maternity care professionals, we may not have the training or skill set to appropriately handle and solve every challenge that faces an expectant woman.  And when we don’t immediately posses those skill sets, we must invite the assistance of other professionals trained to do so.  In the mean time, proactively delivering evidence-based information that empowers (rather than frightens or degrades) expectant women can go a long way toward building confidence and reducing fear.



Posted by:  Kimmelin Hull, PA, LCCE, FACCE

New Research, News about Pregnancy, Preconception Care, Research , , , , , , , ,

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