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Series: On the “Independent Track” to Becoming a Lamaze Trainer

December 2nd, 2014 by avatar

By Jessica English, LCCE, FACCE, CD/BDT(DONA)

Last month, LCCE Jessica English began the path to become an independent trainer with Lamaze International, as part of the just opened “Independent Track”  trainer program.  This new program helps qualified individuals become Lamaze trainers – able to offer Lamaze childbirth educator trainings which is one step on the path for LCCE certification.  She’s agreed to share her trainer journey with us in a series of blog posts; “On the Independent Track to Becoming a Lamaze Trainer”, offering insights at key milestones in the process. If this is a program you are interested in, look for information in 2015 on how to apply for the 2015 cohort.- Sharon Muza, Science & Sensibility Community Manager.

When I first saw the invitation to apply to become an independent trainer with Lamaze International, my heart leapt! As a doula trainer, I’d long wanted to extend my training work to include childbirth educators but I’d heard the process to become a Lamaze trainer was complicated. The announcement that landed in my inbox said that there was a new, simplified pathway to becoming an independent Lamaze trainer. As I prepared to launch a new business venture that included many facets of my skill set: DONA birth doula trainings, childbirth classes, business training/coaching sessions and more, it seemed so clear that becoming a Lamaze trainer fit right in with my path. Yes! Count me in!

© Tanya Strusberg

© Tanya Strusberg

I was “in” wholeheartedly, but I still needed to apply and be approved. The application asked about our qualifications and our vision for a Lamaze program. Several days before the application deadline, Laura Ruth in the Lamaze office told me that they’d already received a lot of applications. My nerves set it! The closer the deadline came, the surer I was that becoming a Lamaze trainer was the right path for me; I hoped the review committee would agree.

The wait to hear back was blessedly short. Less than a week after I submitted my application, I heard back from Lamaze International that I’d been approved as part of the first cohort of independent track trainers. How exciting! I immediately started laying plans to travel to Washington, D.C. for the “train the trainer” session, praying that my November doula clients would either have their babies before I left or wait for my return. I also needed a sub to teach my own Thursday night childbirth class.

Thankfully, three babies came in nine days, I found a fantastic sub, and I headed to D.C. with a clear calendar. (Thank you for aligning, birthy stars!) I arrived Wednesday night and met my roommate, Trena Gallant from Halifax, Nova Scotia. Before our official training ever began, our informal education started with the opportunity to share stories and techniques as experienced educators and (doula) trainers. My LCCE heart was already bursting!

I’d been curious from the beginning about who would be in the training, and it was fun to watch the room fill Thursday morning. Several of my fellow DONA-approved birth doula trainers were in the group, there were a handful of other folks whose names I recognized, and I saw a few new faces. The 12 of us hailed from the United States, Canada and even Australia. Everyone participating in the training was an experienced educator, and we had several accomplished Lamaze trainers and leaders in the room to help guide us as well. I was excited know we’d have the chance to connect throughout the weekend.

The morning began with ice breakers and climate setters with our experienced facilitator, Tom Leonhardt. Once we all felt comfortable together, we dove into the science of adult learning. Even as an experienced educator and trainer, I enjoyed the chance to reanalyze how adults learn. One of the things that I love about Lamaze International is its emphasis on evidence-based information, and this training was no different. There’s great science on adult learning, and Lamaze ensures that your trainers understand how to use that science to help new educators create great classes. I appreciated that the training itself was highly interactive – implementing the same proven techniques we were discussing. I picked up some new ideas and other information was reinforced. I was able to explore my own teaching style and its strengths and weaknesses. An expert facilitator, Tom guided us and brought us back to task when we ventured just a little too far down an occasional rabbit hole.

Saturday was spent on additional teaching analysis and introduction of the primary objectives for our Lamaze curricula. Another reason I adore Lamaze is that they lay down core objectives for educators and then allow each LCCE to teach in his or her own way. I discovered that the trainer process was similar. Each trainer will complete a needs assessment for her community, region or country. We are tasked with using a planning table to detail content for each objective, then listing our teaching techniques and evidence-based resources. In part because all Lamaze International training seminars qualify for nursing contact hours, the process of getting your training program accredited is rigorous – just another reason that Lamaze is the gold standard in our field! I could see the work ahead.

On Saturday afternoon we broke into pairs and developed an assigned training module. Each team delivered its 20-minute teaching session beginning Sunday morning. My partner and I volunteered to present first, which allowed us to fully enjoy the rest of the presentations without any thoughts about our own session. What a delight to watch so many incredible educators work their magic! I think we all picked up techniques and language from one another. We reminded ourselves again and again that we were training educators and not parents. That was an interesting shift, as we’ve all been teaching families for years or even decades. We glowed with the praise from our peers and humbled ourselves to received constructive feedback on what could have gone better. What an excellent model for us to follow as we prepare others to teach!

Saturday ended with an exploration of best practices in dealing with challenging participants. I love that Lamaze International wants us to explore these issues with new instructors! Being a great childbirth educator is about so much more than just understanding birth. The science and art of teaching are critically important to our work and Lamaze International is devoted to helping to build truly great teachers around the world.

As I said goodbye to my new colleagues Monday afternoon and wound my way through a weather-challenged journey home, my thoughts turned to next steps. As my new venture- Heart | Soul | Business ramps up, I’m carving out time to work on my Lamaze curriculum. Branding and marketing are on my mind as I solidify plans to combine birth doula workshops, childbirth educator seminars and advanced business trainings to help other birth workers thrive in this heart-centered work. My background is in marketing, public relations and business administration, so that trifecta of trainings feels like the perfect combination!

A variety of questions remain for me. Which cities need childbirth educator, doula and business trainings? How can I help to even further distinguish the Lamaze name in an increasingly crowded marketplace? What are the pieces of a kick-butt curriculum that will help grow strong, confident educators who can make a difference in diverse communities and in their own unique styles? What will it be like to work on that curriculum with Lamaze International’s amazing lead nurse planner, Susan Givens? I’m strongly committed to continuing to teach families and attend births in my home community, but how will those commitments balance with an increased travel schedule?

Stay tuned, friends. I’m diving in and I’m excited to have you along for the journey.

About Jessica English

jessica english head shotJessica English, LCCE, FACCE, CD/BDT(DONA), is the founder of Heart | Soul | Business. A former marketing and PR executive, she owns Birth Kalamazoo, a thriving doula and childbirth education agency in Southwest Michigan. Jessica trains birth doulas and (soon!) Lamaze childbirth educators, as well as offering heart-centered business-building workshops for all birth professionals.

Childbirth Education, Guest Posts, Lamaze International, Series: On the Independent Track to Becoming a Lamaze Trainer, Uncategorized , , , , ,

Prematurity Awareness Month – Test Your Knowledge on Our Quiz

November 25th, 2014 by avatar

Prematurity Awareness Month 2014As November comes to a close, you may have read or seen many articles on the topic of premature babies.  November is Prematurity Awareness Month, recognized in the United States and around the world.  Prematurity affects 15 million babies a year globally and the downstream health consequences to the babies are significant.  There is also a huge burden in terms of health care dollars that are required to treat the baby after birth and then potentially for many years beyond that.

In 2013, the national preterm birth rate fell to its lowest rate in 17 years.  This decrease helped us to meet the 2020 Healthy People Goals 7 years early, which is something to celebrate.  But overall, our prematurity rate is still nothing to be admired, as the United States has one of the highest rates amongst developed nations.

As childbirth educators, we are in a unique position to share information with families, including signs of preterm labor, risk factors and warning signs.  Having conversations in your classes can help families to recognize when something may not  be normal and encourages them to contact their doctor or midwife if they suspect they may be experiencing some of the signs of a potential preterm birth.  While no family wants to think that this might happen to them, bringing up the topic can help them to seek out help sooner.

Science & Sensibility has put together some resources that you can share with the families that you work with.  We also invite you to take the Prematurity Awareness Month Challenge Quiz, and test your knowledge on some basic facts about preterm birth.  See how well you do and compare your results with others also taking the quiz.

Resources to share

Go the Full 40 – AWHONN’s prematurity prevention campaign, including 40 reasons to go the full 40.

Healthy Babies are Worth the Wait – March of Dimes

Healthy People 2020 – Maternal, Infant & Child Health

March of Dimes Prematurity Report Card – Find your state’s grade

Centers for Disease Control and Prevention – Prematurity Awareness

March of Dimes Videos on Prematurity Awareness

Signs of Preterm Labor – March of Dimes Video

Preterm Labor Assessment Tool Kit for Health Professionals – March of Dimes.

How do you cover the topic of preterm labor in your classes?  What activities do you do?  What videos do you like to show?  Please share with others how you do your part to inform parents about this important topic and help to reduce prematurity in the families you work with.  Let us know in the comments section below.

 

Babies, Childbirth Education, Maternal Quality Improvement, Maternity Care, Newborns, Pain Management, Pre-term Birth , , , ,

Exclusive Q&A with Rebecca Dekker on Evidence for Inducing Labor if the Water Breaks (PROM)

November 20th, 2014 by avatar

Today on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review – What is the Evidence for Inducing Labor if Your Water Breaks at Term?  When membranes are released at term, before a woman is in labor, this is referred to as premature rupture of membranes, or “PROM”.  There does not seem to be a consistent agreement amongst doctors and midwives on what is the appropriate protocol for women who experience PROM.  Rebecca examines the research and helps us (and the families we work with) to understand what might be acceptable options when PROM occurs.  I had a chance to preview the article and ask Rebecca some additional questions that I had.  Her review article along with the questions/answers here can help you to provide the families you work with an update of the most accurate information available. What are you currently sharing with patients, clients and students about best practice around PROM?  What are you seeing in your communities?  Will this information change what you are saying? – Sharon Muza, Science & Sensibility Community Manager.

CLOSEDSharon Muza: What approach do you suggest women and families take in discussing this scenario (PROM) with their health care providers both prenatally and in the moment if PROM should occur?  How can they assure themselves that they will receive evidence based care in either situation?

Rebecca Dekker: Given that one in ten women who give birth at term will experience premature rupture of membranes (PROM), it is important to talk with your health care provider ahead of time about what their recommendation is for PROM that happens at term.

Evidence suggests that in women who meet certain criteria, both waiting for labor to start on its own and inducing labor immediately are evidence-based options. If you hear things like, “You must” do this or “You’re not allowed” to do this in relation to PROM, and those recommendations don’t line up with the evidence, then you may want to seek a second opinion before you go into labor!

Similarly, if you find out that your birth setting has strict requirements for giving birth after PROM (for example, you MUST give birth within 24 hours or you’re required to have a Cesarean, or we NEVER induce for PROM even if it takes you a week to go into labor), then you may want to look into a different birth setting.

The best-laid birth plans are often sidelined by PROM. If you are facing strict rules—either by your provider or hospital—that do not take into account your individual clinical situation, preferences, values, and goals, then you might face pressure to conform to their policies, procedures, or standard practices.

On the other hand, if you know you have a trustworthy care provider and birth setting who will provide you with accurate, evidence-based information about your options, and actively elicit and respect your preferences, then experiencing PROM does not have to be a bad thing!

SM:  Women are often told that a “sterile speculum exam” does not increase their risk of infection after PROM.  What would you say to this?

RD: We found limited evidence that a “sterile speculum exam” does not introduce extra bacteria to the cervix. In one small research study, five women had two sterile speculum exams, and their cervixes were swabbed to check for bacteria after each exam. There was no increase in bacteria on the cervix after the second speculum exam (Imseis et al., 1999).

In contrast, when they swabbed the cervix before and after a digital vaginal exam done with sterile gloves, they found a doubling in the number of types of bacteria on the cervix after the exam. There was also an increase in the growth of bacteria when they cultured the post-exam swab.

So for some reason, vaginal exams using sterile gloves are more harmful than exams using a sterile speculum. The researchers did not say why this might be, but my guess is that perhaps it has to do with the fact that the speculum is made out of a material that does not easily transfer bacteria.

Here’s a funny story for you—when our Evidence Based Birth retreat team was working on the literature search for PROM, we were talking through the whole problem with vaginal exams and the increased risk for infection. One of the clinicians on our team wisely pointed out that it’s not that the gloves are dirty (they’re supposed to be sterile)—it’s that the sterile gloved hand is touching the outside of the vagina and then those germs are delivered by the glove to the cervix. One of us called it the “hostile vagina” syndrome. That term made us laugh really hard.

But in the end, we decided that women’s vaginas aren’t really hostile (and we’re tired of people blaming childbirth problems on women’s bodies!)—it’s that clinicians are using their sterile gloved hands to push bacteria from the lower vagina up to the cervix. Instead of calling it a hostile vagina problem, let’s call it a hostile exam problem!

SM: While conducting your research, did you come across any information that mothers with malpositioned babies were more likely to experience PROM?  How about more PROM during a storm with an extremely low barometric pressure in place?

RD: After an extensive search, we could not find any research that directly looked at the relationship between posterior-positioned babies and the risk of PROM. I did find this book written by Johns Hopkins Medical Center in 1916, where they mentioned anecdotes about posterior babies and PROM. There was also one paper published in 1994 that found 21% of mothers with persistent posterior-positioned babies started labor with PROM. But we have very little evidence to go on here, so not sure if we can say with any certainty whether there is a relationship or not.

There is very little evidence on the topic of PROM during storms with low barometric pressure. This relationship is theoretically possible, but the evidence is limited. I found two studies that found a correlation between low barometric pressure and PROM—however, both of these studies were limited by retrospective (looking backwards in time) designs (Akutagawa et al., 2007; Polansky et al. 1985).

I’m not sure if the barometric pressure relationship with PROM has any clinical relevance, though—what are we going to tell women? Avoid storms at the end of pregnancy?

SM: You wrote that researchers found that 8-10% of women will have PROM, but anecdotally, many HCPs, doulas, CBEs etc., state that it happens more frequently than that.  Do you think it could be higher than the 10% stated, and why do you think experiences do not align with the research?

RD: The reference that most people point to for the one in ten number comes from a really interesting paper published by Gunn et al. in 1970. In this article, they reviewed all of the previous studies on PROM, and they also looked at the rate of PROM in their own institution. Gunn et al. found that previous researchers reported incidences of 2.7% to 17%, with most incidences falling between 7% and 12%. In their own review of medical records at UCLA during a ten year period (1956-1966), they found an overall PROM rate of 10.7%. This rate included preterm and term births, and they defined PROM as the water spontaneously breaking any time before the start of labor.

In the Evidence Based Birth blog article on PROM, we spent a lot of time discussing the known risk factors for PROM. You have to take into account the fact that this 10% is an average, and it may fluctuate depending on risk factors. For example, if you live in an area where most clinicians are doing weekly prenatal vaginal exams starting at 36-37 weeks and routinely stripping the membranes, then you are probably going to see a higher rate of term PROM.

SM: If you could design a study that wanted to determine the best practice for PROM, how would you go about it?

RD: I actually think that the Hannah (1996) TermPROM study was really well designed (with a few exceptions that would need to be changed), and future researchers can learn a lot of lessons from how they went about looking at induction versus expectant management.

If we were going to conduct another study, it would obviously need to use modern protocols for Group B Strep screening, and a better definition of chorioamnionitis.  We also don’t know what would happen if care providers kept their hands out of the vagina—one-third of women in the Hannah study had vaginal exams right away when they entered the study. So making it part of the study protocol to keep those hands out of the vagina at the beginning would be important.

I would also like to see this topic studied in various settings with both low and high Cesarean rates. The Hannah study took place in countries and hospitals where the C-section rates seemed to be pretty low overall—about 15% for first-time moms—which isn’t great, but it’s much lower than the one in four primary Cesarean rate we have in the U.S. It’s quite possible that the Hannah findings about Cesarean rates are NOT generalizable to the U.S. and other countries where Cesarean rates are very high.

Finally, I would love to see a secondary data analysis from the AABC Birth Center study about outcomes from women who gave birth in U.S. birth centers after experiencing PROM. This would not be a randomized trial of course, but it could give us really great information about the general rate of complications women might experience if they give birth in a low-intervention setting with PROM.

SM: In the research you examined, is there any information about women who had PROM in a previous pregnancy more likely to have it again?  (i.e., is this just how labor starts in general for those women.) 

RD: In the studies that we did review, I did not find  any research about this topic.

SM: Given that the risk of a prolapsed cord is around or less than 1%, (and some risk factors make that more likely: breech baby, SGA, preterm, multiples, polyhydramnios for example) what should women consider when they are told by their HCPs to come in immediately after PROM, even when there are no contractions and labor has not yet started.  (I am assuming that is why they are told to come in immediately, even though prolapsed cord would be an obstetrical emergency, not a “head this way now” thing.)

RD: I would recommend finding out more information about your care provider’s intentions and treatment protocols. Prolapsed cord is really rare (reported range with PROM is 0.3% to 0.6% per Gunn et al.’s 1970 extensive review of the literature) and it’s an immediate, life-threatening emergency for the baby, so if they are saying, “You can take a shower, but then you need come to the hospital,” then that can’t be what they are worried about.

As a mother, I would want to know, “Why do you want me to come in immediately? And what are you going to do when I get there? Are there medical reasons (such as GBS) that I need to come in for right away?” Are they just going to verify that the water is broken with a sterile speculum exam and do a quick check with the monitor to make sure baby is doing okay? Are antibiotics indicated? Will the mother be given the choice of induction versus expectant management, and be told that if she wants to, she can wait for labor to begin either at the hospital or at home? Or are they going to insist that she start the induction process as quickly as possible? This is where it is really helpful to know the standard procedure that is practiced in your birth setting, and how rigid their protocols are.

Looking at the evidence that we have available to us, it seems that waiting 6 to 12, or maybe 24 even hours at home for labor to start is probably not going to be harmful—as long as the mom is GBS negative, the fluid is clear, and she is monitoring her temperature and baby’s movements. It is also certainly evidence-based to go in and get evaluated (after all, that was the protocol in the Hannah and Pintucci studies that have given us evidence on the safety of waiting).

It’s best if you figure this out ahead of time—before you experience PROM. It takes honest and careful communication with your care provider, and that discussion simply has to take into account your own personal situation, risk factors for infection, and preferences. It’s so important to find a care provider you can trust, consult with them, and ask their opinion about any information or research you have uncovered. Have open discussions about the evidence with whomever you have hired to take care of you, but find a trustworthy care provider! I can’t emphasize that enough.

ImprovingBirth.org just launched a really great article about how to find care you can trust, and I highly recommend reading it!

SM: Have you read anything about the amniotic membranes being able to reclose after breaking?  I have heard that sometimes if there is a high leak they will “repair” themselves?

RD: Yes, this is possible. In the Gunn et al. (1970) literature review, they referenced studies from the 1950s and 1960s claiming that a break can happen in the membranes in an area above the lower uterine segment. The break can then re-seal itself so that no more fluid loss occurs.

Then in 2006, Devlieger et al. published a review of the literature in the American Journal of Obstetrics and Gynecology on the topic of membrane healing. If you’re interested in this topic, I would recommend reviewing their article, although it mostly focuses on the possibility of resealing the membranes after preterm premature rupture of membranes (not term PROM).

SM: For all the childbirth educators reading this post – what key points should they be sure to cover during class to help their families feel prepared if PROM should happen to them?

RD: Evidence shows that in women who meet certain criteria (single baby, head-first position, clear fluid, no fever or signs of infection in mother or baby, negative Group B Strep test), waiting for labor to start on its own for up to 2-3 days is as safe for the baby as inducing labor right away, although the mother is more likely to get an infection herself. In other words, both inducing labor and waiting for labor are evidence-based options. Families need to know that their preferences and values matter in this situation, and if they are in a setting where the care provider has strict rules that “must” be followed, their preferences might not be honored.

However, you have to keep in mind that as always, there are caveats with the information about the safety of waiting for labor to begin. In the most recent study that we have (Pintucci et al., 2014) showing great outcomes with waiting for labor to begin on its own, women did their waiting in the hospital, and started antibiotics at 24 hours. In the Hannah et al. (1996) TermPROM study, women in the “expectant management” arm of the study came to the hospital first, were assessed and had a non-stress test, and then were given the choice to go home and monitor their temperature there, or stay in the hospital to wait for labor to begin.

Finally, probably the single most important thing that women need to know is to not let people put hands up your vagina after your water breaks! That is the single most important risk factor for infection, and hands need to be kept out as much as possible. A vaginal exam when your water first breaks with PROM is not necessary, and is probably harmful, and can cause infection in you and your baby. Sterile speculum exams are probably okay.

The more vaginal exams you have after PROM, the higher your risk of infection. Keep all hands out!!

SM: Anything else you would like to add or include as a follow up to your informative article?

I want to publicly thank Alicia Breakey, a brilliant PhD candidate from Harvard who is about to graduate very soon (and is looking for a position in maternal health!). Alicia served as first-author on this blog article, and I really couldn’t have published it without her diligent help. I’d also like to thank our clinician expert, Angela Reidner, MSN, CNM, who was also a co-author with us.

Photo source: By Saltanat ebli (Own work) 

References

Akutagawa, O., Nishi, H., & Isaka, K. (2007). Spontaneous delivery is related to barometric pressure. Archives of gynecology and obstetrics275(4), 249-254.

Devlieger, R., Millar, L. K., Bryant-Greenwood, G., Lewi, L., & Deprest, J. A. (2006). Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence. American journal of obstetrics and gynecology195(6), 1512-1520.

Gardberg, M., & Tuppurainen, M. (1994). Persistent occiput posterior presentation-a clinical problem. Acta obstetricia et gynecologica Scandinavica,73(1), 45-47.

Gunn, G. C., Mishell, D. R., & Morton, D. G. (1970). Premature rupture of the fetal membranes. Am J Obstet Gynecol106(3), 469-483.

Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., … & Willan, A. R. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. New England Journal of Medicine334(16), 1005-1010.

Imseis, H. M., Trout, W. C., & Gabbe, S. G. (1999). The microbiologic effect of digital cervical examination. American journal of obstetrics and gynecology,180(3), 578-580.

Pintucci, A., Meregalli, V., Colombo, P., & Fiorilli, A. (2014). Premature rupture of membranes at term in low risk women: how long should we wait in the “latent phase”?. Journal of perinatal medicine42(2), 189-196.

Polansky, G. H., Varner, M. W., & O’Gorman, T. (1985). Premature rupture of the membranes and barometric pressure changes. The Journal of reproductive medicine30(3), 189-191.

Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: demonstration of a durable model. Journal of Midwifery & Women’s Health58(1), 3-14.

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Series: Welcoming All Families: Supporting the Native American Family

November 18th, 2014 by avatar

By Melissa Harley, CD/BDT(DONA), LCCE

November is Native American Heritage Month and LCCE Melissa Harley shares some interesting facts about the rich culture included in some of the varied childbearing year traditions observed by some of the U.S. tribes.  There are many different tribal nations, and each one has their own ceremonies and practices around pregnancy and birth.  Beautiful and fascinating stories that are each unique in their own right.  This post is part of Science & Sensibility’s “Welcoming All Families” series, which shares information on how your childbirth class can be inclusive and welcoming to all. – Sharon Muza, Community Manager, Science & Sensibility.

© Bob Zellar http://bit.ly/1EVALCk

© Bob Zellar http://bit.ly/1EVALCk

As childbirth educators of today, we must strive to have a connection to childbirth of yesterday.   As educators, we should continually be looking for ways to be welcoming of all cultures, customs, and traditions in the classroom setting and when working individually with students.  In order to achieve these goals, it is helpful to better understand how such traditions played out in years gone by.  So often, we look at birth from a very telescopic lens of the past (singling out one or two cultures) rather than looking at history from a more wide panoramic view point.  As we strive to embrace cultural diversity, we should continue to explore populations that are perhaps a little less known.    Have you considered the culture of Native Americans in childbirth and how the past compares to childbirth in our society now? According to the Centers for Disease Control and Prevention (CDC), currently, there are roughly 5.2 million American Indians and Alaska natives spread throughout 565 federally recognized tribes in the US. (CDC, 2013)  Let’s take a look at some of the commonalities that we have with our Native American ancestors and learn a little together about being welcoming, helpful, and inclusive of Native Americans in our classes today!

Native Americans and Pregnancy

Although there are some differing opinions regarding historical pregnancy and birthing traditions of Native Americans, according to historian Ellen Holmes Pearson, PhD, Native Americans were known to take exceptional care of themselves during pregnancy.  Similar to today, maintaining good health throughout pregnancy often led to an uncomplicated labor and birth.  Much regard was taken to ensure that a Native American mother’s health needs were met in a way that would support the nutritional and physical needs of both mom and baby.  From the website teachinghistory.org, Dr. Pearson states   “During their pregnancies, women restricted their activities and took special care with their diet and behavior to protect the baby. The Cherokees, for example, believed that certain foods affected the fetus. Pregnant women avoided foods that they believed would harm the baby or cause unwanted physical characteristics. For example, they believed that eating raccoon or pheasant would make the baby sickly, or could cause death; consuming speckled trout could cause birthmarks; and eating black walnuts could give the baby a big nose. They thought that wearing neckerchiefs while pregnant caused umbilical strangulation, and lingering in doorways slowed delivery. Expectant mothers and fathers participated in rituals to guarantee a safe delivery, such as daily washing of hands and feet and employing medicine men to perform rites that would make deliveries easier.”

In addition to caring for the body in pregnancy, it was extremely important for Native Americans to care for their mind and spirit.   In the Navajo communities, pregnancy and childbirth were approached as a spiritual event.  Much time and effort was spent making sure that the mother had a positive pregnancy.  Ceremonies in the Navajo community in general were very important.  Some ceremonies could last for days and days.  It was only natural that the tribes would hold Blessing Ways for expectant mothers.   Unlike many other Navajo ceremonies, the Blessing Way was not held to cure a sickness, but rather to invoke positive blessings and avert misfortune. Contrary to current use of the Blessing Way, the traditional Navajo tribes used the Blessing Way for more than just pregnancy and birth.  The ceremony was also used for blessing of the home, and also to enhance good fortune through the kinaalda (girl’s puberty rites).  Native Americans today that wish to connect with their heritage during the childbearing time often do so by being very careful about their spiritual surroundings.  It is quite important for mothers to keep their thoughts positive, and to maintain a climate of peace with those around them.  It is also suggested that mothers should avoid arguing with others during pregnancy, or to allow bad thoughts to enter their minds.

Native Americans and Birth

Native Americans were known to give birth in a simple way, with only other women in attendance as men were never allowed to see a woman give birth.   In general, Indian women likely gave birth without much assistance at all.  A midwife would at times attend the birth, along with other female family members from the tribe.  In very simplistic style, the baby would be birthed directly onto the leaves below the mother who used upright posturing for birth.   The baby would be welcomed by the earth, rather than by man’s hands.

To hasten labor and reduce pain during the birth, tribes sometimes utilized herbal remedies.   Cherokees made a tea with Partridgeberry and started consuming it several weeks before the birth.  They were also known to use Blue Cohosh to promote rapid delivery and to speed delivery of the placenta. To relieve pain, the Cherokees turned to wild black cherry tea made with the inner bark from the tree. The Koasati tribes made a tea of the roots from the plant of cotton that reduced pain for birthing women.

In some tribes, rituals to “scare” the baby out were utilized.  An elder female would often yell “Listen! You little man, get up now at once. There comes an old woman. The horrible [old thing] is coming, only a little way off. Listen! Quick! Get your bed and let us run away. Yu.”

Another common tradition in birth was the use of the rope or Sash Belt thrown over tree limbs for the mother to hold.  The traditional Navajo sash belt is made of intricate-colored sheep wool that is woven upon a wooden loom.  Some hospitals today near Indian reservations have a Sash Belt installed in the ceiling for mothers to use.

Connecting the Past and the Present

While the mothers of today might not fear that eating speckled trout will cause birthmarks, most do still have concerns  and want to take steps to ensure a healthy baby.  We see mothers avoiding large amounts of caffeine and high mercury fishes. While we don’t often see our students choosing to give birth without much assistance onto the leaves of the trees, many do still choose upright posturing.  We also see a desire at times to hasten the labor, and some mothers turn to herbal or medicinal means to help that happen.   As childbirth educators, we can at times be of comfort to our students as they prepare for the healthiest birth possible. We can connect the past with the present, allowing parent’s space to explore the traditions within their cultures while also honoring current evidence and research based maternity care.  As I say in my classes, while pointing students to the evidence associated with Healthy Birth Practice #5, those mamas from long ago knew something intuitive: that using upright positions for labor and birth made a difference!

Health Services for Native Americans Today

If you live and work near an Indian reservation, you may be familiar with Indian Health Service (IHS).   IHS was established in 1955 with a goal to raise the health status to the highest possible level for Native Americans registered in a federally recognized tribe.   As childbirth educators, some of our students may seek medical attention at one of the nation’s 33 IHS hospitals or 59 IHS health centers.   Dr. Michael Trujillo, past director of IHS states in regard to IHS, “The values of human dignity, honesty, compassion, coupled with shared values of many different tribes and cultures, that have come to be spoken of as “Indian values, of listening, mutual respect, dignity, and harmony must always be at the forefront of what we do and how we do it. We must be professional in all our actions.”

This year, in accordance with the Affordable Care Act, the Indian Health Care Improvement Act was permanently reauthorized.  This provision in the current law will increase access of quality health care to Native Americans near IHS facilities as well as those who do not live near an IHS facility.  The ACA includes some very specific benefits that will impact American Indians and Alaskan Natives.  Tribes across the country are encouraging members to become familiar with the new laws, and to evaluate how the provisions can increase access and affordability to quality healthcare for their members.

Connecting our Native American clientele with quality prenatal care is extremely important.   Consider the following statistics from the CDC:

  • American Indian/Alaska Natives have 1.6 times the infant mortality rate as non-Hispanic whites.
  • American Indian/Alaska Native babies are 2.2 times as likely as non-Hispanic white babies to die from sudden infant death syndrome (SIDS).
  • American Indian/Alaska Native infants were 2.5 times as likely as non-Hispanic white infants to have mothers who began prenatal care in the 3rd trimester or not receive prenatal care at all.

What’s a Childbirth Educator to Do?

As we strive to better serve the mothers of today, first and foremost, we should recognize the importance of the history that First Nations people bring to birth.   Many Native Americans today still practice customs and traditions from years gone by.  If you currently service a population that includes American Indians and Alaskan Natives, then you may already be aware of the customs in your area.

© Ursula Knoki-Wilson

© Ursula Knoki-Wilson

To help Native Americans feel welcomed in class, ensure that visuals of contemporary Native Americans are included in your curriculum.   You might also offer a segment in your comfort measures class that specifically addresses the customs from that population.  In general, keeping language inclusive of a variety of cultures can also lead to a sense of acknowledgement and acceptance. Simply recognizing that you are aware of different cultural traditions in class can lead to parents feeling more comfortable, thus opening a door for sharing and further education.

Regardless of your target clientele, it would be helpful for a childbirth educator to become familiar with the many different traditions surrounding childbirth in the cultures around us.  A quick internet search can lead to a wealth of information that might be helpful in class.  As with any tradition or culture that you are not familiar with, education is power!  If you are on or near a reservation, perhaps reaching out to the IHS facility nearby might be an option.  Some facilities have staff members that hold workshops and courses to help the people within their tribes stay connected with tradition. In addition, it might be helpful to inform area IHS facilities that there is a childbirth educator nearby who is sensitive to the mental, physical and spiritual needs of the tribe members. It would also be advisable for childbirth educators to become aware of the provisions in the ACA for American Indians, as to be prepared with resources, if you are asked any questions in regard to healthcare for American Indians.   As childbirth educators, we are in a unique position to encourage our clients to seek quality prenatal care.  Working together with the families in our classes, we can positively impact the infant mortality rates among these populations by educating the families about safe and healthy birth practices and the options available to them.

Ultimately, it is important to keep our space open for all cultures and honor the individual traditions of the parents that attend our classes.  By becoming more educated and sensitive to the cultures around us we can better serve our clientele as a whole.  And for our Native American students, I’ll leave you with this blessing:

Earth’s Prayer
From the heart of earth, by means of yellow pollen blessing is extended.
From the heart of Sky, by means of blue pollen blessing is extended.
On top of pollen floor may I there in blessing give birth!
On top of a floor of fabrics may I there in blessing give birth!
As collected water flows ahead of it [the child], whereby blessing moves along ahead of it, may I there in blessing give birth!
Thereby without hesitating, thereby with its mind straightened, hereby with its travel means straightened , thereby without its sting, may I there in blessing give birth!S.D. Gill, Sacred Words

Note: to read more information about the images of the cradleboard welcoming home two generations of families, please follow this link to the Turtle Track organization for the full story. – SM

References

American Indian & Alaska Native Populations. (2013, July 2). Retrieved November 15, 2014, from http://www.cdc.gov/minorityhealth/populations/REMP/aian.html

Blessingway (Navajo ritual). (n.d.). Retrieved November 15, 2014, from http://www.britannica.com/EBchecked/topic/69323/Blessingway

Holmes Pearson, E. (n.d.). Teaching History.org, home of the National History Education Clearinghouse. Retrieved November 15, 2014, from http://teachinghistory.org/history-content/ask-a-historian/24097

Infant Mortality and American Indians/Alaska Natives. (2013, September 17). Retrieved November 15, 2014, from http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=38

Knoki-Wilson, U.M. (2008). Keeping the sacred in childbirth practices: Integrating Navajo cultural aspects into obstetric care. [PowerPoint slides].  Retrieved from Naho.ca website http://www.naho.ca/documents/naho/english/IG_Presentations2008/009KnokiWilsonUrsula.pdf

About Melissa Harley

melissa harley head shotMelissa Harley, CD/BDT(DONA), LCCE has worked with birthing women since bearing witness to the vaginal birth of her twin nieces in early 2002. She is a Native American registered in the  Cherokee Nation Tribe (OK) and the owner of Capital City Doula Services in Tallahassee, Florida.   Melissa holds certifications as a Lamaze Certified Childbirth Educator, DONA International Certified Doula and an Approved Birth Doula Trainer(DONA). She currently holds leadership positions with DONA International as a Florida state representative, and she sits on both the DONA International Education and Certification Committees.Melissa is a contributor to several birthing publications including the Journal for Perinatal Education (JPE), the Bearing Witness Series: Childbirth Stories Told By Doulas, and the sequel book Joyful Birth: More Childbirth Stories Told By Doulas.Married for 16 years and the homeschool mother of two teenagers, Melissa, values education and a life-long pursuit of learning. Her teaching style is comfortable, fun, and interactive, with an emphasis on leading the learner to have their own “light bulb” moments. As a childbirth educator and doula, Melissa most enjoys watching women become empowered to listen to their inner voice and acknowledge their own strength to birth.  Mentorship and education are both her passions, and Melissa is dedicated to fulfilling those passions by actively facilitating childbirth education classes as well as training and mentoring new doulas regularly.  Melissa can be reached at Melissa@capitalcitydoulaservices.com

Babies, Childbirth Education, Newborns, Series: Welcoming All Families , , , , ,

Practice Variation in Cesarean Rates: Not Due to Maternal Complications

November 13th, 2014 by avatar

By Pam Vireday

Pam Vireday, an occasional contributor to Science & Sensibility reviews the recent study by Katy Kozhimannil, PhD and colleagues that examined the differences in cesarean rates between over a thousand hospitals in the USA.  Consumers of maternity care quite possibly do not realize what a significant impact their choice of facility (and provider) may have on their birth outcome.  Can you think of hospitals in your own community serving similar populations of pregnant families that have drastically different cesarean rates.  Have you considered why that might be?  Do you think that the families you work with have explored this too?  Do they even have access to this information?  Read Pam’s discussion of this recent study below.  – Sharon Muza, Community Manager, Science & Sensibility.

© Patti Ramos Photography

© Patti Ramos Photography

There’s a new study out that discusses the variation in cesarean rates between hospitals in the United States. “Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database” was released late last month and has received a lot of press and discussion ever since.

Practice variation is a serious problem in obstetrics (Arcia 2013). Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population (Arnold, January 2013 and August 2012).

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn’t explain the wide variation in rates between many hospitals (Clark 2007).

For example, in a press release about the new study, the mother’s risk status and diagnoses did not explain the variation in cesarean rates between hospitals:

“We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Other key points highlighted included:

  • Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
  • Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
  • Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates? (Declerq 2006, Oganowski 2011)

This study is not the first to show that the culture of a hospital, its policies, and its routine practices all help determine how likely a woman is to “need” a cesarean in that hospital.

For example, Cáceres 2013 found that even after adjusting for socio-demographic and clinical factors and including only NTSV (Nulliparous, Term, Singleton, Vertex) pregnancies, the cesarean rate varied significantly between Massachusetts hospitals, “suggesting the importance of hospital practices and culture in determining a hospital’s cesarean rate.”

In addition, a 2014 consensus statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine notes, “Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.”

Preventing cesareans when possible is important because while cesareans can be life-saving at times, they present more risk for maternal infection, bleeding and blood clots, and more neonatal breathing problems (Liu 2007, Visser 2014).

Notably, a large case-control study in U.K. maternity units found that delivery by cesarean was a strong risk factor for severe sepsis (Acosta 2014). Other research has found a high rate of maternal complications (Pallasmaa 2010) and poorer neonatal outcomes (Kolås 2006) associated with cesareans.

In addition, a cesarean’s potential negative effect on future pregnancies is important (Silver 2012). One American study found that the rate of an abnormal placental attachment increased in conjunction with the rise in cesarean delivery rate (Wu 2005), while a Canadian study found that a prior cesarean was associated with an increased risk for adverse neonatal outcomes in subsequent pregnancies (Abenhaim and Benjamin 2011).

Bottom line, it matters where and with whom a woman gives birth in order to lessen the risk for complications, both now and in the future.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use (Arnold 2014, Arnold January 9 2013).

Childbirth Connection, a leading consumer education site, points out:

Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate.

Yet it is not always easy to find out the cesarean rates of local hospitals in some areas. For example, the health departments of Missouri, South Carolina, and Washington D.C. do not make hospital-level cesarean rates available to consumers.

Hospitals remain largely unaccountable for high cesarean rates, although we are beginning to see marginal progress in some places towards more accountability (Gentry 2014 and Dekker 2014). In the meantime, however, thousands of women are undergoing cesareans, many of which might be preventable with changes in clinical practices (Boyle 2013).

And even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals (Alonso-Zaldivar 2014). It’s not just about how many cesareans are done, but also about which hospitals have the best outcomes when a cesarean is done. Without more information, how is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states:

Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth…and these results indicate that we have a long way to go toward reaching this goal in the U.S.

*To search for hospital-level cesarean rates in your area, see www.cesareanrates.com or the 2014 Consumer Reports article (subscription required) rating hospitals in 22 states.

Do you ever encourage your students and clients to look at the cesarean rates (and rates of other interventions which may lead to cesareans) of the hospitals they are considering birthing in.  Please share your experience in our comments section. – SM

References

Abenhaim, H. A., & Benjamin, A. (2011). Effect of prior cesarean delivery on neonatal outcomes. Journal of perinatal medicine39(3), 241-244. PMID: 21426242

Acosta, C. D., Kurinczuk, J. J., Lucas, D. N., Tuffnell, D. J., Sellers, S., & Knight, M. (2014). Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study. PLoS medicine11(7), e1001672. PMID: 25003759

Alonso-Zaldivar, R (2014, August 27). Study: Wide hospital quality gap on maternity care. Retrieved from http://www.fosters.com/apps/pbcs.dll/article?AID=/20140827/GJLIFESTYLES/140809539/0/SEARCH.

Arcia, A (2013, February 3). What is practice variation in obstetrics and why should I care? Retrieved from http://www.cesareanrates.com/blog/2013/2/3/what-is-practice-variation-in-obstetrics-and-why-should-i-ca.html.

Arnold, J (2012, August 22). Practice variation in New Jersey: 27 miles and 28 percentage points. Retrieved from http://www.cesareanrates.com/blog/2012/8/22/practice-variation-in-new-jersey-27-miles-and-28-percentage.html.

Arnold, J (2013, January 9). Practice variation in East Los Angeles cesarean rates. Retrieved from http://www.cesareanrates.com/blog/2013/1/9/practice-variation-in-east-los-angeles-cesarean-rates.html.

Arnold, J (2013, January 7). Practice variation in West Virginia: 60 miles and 54 percentage points. Retireved from http://www.cesareanrates.com/blog/2013/1/7/practice-variation-in-west-virginia-60-miles-and-54-percenta.html.

Arnold, J (2014, March 13). Three miles/Cinco Kilometros. Retrieved from http://www.cesareanrates.com/blog/2014/3/13/three-miles-cinco-kilometros.html.

Boyle, A., Reddy, U. M., Landy, H. J., Huang, C. C., Driggers, R. W., & Laughon, S. K. (2013). Primary cesarean delivery in the United States. Obstetrics & Gynecology122(1), 33-40. PMID: 23743454

Cáceres IA, Arcaya M, Declercq E, Belanoff CM, Janakiraman V, Dohen B, Ecker J, Smith LA, Subramanian SV (2013). Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact. PLOS One, 8(3):e57817. doi: 10.1371/journal.pone.0057817. PMID:23526952

Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM (2007). Variation in the rates of operative delivery in the United States. American journal of obstetrics and gynecology, 196(6):526.e1-526.e5.  PMID: 17547880

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. doi: 10.1016/j.ajog.2014.01.026. PMID:24565430

Declercq, E., Menacker, F., & MacDorman, M. (2006). Maternal risk profiles and the primary cesarean rate in the United States, 1991–2002. American journal of public health, 96(5), 867. PMID: 16571712

Dekker, R (2014, October 29). U.S. hospitals held accountable for C-section rates. Retrieved from http://www.birthbythenumbers.org/?p=1731

DePoint, M (2014, October 22). Maternal diagnoses doesn’t explain variation in cesarean rates across US hospitals. University of Minnesota, School of Public Health. Retrieved from http://sph.umn.edu/maternal-diagnoses-doesnt-explain-variation-cesarean-rates-across-us-hospitals/.

Gentry, C (2014, May 14). FL still C-section hotspot. Retrieved from http://health.wusf.usf.edu/post/fl-still-c-section-hotspot.

Kolås, T., Saugstad, O. D., Daltveit, A. K., Nilsen, S. T., & Øian, P. (2006). Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. American journal of obstetrics and gynecology,195(6), 1538-1543. PMID: 16846577

Kozhimannil KB, Arcaya MC, Subramanian SV (2014). Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database.  PLoS medicine, 11(10):e1001745. doi: 10.1371/journal.pmed.1001745. PMID: 25333943

Liu, S., Liston, R. M., Joseph, K. S., Heaman, M., Sauve, R., & Kramer, M. S. (2007). Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian medical association journal176(4), 455-460. PMID: 17296957

Oganowski, K (2010, January 13). The C-section blame game: I’ve reached my boiling point. Retrieved from http://birthingbeautifulideas.com/?p=1245.

Pallasmaa, N., Ekblad, U., AITOKALLIO‐TALLBERG, A. N. S. A., Uotila, J., Raudaskoski, T., ULANDER, V., & Hurme, S. (2010). Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta obstetricia et gynecologica Scandinavica89(7), 896-902. PMID: 20583935

Phend, C (2013, March 5). C-Section rates vary widely between hospitals, study finds. MedPage Today. Retrieved from http://abcnews.go.com/Health/section-rates-vary-widely-hospitals-study-finds/story?id=18656847.

Silver, R. M. (2012, October). Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. In Seminars in perinatology (Vol. 36, No. 5, pp. 315-323). WB Saunders. PMID: 23009962

Visser GH (2014). Women are designed to deliver vaginally and not by Cesarean section: An obstetrician’s view. Neonatology, 107(1):8-13. PMID: 25301178

What every pregnant woman needs to know about Cesarean section (2012). Childbirth Connection. Retrieved from http://www.childbirthconnection.org/pdfs/cesareanbooklet.pdf.

What hospitals don’t want you to know about C-sections (2014, May). Consumer Reports. Retrieved from http://consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm.

Wu, S., Kocherginsky, M., & Hibbard, J. U. (2005). Abnormal placentation: twenty-year analysis. American journal of obstetrics and gynecology192(5), 1458-1461. PMID: 15902137

A version of this post originally appeared on www.wellroundedmama.blogspot.com

About Pam Vireday

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

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

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , ,