Posts Tagged ‘book review’

Interview with Alice Callahan about Science of Mom: A Research-Based Guide to Your Baby’s First Year.

October 6th, 2015 by avatar

In an earlier post on Science and Sensibility, regular contributor Anne Estes, PhD reviewed Science of Mom: A Research-Based Guide to Your Baby’s First Year, a new evidence-based book focused on answering questions on health, sleeping, and feeding for an infant’s first year. The book grew out of author Dr. Alice Callahan’s blog, Science of Mom, that she began writing as a new mother. Dr. Callahan took some time out of her busy schedule to talk with Anne about her new book and how it might be helpful for childbirth educators and new parents.  Readers will also want to pop over to Anne’s blog – Mostly Microbes, to listen to a podcast of  a more detailed interview with Dr. Callahan, the author of The Science of Mom. We’d also like to congratulate Amy Lavelle for being randomly chosen from the commenters on the original post. Amy wins herself a free copy of the book.  We hope that she will enjoy reading it.  – Sharon Muza, Community Manager, Science & Sensibility.

Science of Mom Cover HiDefAnne Estes: What do you see as the role of this book for childbirth educators and other birth professionals?

Alice Callahan: First, my book gives a really in-depth look at several newborn medical procedures, including timing of cord clamping, the vitamin K shot, and eye prophylaxis, plus shorter sections on newborn screening, the hepatitis B vaccine, and the newborn bath. Childbirth educators will take away a clear understanding of the evidence behind these procedures, and they can pass that knowledge onto students and clients. Second, and just as useful, those in-depth sections serve as excellent case studies for how to look at scientific evidence. My hope is that this background will give readers the tools needed to evaluate scientific evidence on their own as they encounter new questions – and I’m sure birth professionals are constantly faced with new questions!

AE: Why should childbirth educators suggest your book as a resource for interested parents?

AC: New parents are often taken off guard by the number of questions they have about childbirth and caring for a new baby. In online forums and playground conversations, they’re suddenly thrown into discussions of what is best for babies, and they find themselves trying to sort through lots of conflicting opinions and misinformation, trying to make the best choices for their own babies. It’s tremendously valuable and empowering to be able to understand how science can inform these decisions and how to find evidence-based resources. My book not only gives parents evidence-based information on infant health, feeding, sleep, and vaccines, but it also illustrates for parents how to find it themselves.

AE: What message from your book is most important for childbirth educators to share with their students?

AC: Seek evidence to inform your decisions. Be very skeptical of everything you read on the Internet, and make sure you’re getting your information from an accurate source. There’s so much misinformation out there that can be very misleading and even dangerous for parents and their babies. Don’t assume that something more natural or involving less intervention is always better. That isn’t always the case. Instead, look for objective evidence of risks and benefits, and make an informed choice.

AE: How did you choose the topics for your book? Was it difficult to decide what to leave out?

AC: I tried to choose topics that I think are some of the most common causes of confusion and anxiety for parents, based on questions that I get on my blog or that I see in online parenting forums. To be honest, my original proposal for this book included several more topics, but as I fleshed out chapters, I realized that it was more interesting to look at several topics in a really in-depth way rather than skim the surface on lots of different topics. But honestly, if I’d been able to devote another year or two to it, it could easily have been twice as long, because there are just so many great questions that parents have about the first year of life. I would have liked to cover topics like emerging research on the microbiome and concerns about chemical exposures, for example, but I may have to save those for another book!

AE: What do you feel is the most controversial topic in your book? 

AC: The safety of bedsharing is probably the most controversial topic in the book. Sleep practices are just so personal, and many parents really value bedsharing with their babies for cultural, emotional, or practical reasons. This is an area where you’ll find very conflicting advice, and everyone cites scientific studies to back their stance. In the book, I do my best to look honestly at the evidence for and against bedsharing safety. I explain that multiple studies do show risk of bedsharing in certain circumstances, especially with babies in the first few months of life, but I acknowledge the limitations of those same studies. And I also point out that individual factors, such as ease of breastfeeding or alternatives to bedsharing (including the risks of falling asleep with your baby on a couch or trying to drive a car while severely sleep deprived, for example) might make careful bedsharing a reasonable choice. I think we need to share all of this information with parents and discuss how to set up a bed to make bedsharing as safe as possible if that is the choice.

AE: Could you describe how you determine which findings from the scientific literature are best for answering a parenting question?

AC: In the book, I give a rough guide to types of study designs and explain which ones are most likely to give us strong evidence that is relevant to parenting decisions. Systematic reviews and meta-analyses are usually most useful, because they combine the results of multiple studies so are more likely to give us a big picture consensus about a question. (This assumes that the authors selected high quality studies for the review, so you have to be a little careful here.) Looking at single studies, randomized controlled trials are the best quality, whereas observational studies are usually limited by confounding factors and can only show correlations, not causation. Studies conducted in animal models or cell culture are an important step in scientific research, but we really want to see follow-up in human studies before we change our lives over the results. As you look at studies, you also want to pay attention to how many people were included in the study and whether or not the population is similar to your own. Evaluating scientific evidence takes some practice, and I go into lots more detail in the book.

AE: I was shocked to read that immediate cord clamping and cutting and stomach sleeping were practices changed in the mid-1900s without any evidence. Could you talk about how one of those practices began, the implications, and what it took (or will take in the case of umbilical cord clamping) for the original practices to be put back into place?

AC: It’s surprisingly difficult to pin down exactly when the shift to immediate cord clamping occurred, but it probably happened in the early to mid-1900s. Before this, it was likely standard practice to wait a few minutes or until the cord stopped pulsing before clamping it. The shift to immediate cord clamping seemed to coincide with the movement of birth from the purview of midwives in homes to obstetricians in hospitals. Immediate cord clamping was also part of the practice of active management of the third stage of labor, which was introduced in the 1960s. However, there was no evidence then that immediate cord clamping was beneficial to either mom or baby, and studies show that delayed cord clamping does not increase the mom’s risk of postpartum hemorrhage (which was a belief for a while).

Immediate cord clamping is an example of an intervention put into place because it was convenient, not because it was evidence-based. We now have good evidence that delayed cord clamping is beneficial to infants, especially those born preterm. For term infants, the biggest benefit is a boost in iron stores that can prevent iron deficiency later in infancy. There is some evidence that the risk of jaundice is increased, but as I discuss in the book, this is controversial. We’re seeing some obstetricians making delayed cord clamping their standard of care, but practice is really mixed in the U.S. At this time, ACOG recommends a delay of 30-60 seconds for preterm infants, but they refrain from making any recommendation for term infants, citing insufficient evidence. I actually appreciate that they’re careful to ensure there is adequate evidence before changing practice, but I do think we have enough evidence now that we should really be going back to delayed cord clamping whenever possible. I think that with a little more time and a few more studies, delayed cord clamping will again become standard practice, especially with doctors in the U.K. testing a resuscitation trolley that allows the cord to remain attached even if the infant requires resuscitation.

AE: What did you do to feel prepared for your labor and birth, and first weeks of parenting? Did you choose to take a childbirth class?  Do you feel it helped you feel prepared and confident?

AC: Before the birth of my first child, I took a childbirth class through a local hospital. It was very helpful in terms of knowing generally what to expect with labor and learning some ways to cope with discomfort. To prepare for the birth of my second baby four years later, my husband and I both read The Birth Partner by Penny Simkin. I liked that it was evidence based and a straight-forward source of information, and my husband put Simkin’s suggestions into action to truly be a great birth partner.

One of the most important aspects of birth preparation for me was developing a trusting and respectful relationship with my healthcare providers. My babies were delivered by two different OBs, and both were wonderful at communicating options to me as things progressed. Based on our discussions throughout pregnancy, I knew that I could trust them to be evidence based in their practice, and that helped me relax in labor and focus on my job of giving birth.

How did I prepare for the first few weeks of caring for a newborn? I did what women have been doing throughout the history of our species – I invited my mom to come and help! She was a wonderful help after the birth of both of my babies, and I felt lucky to have her.


AE: What future topics are you looking forward to writing about next?

AC: Readers of my blog keep me well-supplied with questions about parenting, and I have a huge list of topics that I’d like to tackle. One of my favorite areas of focus is nutrition, as that is the field of my PhD training, so I’d like to develop more information about infant nutrition on my blog.

While I was researching and writing my book, I had three miscarriages. That brought up lots of questions for me about miscarriage and infertility, but I didn’t have time to write much about these topics because I was working so hard on The Science of Mom. I’d like to write more about them now. I think there is a real need for compassionate and evidence-based writing about these tough topics.

About Anne M. Estes, PhD

AnneMEstes_headshot 2015Anne M. Estes, PhD is a postdoctoral fellow at the Institute for Genome Sciences in Baltimore, MD. She is interested in how microbes and their host organisms work together throughout host development. Anne blogs about the importance of microbes, especially during pregnancy, birth, first foods, and early childhood at Mostly Microbes.

Babies, Book Reviews, Childbirth Education, Evidence Based Medicine, Guest Posts, Newborns , , , , , ,

Book Review: The Science of Mom: A Research-Based Guide to Your Baby’s First Year

September 3rd, 2015 by avatar

By Anne M. Estes, PhD

Today on Science & Sensibility, Anne M. Estes, PhD reviews a new book – The Science of Mom: A Research-Based Guide to Your Baby’s First Year.  Lamaze International and Science & Sensibility are all about providing families and professionals with evidence based information that can help inform decision making.  Seems like this book might fit in nicely with the philosophy that Lamaze has held for decades.  Regular contributor Anne M. Estes, PhD shares her review on this new book and lets us know if it might be something to add to our resource list for new parents.  See the end of the review to learn how you can enter to be chosen for a free copy of this book courtesy of the author,  Alice Callahan. – Sharon Muza, Community Manager, Science & Sensibility. 

Science of Mom Cover HiDefMitchell Kapor once said, “Getting information off the Internet is like drinking from a fire hydrant.” New parents and child care professionals are certainly easily drenched by all the information that can be acquired on the internet from a variety of sources. As newly minted scientist-mom seven years ago, I was frustrated at the number of opinion and experienced-based baby books that lacked scientific support. The Science of Mom: A Research-Based Guide to Your Baby’s First Year, now fills that gap. Alice Callahan, a PhD in nutritional biology and mom of two, systematically examines common questions and concerns about infant care from a scientific perspective. In each chapter, she discusses the historical practice of the question, recommendations of different organizations, the current research, and the risks and benefits of a practice. Dr. Callahan does an excellent job presenting the strengths and limitations of particular studies and the logic behind different recommendations. Although The Science of Mom is science-focused, it is well-written and easy to read. The style of the book is personal and conversational. Personal experiences are intermingled with the science to illustrate her points well. A list of both the references used for each chapter and recommended books and websites are also given to help parents identify credible resources instead of getting lost in the fog of Internet “experts”.

Potential readers

For childbirth professionals and parents or parents-to-be interested in evidence-based practices for birth and an infant’s first year, The Science of Mom is a new and invaluable resource. Questions covered include: When is the right time to cut the umbilical cord? Which newborn treatments are necessary? How do newborns experience and explore their world? What are the differences between breastmilk and formula feeding? Where and how can babies sleep safely? What is the evidence for vaccinations? When and what kinds of solid food are best for babies?

Importance of evidence based decisions

Perhaps it’s also my bias as a scientist, but I greatly enjoyed reading such an insightful description of the process of science, the importance of scientific consensus, differences in quality across studies, and how scientific data can assist families in making informed decisions. Though readers of an evidence based blog like Science and Sensibility may already understand these points, the introduction could be helpful when introducing the rationale behind evidence based practices during child birth classes. It also serves as a guide for anyone who wants to research their own questions in the scientific literature.

I was particularly surprised to read about two instances where changes to medical practices in the early to mid 1900s had occurred without any evidence based support. One example was timing of cutting the umbilical cord. The author speculates that perhaps due to efficiency or convenience, the umbilical cord began to be cut before all the blood was pumped into the newborn. This practice is now being reconsidered due to the increased iron stores in the first 6 months of life of infants when cord clamping is delayed. Such an example certainly reinforces the importance of having evidence of benefit before new procedures are introduced or changes are made in traditional birth procedures.

Filling a gap in the bookshelf

In science and medicine there are no borders and no “right” answers. The Science of Mom is the same. Throughout the book, the author explores how a variety of countries and cultures deal with issues from giving Vitamin K to newborns (oral vs injected) to sleep practices (bed/room sharing vs separate sleeping arrangements). Different personal health conditions and prevalence of disease differ across the globe, making the need for some newborn treatments, such as eye prophylaxis, less clear. Dr. Callahan provides the data and information for people to make informed choices for their own family’s practices and situations. I found the honest, open, and nonjudgmental tone throughout the book refreshing.

Callahan author photo

Author Alice Callahan and her newborn © Alice Callahan

What a scientist-mom adds to the conversation

Each profession trains people to strengthen different skill sets. Training in the life sciences, especially at the PhD level, encourages a person to gather resources, sort through different quality data, synthesize data, and reach a conclusion based on that data for a given situation. Add to that training first-hand experience with raising two kids – knowledge of what it’s like to be in the parenting trenches, experience the “mommy wars”, and feel the exhaustion and yet love and concern of being a parent – and you’ve got a winning combination. The author is not a medical professional and most likely has only attended the births of her own two kids. However, in Science of Mom, Alice Callahan, PhD combines the critical eye of a scientist with the heart of a mother to create a helpful resource for all people interested in evidence based infant care and parenting.

What is missing?

What The Science of Mom does not do in general is to give you prescriptives for answering many of the parenting questions she poses. Data are still being collected and debated for many birth and parenting questions. There simply may not be one “right” way. In these cases, the scientific data are presented, the pros and cons of the different perspectives are addressed, then Dr. Callahan recommends following your baby’s lead and doing what feels best for your own family. After all, parenting is an art as well as a science.

In situations where scientists have reached a consensus, such as with the benefits of vaccines or back sleeping for infants, the author provides insight into how and why that consensus was reached by the scientific community. In such cases, Dr. Callahan provides additional information such as the role of each ingredient in the vitamin K shot in order to provide additional comfort to worried parents.

The Science of Mom is an excellent new addition to the bookshelves of any birth professional or parent who is interested in evidence-based parenting practices. Although the copy of The Science of Mom that I reviewed was complementary, I have given copies to several scientist-mom friends with newborns who also enjoy the nonjudgmental and objective tone of the book. For those wanting to read more of Dr. Callahan’s excellent commentary on the science of parenting, you can find her writing at the blog, The Science of Mom.

Enter to win your own copy of The Science of Mom

Have you had a chance to read this book?  What did you think of it?  Does this sound like a book that you would like to read?  Would you consider adding it to your resource list?  Share your thoughts about the book, how necessary or needed a book such as this might be, or other favorite resources for families to get evidence based information in understandable and easy to digest formats in the comments section below and include your email address.  All comments will be entered in a drawing for your own copy of the book.  The winner will be announced next month when Anne Estes interviews Dr. Callahan about her book. – SM

About Anne Estes

AnneMEstes_headshot 2015Anne M. Estes, PhD is a postdoctoral fellow at the Institute for Genome Sciences in Baltimore, MD. She is interested in how microbes and their host organisms work together throughout host development. Anne blogs about the importance of microbes, especially during pregnancy, birth, first foods, and early childhood at Mostly Microbes.

Babies, Book Reviews, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, New Research, Newborns, Parenting an Infant , , , , , , , ,

Book Review: “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers”

May 28th, 2015 by avatar

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

monograph cover_tn_kenKathleen Kendall-Tackett, Ph.D, author, IBCLC, researcher, internationally acclaimed speaker and occasional contributor to our blog, has written a new book – “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers,” that tries to lay to rest the myth that receiving help for a postpartum mood disorder and breastfeeding are not compatible.  I asked Cynthia Good Mojab to share her expert review of the book to commemorate the end of Perinatal Mood Disorders Awareness Month.  Cynthia is the perfect person for this task as she wears the hat of both a lactation consultant and a clinical counselor.  As birth professionals who work with families throughout the childbearing year, we have a sincere responsibility to provide information and screening resources so that families can be evaluated and directed to receive help that continues to support the breastfeeding dyad if breastfeeding is the parent’s desire.  Read Cynthia’s review and consider what you can do to increase awareness of perinatal mood disorders and offer your clients and students the best evidence based information available about how treatment options and breastfeeding are not mutually exclusive. – Sharon Muza, Community Manager, Science & Sensibility

Globally, the prevalence of postpartum depression is as high as 82.1% when measured using self-report questionnaires and as high as 26.3% when measured using structured clinical interviews (Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). These high rates mean that a significant proportion of families navigate breastfeeding in the context of postpartum depression.

As a perinatal mental health care provider and an IBCLC, I am frequently contacted by parents who found me after having been unable to access breastfeeding-compatible mental health care for postpartum depression (Good Mojab, 2014). They report feeling as though they are caught between a rock and a hard place: they’ve been diagnosed with postpartum depression and have been told by their primary care provider and/or their mental health care provider that they must wean in order to treat their depression. Sometimes they are even told that breastfeeding is causing their depression. Not only is that not true, but the relationship between infant feeding and postpartum depression is actually quite complex (Nonacs, 2014). While breastfeeding problems increase the risk of postpartum depression, breastfeeding itself is protective (Kendall-Tacket, n.d.). And research shows that infant-feeding intentions matter: breastfeeding mothers who are unable to accomplish their breastfeeding goals are two-and-a-half times more likely to develop postpartum depression (Borra et al., 2015). These research findings match what I see in my private practice: the partial or complete loss of a parent’s desired experience of breastfeeding can precipitate deep grief and worsen or precede the onset of postpartum depression.

Fortunately, there are many breastfeeding-compatible treatments for postpartum depression which health care providers and mental health care providers can use to effectively treat the vast majority of their clients. Dr. Kathleen Kendall-Tackett’s new book, “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers,” presents an up-to-date overview of the related research in an outline format that is quick and easy to read. She presents a compelling case for ensuring that families coping with breastfeeding problems receive additional lactation support and that breastfeeding parents coping with postpartum depression have access to treatment that is compatible with the continuation of breastfeeding.

In the first chapter, Kendall-Tackett introduces the rationale for screening for, referring for, and treating postpartum depression: postpartum depression is common in new parents and untreated postpartum depression has significant, immediate, and long-term negative consequences for both parent and child. She then presents research showing that breastfeeding does not cause depression (as some health care providers falsely believe); rather, breastfeeding serves to protect the dyad from the deleterious consequences of postpartum depression via its dampening of the stress response and via its facilitation of ongoing engagement between parent and baby. (When we shift our culturally based reference frame in recognition that breastfeeding is the biological norm for humans, we can see that this research also shows that formula feeding increases the risk of deleterious consequences from postpartum depression through increasing the stress response and potentially lessening ongoing engagement between parent and baby.) The substantial evidence base for why the effective treatment of postpartum depression is so critical—briefly introduced in chapter 1—is presented in more detail in chapter 3. Psychological disorders that often co-occur with postpartum depression, such as posttraumatic stress disorder, bipolar disorder, eating disorders, and obsessive-compulsive disorder, are then described. Chapter 5 reviews the complex causes of postpartum depression, including inflammation, fatigue and sleep disturbance, pain, traumatic birth experiences, infant characteristics such as illness and prematurity, and maternal characteristics, life history, psychiatric history, and social context.baby breastfeeding

Chapter 6 emphasizes the importance of screening for postpartum depression. Kendall-Tackett wisely advocates that validated screening tools be used (rather than relying merely on casual observation) and that screening occur in a variety of care settings—prenatal, hospital, home, and pediatric office visits. The recommendation for prenatal screening is very important. Depression during pregnancy is common (11% to 23% of pregnant women experience depression), is a risk factor for adverse reproductive outcomes such as preterm delivery, and is among the strongest predictors of postpartum depression (Gaynes, et al., 2005; Yonkers, et al., 2009; Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). Kendall-Tackett describes three reliable screening tools—two of which (the Patient Health Questionnaire-2 and the Edinburgh Postnatal Depression Scale) are in the public domain. This excellent chapter would be improved further with information about how to implement perinatal mental health screening in various settings, including the need to build a breastfeeding-friendly referral network prior to initiating screening and the need to develop or obtain materials (e.g., brochures, handouts, posters, resource lists, referral lists) that provide anticipatory guidance and help parents more easily access information, support, and treatment for postpartum depression (Good Mojab, 2015).

In chapter 7, Kendall-Tackett presents the development of a breastfeeding-friendly treatment plan as being grounded in the facilitation of informed decision making—something perinatal care providers are ethically obligated to do. Informed decision making requires that parents be offered evidence-based information that will allow them to weigh the risks and benefits of a variety of treatment options. This final chapter presents such information in the form of a succinct review of the available research on treatments that have been shown to be effective in treating depression, including: 1) “alternative” treatments (i.e., long-chain omega-3 fatty acids, exercise, S-Adenosyl-L-Methionine, and bright light therapy), 2) psychotherapeutic treatments (i.e., cognitive behavioral therapy and interpersonal therapy), 3) herbal medications (i.e., St. John’s Wort); and 4) anti-depressant medications. The reader is referred to the Infant Risk Center for up-to-date information about the use of particular anti-depressant medications during breastfeeding. Additionally, Medications and Mothers’ Milk: A Manual of Lactational Pharmacology is listed among the references. The LactMed app, though not mentioned in the book, is another useful resource for facilitating informed decision making regarding the use of drugs and supplements during breastfeeding.

The appendices are helpful for readers who have not yet begun to screen for perinatal depression and are looking for appropriate screening tools. Included are the Postpartum Depression Predictors Inventory—which can be used to identify risk factors for postpartum depression—and the Edinburgh Postnatal Depression Scale—which is well-validated as a screening tool for perinatal depression in mothers, in many cultures and languages, and in fathers. (A gender/prenatal/postpartum inclusive version of the EPDS is available here.) Because postpartum depression often includes symptoms of anxiety and/or co-occurs with an anxiety disorder, the appendices would have been improved by including the well-validated Generalized Anxiety Disorder 7-item (GAD-7) Scale, which is also in the public domain.

Scattered throughout the book are links to video clips that provide information on topics such as how breastfeeding protects maternal mental health and how breastfeeding ameliorates the negative effects of sexual assault. Readers with an auditory learning style will especially appreciate this access to online interviews and mini-presentations. Unfortunately, the dark gray links on a light gray background can sometimes be hard to read, leaving the reader to wonder “is that character a capital I, a lowercase L, or a numeric 1?” But, the video resources are worth the trial and error needed to open a couple of the links. Those with access to a smartphone with a QR code reader or barcode scanner can simply scan the code for each video clip to open the links, which greatly simplifies the process.

While the title of the book, “A Breastfeeding-Friendly Approach to Postpartum Depression,” is gender neutral, readers should know that the book is focused on cisgender mothers and uses cisnormative language. Certainly, there is a dearth of research on transgender and gender non-conforming parents which makes it difficult to write an evidence-based book addressing their needs in the context of breastfeeding/chestfeeding and postpartum depression. Nonetheless, we can infer that the high rate of clinical depression (44.1%) among transgender individuals means that transgender parents are at high risk for postpartum depression. And, the fact that transgender individuals experience “gender insensitivity, displays of discomfort, denied services, substandard care, verbal abuse, and forced care” in health care settings (Bockting, et al., 2013) means that transgender parents are also at high risk of being unable to access effective mental health care, much less breastfeeding/chestfeeding-compatible mental health care. Perinatal care providers need to be aware of these higher risks and learn how to bring their services into compliance with the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Bockting, et al., 2011). The lactation-friendly treatment options for postpartum depression that are reviewed in the book are likely to also be effective for transgender and gender non-conforming parents who breastfeed, chestfeed, or feed their expressed milk to their babies. The effective treatment of breastfeeding/chestfeeding parents with postpartum depression will also need to include responding to whether and how they are experiencing gender dysphoria during lactation.

Although written for health care providers, “A Breastfeeding-Friendly Approach to Postpartum Depression” will also be useful for childbirth educators, doulas, lay supporters, lactation specialists, and perinatal mental health care providers as they strive to do their part to offer families evidence-based anticipatory guidance about postpartum depression and its treatment options, advocate for more lactation support for families coping with breastfeeding difficulties, screen for postpartum depression, refer to and effectively collaborate with other breastfeeding-friendly perinatal care providers, and provide services that avoid iatrogenically increasing the risk of negative health, developmental, and mental health consequences for parents and babies through the unnecessary undermining of breastfeeding. The more widely Dr. Kendall-Tackett’s powerful little book is read and applied in practice, the more breastfeeding families will have access to breastfeeding-compatible treatment that truly meets their needs in the context of postpartum depression.


Bockting, W., Miner, M., Swinburne, R., Hamilton, A., and Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health, 103:943–951. Accessed: May 23, 2015. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698807/pdf/AJPH.2013.301241.pdf

Borra, C., Iacovou, M., and Sevilla, A. (2015). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal, 19:897–907. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353856/pdf/10995_2014_Article_1591.pdf

Coleman, E., Bockting, W., Botzer, M., et al. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13:165–232. Accessed May 23, 2015. Url: http://www.wpath.org/uploaded_files/140/files/IJT%20soc,%20v7.pdf

Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., Brody, S., Miller, W., et al. (2005). Perinatal depression: Prevalence, screening accuracy and screening outcomes;Evid Rep Technol Assess (Summ). 119:1–8.

Good Mojab, C. (2014). Mental Health Care for Postpartum Depression During Breastfeeding. Lynnwood, WA: LifeCircle Counseling and Consulting, LLC. Accessed May 23, 2015. Url: http://lifecirclecc.com/yahoo_site_admin/assets/docs/MentalHealthCarePPDBfd2014.pdf

Good Mojab, C. (2015). The Basics of Perinatal Screening. Accessed May 23, 2015. Url: http://www.lifecirclecc.com/professionals/perinatal_screening

Hale, T. and Rowe, H. (2014). Medications and Mothers’ Milk: A Manual of Lactational Pharmacology. Amarillo, TX: Hale Publishing.

Kendall-Tackett, K. (n.d). Why Breastfeeding and Omega-3s Help Prevent Depression in Pregnant and Postpartum Women. Accessed May 23, 2015. Url: http://www.uppitysciencechick.com/why_bfand_omega_3s.pdf

Kosenko, K., Rintamaki, L., Raney, S., and Maness, K. (2013). Transgender patient perceptions of stigma in health care contexts. Med Care, 51(9):819-22.

Nonacs, R. (2014). Breastfeeding and Postpartum Depression: Further Insights Into a Complicated Relationship. Massachusetts General Hospital Center for Women’s Mental Health. Accessed: May 23, 2015. Url: http://womensmentalhealth.org/posts/breastfeeding-postpartum-depression-insights-complicated-relationship/

Norhayati, M., Nik Hazlina, N., Asrenee, A., & Wan Emilin, W. (2014). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175C, 34-52.

Yonkers, K. Wisner, K., Stewart, D. Oberlander, T., Dell, D., Stotland, N., Ramin, S., et al. (2009). The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 114(3):703–713. Accessed: May 28, 2015. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094693/pdf/nihms293837.pdf 

About Cynthia Good Mojab

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


Babies, Book Reviews, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Newborns, Perinatal Mood Disorders, Postpartum Depression, Uncategorized , , , , , , , ,

Book Review: Birth Ambassadors; Doulas and the Re-Emergence of Woman-Supported Birth in America.

May 7th, 2015 by avatar


May is International Doula Month and Lamaze International recognizes the importance of labor support. (Note – there are both birth and postpartum doulas who work with families during the childbearing year. We are grateful for the work that they both do.)  In fact, our third Healthy Birth Practice specifically addresses doulas and support people as an effective component of safe and healthy birth. The American College of Obstetricians and Gynecologists (ACOG) in their 2014 Safe Prevention of the Primary Cesarean Obstetric Care Consensus Statement stated “published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”  Childbirth educators and health care providers have ample opportunity to inform parents about the benefits of a doula when they are meeting with families and patients.  

In mid-2014, sociologist Christine Morton, Ph.D. with Elayne G. Clift, MA, wrote a book, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America examining doulas from both an historical perspective as well as an assessment of the role of the doula in current American society . Kim James, LCCE and certified DONA birth doula, reviews this book and shares her perspective and take-aways with readers of this blog.

This book would make a great read for a book club book for birth professionals, and Kim generously shares some discussion questions at the end of today’s post to facilitate your discussion, should you wish to participate.  Alternately, if you have read the book, please feel free to respond in our comments section. 

Science & Sensibility and Lamaze International want to thank all the doulas who work tirelessly to support families as they birth their babies and transition to parenthood. Happy International Doula Month. – Sharon Muza, Science & Sensibility Community Manager. 

idm15 lamazeBirth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, written by Christine Morton, Ph.D. with Elayne G. Clift, MAis a thorough and compelling documentary of the history of doula support, the current dilemmas and issues facing the doula occupation, what drives doulas to pursue this work and how the work of doula support might fit into the future as the United States strains to find better ways of providing quality improvements in maternity care. For doula trainers and doulas looking to pursue this work in a professional manner, Birth Ambassadors is critical, mandatory reading. (For trainers and doulas interested in how to use this book to critically assess your work, please see the discussion questions below this article).

But what about for childbirth educators? What in it for them?

While the history is fascinating, it’s the critical sociological analysis of the current dilemmas and issues facing the doula occupation that childbirth educators’ need to thoroughly understand, especially Lamaze certified childbirth educators.

Lamaze International’s third Healthy Care Practice, ‘Bring a Loved One, Friend or Doula for Continuous Support’, outlines why continuous support is important and how a doula performs their work:

  • Continuous support can help alleviate fear and worry.
  • A doula’s intuitive sense and training mean emotional and physical needs are met with timely, individualized care.
  • Greater emotional and physical comfort may encourage the most efficient and healthy labor progress.

While most childbirth educators are aware of the intended benefits of doula care, not all are aware of the dilemmas doulas face in performing their work and the institutional and cultural issues that prevent doulas from having the greatest beneficial impact. Lamaze certified childbirth educators must have a firm understanding of these dilemmas so as not to ‘over-promise’ what the third Lamaze Healthy Care Practice is intended to deliver.

I want to highlight three dilemmas facing doulas that childbirth educators should be aware of and what they can do to educate parents who want doula-supported birth experiences:

Kim James' well read Birth  Ambassadors

Kim James’ well read Birth Ambassadors

First dilemma

The ecological fallacy of applying aggregate results of research that show doula efficacy to an individual family’s outcome. The cultural and institutional context of most US hospital births limit the doula’s efficacy, often by prohibiting truly continuous support and refusing to recognize a doula’s unique scope of practice. Childbirth educators should lead discussions with parents about what hospitals and which care providers in their areas are most and least supportive of doula care. Childbirth educators are instrumental in helping parents understand the questions they can ask during hospital tours and prenatal visits to find out if their chosen place of birth and attendant understand and support doulas attending families at births.

Second dilemma

The frequent contradiction between a doula’s personal values (often a deep belief in the optimality of the midwifery model of care, natural, drug-free childbirth or specific parenting practices) and her obligation to provide unconditional support for parents’ birth and parenting choices. Childbirth educators must help parents clarify their values around birth and parenting so that parents can find the support people who suit them best. Not every doula will be the best support for every parent.

Third dilemma

No occupation-wide standard for training or certification. The competing tensions within doula organizations between increased professionalization and maintaining low barriers to entry for all people to become doulas remain unresolved. While the majority of doulas are well-trained through recognized, long-standing organizations, some will only have received light, if any, training possibly through correspondence and online courses. Not every doula’s skill set is the same. Not every doula will practice within a scope of practice that is evidence based. Not every doula will pledge to follow a recognized code of ethics backed by an organization with an active grievance policy. Childbirth educators who make referrals to families asking for doulas should always make referrals to doulas who are well-trained, consistently receive excellent feedback from the families they serve and most importantly practice in a manner that is consistent with the evidence based third Lamaze Healthy Care Practice.

As a current Lamaze certified childbirth educator and professionally-working certified doula, I found my own experiences reflected in this book. While at times uncomfortable to confront the dilemmas and issues our occupation faces, Birth Ambassadors is well worth reading for the history and reflections for the future. It will give childbirth educators who are not currently practicing doulas good data on what the real impact of doula support means for the families that hire them.

Book club discussion questions

When Birth Ambassadors was newly released, I hosted a book club-style discussion group with several local doulas to discuss this book’s implications for our current and future work. Here are the big questions that came up for our group representing doulas who were well-established in their practices, those who were just starting out and both certified and non-certified doulas.

  • When is your personal bias stronger than your ability to offer unconditional support? (Reference: page 195).
  • Analyze this: “Doulas advocate evidence-based care for physiologic birth, yet are not trained clinically to recognize or treat women when their pregnancies and labors become non-normal”. (Reference: page 37).
  • The original purpose of the first doula organizations was to provide moral support for each other. What do we need from our organizations now? (Reference: page 90)
  • Do we have the training to be professionally non-judgmental? (Reference: page 196).
  • Doula neutrality –When do you abandon it? How do you maintain it? (Reference: page 261).
  • What are the current debates around our standard of practice and code of ethics? (Reference: page 81).
  • Outcome-based care vs emotional companionship: What are you drawn to in this work? (Reference: page 260)
  • Are you comfortable with the “outsider-within” role? Does attract or repel you? (Reference: page 36)

How do you talk about doulas in your childbirth classes?  In your midwifery or obstetrical practice?  Have you read Birth Ambassadors?  What were your big take-aways?  Have you shared Lamaze International’s “Who Says Three’s a Crowd?” infographic with the families you work with?

Note: Christine Morton is a member of Lamaze International’s Board of Directors.

About Kim James 

Kim James HeadshotKim James BA, BDT(DONA), CD(PALS), ICCE, LCCE, is an ICEA and Lamaze certified childbirth educator teaching at Parent Trust for Washington Children/Great Starts where she sits on the Education Committee. She owns and operates www.DoulaMatch.net and is a DONA International and PALS Doulas certified birth doula as well as a DONA-approved birth doula trainer working at the Simkin Center/Bastyr University. Kim also volunteers her time on the Lamaze International membership committee and serves as Washington State DONA SPAR. Her daughters are 9 and 16 years old.  Kim and her family live in Seattle, Washington.

Babies, Book Reviews, Childbirth Education, Doula Care, Guest Posts, Healthy Birth Practices, Lamaze International, Newborns , , , , , ,

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

March 17th, 2015 by avatar

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

© Walker Karraa

© Walker Karraa

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About Cynthia Good Mojab

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

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

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