24h-payday

Archive

Posts Tagged ‘guest post’

Henci Goer – Fact Checking the New York Times Home Birth Debate

February 26th, 2015 by avatar
home birth

© HoboMama

An article in The New York Times Opinion Pages – Room for Debate was released on February 24th, 2015.  As customary in this style of article, the NYT asks a variety of experts to provide essays on the topic at hand, in this case, the safety of home birth. Henci Goer, author and international speaker on maternity care, and an occasional contributor to our blog, takes a look at the facts on home birth and evaluates how they line up with some of the essay statements. Read Henci’s analysis below.  – Sharon Muza, Science & Sensibility Community Manager

As one would predict, three of the four obstetricians participating in the NY Times debate “Is Home Birth Ever a Safe Choice?“assert that home birth is unacceptably risky. Equally predictably, the evidentiary support for their position is less than compelling.

John Jennings, MD president of the American Congress of Obstetricians & Gynecologists, in his response- “Emergency Care Can Be Too Urgently Needed,” cites a 2010 meta-analysis by Wax and colleagues that has been thoroughly debunked. Here is but one of the many commentaries, Meta-Analysis: The Wrong Tool Wielded Improperly, pointing out its weaknesses. In a nutshell, the meta-analysis includes studies in its newborn mortality calculation that were not confined to low-risk women having planned home births with a qualified home birth attendant while omitting a well-conducted Dutch home birth study that dwarfed the others in size and reported equivalent newborn death rates in low-risk women beginning labor at home and similar women laboring in the hospital (de Jonge 2009).

The other naysayers, Grunebaum and Chervenak, in their response – “Home Birth Is Not Safe“, source their support to an earlier NY Times blog post that, in turn, cites a study conducted by the two commentators (and others) (Grunebaum 2014). Their study uses U.S. birth certificate data from 2006 to 2009 to compare newborn mortality (day 1 to day 28) rates at home births attended by a midwife, regardless of qualifications, with births attended by a hospital-based midwife, who almost certainly would be a certified nurse midwife (CNM) in babies free of congenital anomalies, weighing 2500 g or more, and who had reached 37 weeks gestation. The newborn mortality rate with home birth midwives was 126 per 10,000 versus 32 per 10,000 among the hospital midwives, nearly a 4-fold difference. However, as an American College of Nurse-Midwives commentary on the abstract for the Society for Maternal-Fetal Medicine presentation that preceded the study’s publication observed, vital statistics data aren’t reliably accurate, don’t permit confident determination of intended place of birth, and don’t follow transfers of care during labor.

As it happens, we have a study that is accurate and allows us to do both those things. The Midwives Alliance of North America study reports on almost 17,000 planned home births taking place between 2004 and 2009 (Cheyney 2014b), and therefore overlapping Grunebaum and Chervenak’s analysis, in which all but 1000 births (6%) were attended by certified or licensed home birth midwives. According to the MANA stats, the newborn death rate in women who had never had a cesarean and who were carrying one, head-down baby, free of lethal congenital anomalies was 53 per 10,000, NOT 126 per 10,000. This is less than half the rate in the Grunebaum and Chervenak analysis. (As a side note, let me forestall a critique of the MANA study, which is that midwives simply don’t submit births with bad outcomes to the MANA database. In point of fact, midwives register women in the database in pregnancy [Cheyney 2014a], before, obviously, labor outcome could be known. Once enrolled, data are logged throughout pregnancy, labor and birth, and the postpartum, so once in the system, women can’t fall off the radar screen.)

We’re not done. Grunebaum and Chervenak’s analysis suffers from another glaring flaw as well. Using hospital based midwives as the comparison group would seem to make sense at first glance, but unlike the MANA stats, which recorded outcomes regardless of where women ultimately gave birth or who attended them, hospital-based midwives would transfer care to an obstetrician when complications arose. This would remove labors at higher risk of newborn death from their statistics because the obstetrician would be listed on the birth certificate as the attendant, not the midwife. For this reason, the hospital midwife rate of 32 per 10,000 is almost certainly artificially low. So Grunebaum and Chervenak’s difference of 94 per 10,000 has become 21 per 10,000 at most and probably much less than that, a difference that I’d be willing to bet isn’t statistically significant, meaning unlikely to be due to chance. On the other hand, studies consistently find that, even attended by midwives, several more low-risk women per 100 will end up with cesarean surgery—more if they’re first-time mothers—then compared with women planning home births (Romano, 2012).

Hopefully, I’ve helped to provide a defense for those who may find themselves under attack as a result of the NY Times article. I’m not sanguine, though. As can be seen by Jennings, Grunebaum, and Chervenak, people against home birth often fall into the category of “My mind is made up; don’t confuse me with the facts.”

photo source: creative commons licensed (BY-NC-SA) flickr photo by HoboMama: http://flickr.com/photos/44068064@N04/8586579077

References

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health, 59(1), 8-16. doi: 10.1111/jmwh.12165 http://www.ncbi.nlm.nih.gov/pubmed/24479670

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014b). Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of north america statistics project, 2004 to 2009. J Midwifery Womens Health, 59(1), 17-27. doi: 10.1111/jmwh.12172 http://www.ncbi.nlm.nih.gov/pubmed/24479690

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed?term=1177%5Bpage%5D+AND+2009%5Bpdat%5D+AND+de+jonge%5Bauthor%5D&cmd=detailssearch

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2014). Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol, 211(4), 390 e391-397. doi: 10.1016/j.ajog.2014.03.047 http://www.ajog.org/article/S0002-9378(14)00275-0/abstract

Romano, A. (2012). The place of birth: home births. In Goer H. & Romano A. (Eds.), Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing.

Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3), 243.e241-e248. http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract

About Henci Goer

Henci Goer

Henci Goer

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

 

 

Babies, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , ,

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

January 15th, 2015 by avatar

By Michele Ondeck,RN, MEd, IBCLC, LCCE

© Sarah Buckley

© Sarah Buckley

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© Sarah Buckley

© Sarah Buckley

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

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

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

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

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

About Michele Ondeck

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

 

 

 

 

 

 

 

Babies, Childbirth Education, Guest Posts, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns , , , , , ,

Sarah Buckley’s “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” – A Review for Birth Educators and Doulas

January 13th, 2015 by avatar

by Penny Simkin, PT, CD(DONA)

Today, a long awaited report written by Dr. Sarah Buckley, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” is being released by Childbirth Connection. In this valuable report, Dr. Buckley gathers the most current research and provides the definitive guide for the role of hormones in normal, natural birth.  Esteemed childbirth educator, doula and author/filmmaker Penny Simkin has reviewed Dr. Buckley’s latest offering and shares today on Science & Sensibility how childbirth educators, doulas and other birth professionals can use this information to inform parents on how best to support the physiological process of childbirth.  In coordination with this research report, Dr. Buckley and Childbirth Connection are releasing a consumer booklet geared for families and consumers as well as other material, including infographics in support of this report.  On Thursday, Lamaze International Past President Michele Ondeck will share her interview with Dr. Buckley. In that interview,  S&S readers can get the full story directly from Dr. Buckley, on just what it took to create this remarkable tome. – Sharon Muza, Community Manager, Science & Sensibility.

© Childbirth Connection

© Childbirth Connection

Introduction

For many of us who work in the maternity field, Sarah Buckley’s fine work is well-known. Her book, “Gentle Birth, Gentle Mothering” (Buckley, 2009) has provided scholarly and enlightening guidance on natural childbirth and early parenting for many years. Her 16 page paper, “Ecstatic Birth,” (Buckley, 2010) guides educators and doula trainers, who rely heavily on her explanations of hormonal physiology in childbearing, for teaching about labor physiology and psychology and the impact of care practices.

Her newest publication, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care,” (Buckley, 2015) is a gift to us all. It represents a massive scholarly effort, a review of all the related scientific literature on the topic. With 1141 references, most of which were published in recent years, Dr. Buckley’s overview provides the transparency to allow readers to trace her statements to the evidence on which they are based. She exercises caution in drawing concrete conclusions when the evidence is insufficient; she presents such information as theory (rather than fact), and points out when more research is necessary for concrete conclusions. The “theory” that undisturbed birth is safest and healthiest for most mothers and babies most of the time is impressively supported by her exhaustive review, as stated in the conclusion (Buckley, 2015):

“According to the evidence summarized in this report, the innate hormonal physiology of mothers and babies – when promoted, supported, and protected – has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, likely extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.”

The Precautionary Principle, to which she refers, has been stated as follows:

“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. . . . It (the activity) must also involve an examination of the full range of alternatives, including no action.” (Science and Environmental Health Network, 1998).

In other words, when applied to maternity care, The Precautionary Principle states that when a practice, action, or policy may raise threats of harm to mother, baby, or family, the burden of proof that it will result in more good than harm falls on those who wish to adopt it – the policy maker, caregiver, or administrator, not on the pregnant person.

© Sarah Buckley

© Sarah Buckley

What’s new in this document and how might you use it and apply it in your classroom or practice?

This document represents the “State of the Science” regarding hormonal physiology of childbirth (HPOC). It should be the starting point for consideration of proposed changes in maternity care management and education. The question, “How might this policy, practice, or new information impact the HPOC and subsequent outcomes for mother and/or baby?” should be asked and answered about both existing and proposed interventions.

Sarah Buckley has asked and answered this question, and reveals the unintended consequences of numerous widespread practices, including scheduled birth – induced labor or planned cesarean; disturbance and excessive stress during labor; synthetic oxytocin (Pitocin); opioids and epidural analgesia for labor pain; early separation of mother from infant or wrapping the infant in a blanket to be held (i.e., no skin-to-skin contact); breastmilk substitutes, and many more. All of these practices cause more harm than good, except in unusual or abnormal circumstances.

One of the greatest contributions of this book is showing that hormonal physiology is affected by virtually every intervention –major and minor — and understanding this is the key to appropriate maternity care. The topic is complex and not nearly fully understood, but Sarah Buckley has pulled together just about everything that is now known on this topic. If you’re a maternity care practitioner or student, who wants to approach the care you give from a physiological perspective, or want information on the impact of common interventions on the physiological process, it’s all here. If you’re a researcher interested in studying some aspect of HPOC, your literature search has already been done for you and you can discover the many areas that have been insufficiently studied and plan where to go from there.

If you’re a childbirth educator seeking to give accurate information to expectant parents about how normal childbirth unfolds and how it can be altered (for better or worse) with common procedures and medications, you can learn it here. If you’re a doula who wants to understand how your presence and actions may contribute to normalcy, you can learn it here. If you’re an expectant parent who wants to make choices that maintain or improve the pregnant person and infant’s well-being, you can learn it here or access the consumer guide.

Organization of the Chapters

This book, with its numerous references, sheer number of pages, level of detail and broad scope, may seem daunting at first. However, if you take some time to familiarize yourself with the layout of the book before plunging in, you will find that the material in each chapter is arranged so that readers can explore each topic at varying levels of detail.

The book begins with a very helpful 10 page executive summary of the contents. There are then two chapters introducing concepts relevant to HPOC, and on the physiologic vs. scheduled onset of birth (induction and planned cesarean birth). The 7 chapters are organized with topics and subtopics. The first paragraph beneath the headings for each topic or sub-topic briefly and clearly summarizes the information in that section in italics, so that you can skim each topic by reading only the italicized summary. If you wish to investigate some subtopics more deeply, you can read everything included on those topics. Each chapter also ends with a summary of the entire chapter. Chapters 3, 4, 5, and 6 (Chapter 3 — “Oxytocin;” 4 —“Beta-Endorphins;” 5 —“Epinephrine-Norepinephrine and Related Stress Hormones;” ; and 6 —“Prolactin”) follow the same outline of topics and subtopics.

Using Chapter 6 (“Prolactin”) as an example, here is the outline:

  • 6.1 Normal physiology of prolactin
    • 6.1.1 Introduction: Prolactin
    • 6.1.2 Prolactin in pregnancy
    • 6.1.3 Prolactin in labor and birth
    • 6.1.4 Prolactin after birth
  • 6.2 Maternity care practices that may impact the physiology of prolactin
    • 6.2.1 Possible impacts of maternity care provider and birth environment on prolactin
    • 6.2.2 Prostaglandins for cervical ripening and labor induction: possible impacts on prolactin
    • 6.2.3 Synthetic Oxytocin in labor for induction, augmentation, and postpartum care: possible impacts on prolactin
    • 6.2.4 Opioid analgesic drugs: possible impacts on physiology of prolactin
    • 6.2.5 Epidural analgesia: possible impacts on physiology of prolactin
    • 6.2.6 Cesarean section: possible impacts on physiology of prolactin
    • 6.2.7 Early separation of healthy mothers and newborns: possible impact on physiology of prolactin
  • 6.3 Summary of all findings on prolactin

For childbirth educators: how might we use this information to benefit our students?

I especially appreciate that Dr. Buckley begins every section with a description of the relevant physiology. In order to be truly effective, we educators should do the same in our classes, to ensure that our students understand how and when their care is consistent with physiological childbearing and when (and why) it is not. “’Physiological childbearing’ refers to childbearing conforming to healthy biological processes,” (Buckley, 2015, page 11) as opposed to what many might refer to as “medicalized childbearing,” in which the physiologic process is altered or replaced with interventions and medications.

© Childbirth Connection

© Childbirth Connection

Childbirth education should be designed to allay the pregnant person’s anxiety, not by avoiding mention of potentially troubling labor situations, or minimizing concerns mentioned by the students, but rather by giving realistic portrayals of birth, encouraging expression of feelings, and dealing with them by informing, reframing, desensitizing, and strategizing ways to handle troubling situations. Following is an example of how an educator might include hormonal physiology of childbearing to teach about one critical topic – Physiologic Onset of Labor, which is Lamaze International’s First Healthy Birth Practice.

Let labor begin on its own: How to teach from the standpoint of HPOC

Chapter 2 in HPOC , “Physiologic Onset of Labor and Scheduled Birth,” details the ‘highly complex orchestrated events that lead to full readiness for labor, birth and the critical postpartum transitions of mother and baby.” (Buckley, 2015). As educators, we should try to convey this information, in simplified form, to help our students appreciate the beauty and connectedness of the whole mother-baby dyad. They need to understand the consequences of interrupting the chain of events that usually result in optimal timing of birth. Most parents (and many caregivers as well) have no idea that the fetus determines the onset of labor. Nor do they know that fetal readiness for labor (including protection against hypoxia and readiness for newborn transitions after birth) is coordinated with preparation of the mother’s body for labor, breastfeeding and mother-infant attachment. Once students have some grasp of these processes, they appreciate and want to protect them from interruption or replacement by medical means. As we know, most inductions and many planned cesareans are done without medical reason (ACOG, 2014). Out of ignorance and/or misinformation from their caregivers, parents often agree or even ask for these procedures.

While many educators know and teach about the risks and benefits of induction and planned cesarean, they often don’t convey the physiology on which the benefits and risks are based. It’s all here in HPOC, and this information may inspire parents to question, seek alternatives or decline these procedures.

Over the years, I have wrestled with the challenge of conveying this information fairly simply and concisely, and now, with the help of Katie Rohs, developed a new animated PowerPoint slide, “The Events of Late Pregnancy” (Simkin, 2013) that I use in class. You may access this animated slide and accompanying discussion points/teacher guide here.© Penny Simkin

© Penny Simkin

This is just one example of how we may shift our focus as teachers to incorporate basic hormonal physiology as a starting point. Dr. Buckley gives us a solid understanding of what is known about the key role the endocrine system plays in orchestrating the whole childbearing process, and why we shouldn’t disrupt this elegant process without clear medical reasons. If we teachers and other birth workers incorporate this information in our practices and in our teaching, outcomes will improve.

“Hormonal Physiology of Childbearing” is surely the most extensive search ever done on this topic, and is a solid guide to learning this crucial information. Encyclopedic in its scope, and multi-layered in its depth, this book will be most useful as a reference text, rather than a book to read straight through. It is pretty dense reading, but when you have a question relating to reproductive physiology or the effects of interventions, you can search for well-explained answers. The evidence-based conclusions that Sarah Buckley has synthesized from an abundance of research (1141 references!) are authoritative and must be made accessible. This is truly “State of the Science” on Hormonal Physiology of Childbearing.

Conclusion

Typical maternity care today has departed so far from physiology that in many cases it causes more harm than good, as borne out by Dr. Buckley’s discussions throughout the book of the impact (i.e., unintended consequences) of common maternity care practices on hormonal physiology and mother-baby outcomes. Our job is to inform expectant parents of these things and help them translate information into preparedness and confident participation in their care. If we do our job well, our students will want to support, protect, and participate in the physiological process, which has yet to be improved upon. Parents and their babies will benefit! Our thanks should go out to Sarah Buckley and to Childbirth Connection for bringing this gift to us.

In conclusion, Sarah Buckley’s “Hormonal Physiology of Childbearing” is an impressive exploration of the major hormonal influences underlying all aspects of the labor and birth process. As we understand and incorporate the knowledge included in the book, the birth process will become safer, with effects lasting over the life span.

References 

American College of Obstetricians and Gynecologists and Society of Maternal-Fetal Medicine, 2014. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus Number 1. Obstet Gynecol ;123:693–711.

Buckley S. Ecstatic Birth. Nature’s Hormonal Blueprint for Labor. 2010. www.sarahbuckley.com

Buckley S. 2009, Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, Berkeley

Buckley S. 2015. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Childbirth Connection, New York

Science & Environmental Health Network. 1998. Wingspread Conference on the Precautionary Principle. Accessed Jan. 8, 2015, https://www.google.com/search?q=The+Precautionary+Principle&ie=utf-8&oe=utf-8.

Simkin P. 2013, Events of Late Pregnancy. Childbirth Education Handout and Slide Penny Simkin, Inc. Seattle. https://www.pennysimkin.com/events-powerpoint

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 13,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2013), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

 

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Guest Posts, Healthy Birth Practices, Infant Attachment, Maternity Care, Medical Interventions, New Research, Newborns, Uncategorized , , , , ,

New Series: “BABE”- Brilliant Activities for Birth Educators! “Got Oxytocin?”

January 9th, 2015 by avatar

By Kyndal May, MFA, LMP, CD(DONA), BDT(DONA), LCCE

Today on Science & Sensibility, we start a new series on teaching ideas and techniques for you to use in your birth classes. The BABE series (Brilliant Activities for Birth Educators) will bring you exciting and innovative methods to teach the topics normally covered in a Lamaze CBE series. We will be highlighting a variety of childbirth educators as they share some of their favorite activities from their classes.  Today, we welcome Kyndal May, a childbirth educator in Boise, ID, as she shares how she covers the hormones of birth, and the role of oxytocin.  Do you have a creative method of teaching a CB topic?  Let me know via email, and we can connect about sharing in a future BABE blog post!  Everyone loves to learn new ideas and refresh their class activities.  I would love to hear from you.- Sharon Muza, Community Manager, Science & Sensibility.

© Kyndal May

© Kyndal May

This past September, I was among many doulas and childbirth educators lucky to attend Sarah Buckley’s session on The Hormonal Physiology of Childbearing at the Lamaze International/DONA International Confluence in Kansas City, MO. Following Dr. Buckley’s U.S. tour of her Undisturbing Birth Workshops, I suspect many childbirth educators may be revisiting the way we approach and explore the topic of the hormones of labor in our classes.  After viewing her DVD, Undisturbed Birth: the Science and the Wisdom, I am currently working to adapt both my childbirth classes and my birth doula workshops to incorporate this information in a new way.

While I play with what that will look like and how best to make that learning both powerful and playful, I’ll share how I have long taught about the hormones of labor –with a focus on oxytocin and a few activities (both past and present) that make it meaningful and fun.

Like everything in my classes, both content and my facilitation style is constantly changing based on what I am reading at the time, what I am witnessing in births, and the dynamics of the group. My students’ interactions and participation bring so much to the experience that they unknowingly contribute (often month to month) to what stays and what gets tossed.

I doubt that I am that different from other passionate childbirth educators who tend to see life through a “birth lens” if you will, meaning that very often, what I see, hear, and experience goes through the “how does this relate to birth?” or “could I tweak this to be a teaching tool?” filter in my brain. So, in 2009, when I saw t-shirts with messages like “I love my midwife” and “My midwife helped me out,” I immediately starting thinking of a t-shirt message I could use in my class and quickly put in a custom order for my “Got Oxytocin?” t-shirt.

© Kyndal May

© Kyndal May

I wore this t-shirt under another shirt through the first half of class one but I wait to show it to the class until we have explored the role of oxytocin in relation to birth. For example, oxytocin as a smooth muscle contractor – the perfect lead-in to discovering the unique structure of the myometrial musculature and watching as moms and their partners come to appreciate the uterine muscle and its work in labor in a new and meaningful way; oxytocin as ejection reflex initiator – the perfect lead-in to discussing oxytocin’s role both in the second stage and in orgasm and watching the connections made by each couple as they realize the essential environmental commonalities between the two and the need for a safe, private space for both.

At this point, orgasm becomes the perfect lead-in for understanding the role of beta-endorphins — as pain-suppressant and pleasure/transcendence producer — through a brief lesson on the etymology of the word (sometimes using smart phones).

Endorphin

With a consensus regarding the pleasure of orgasm and the pulsating rhythm of labor, everyone would very much like to know how to avoid inhibiting that process. So, epinephrine and norepinephrine become the perfect lead-in to receptors and …a short detour actually, to the brain, where we acknowledge the differences between a “typical male” and “typical female” brain through the perspective of the adolescent brain, in particular. Here, we compare the fight or flight response to ‘tending and befriending’ and what that can look like in different settings.

Throughout this process, we pause so that each couple can answer a few questions together and privately identify their own unique styles of co-creating an oxytocin-rich environment in their day-to-day living and connect it to their mutual vision of a safe birthing space.

Sound complex? It is – as complex as the interactions of these hormones, but just as rewarding and very fun. At this point, we take a break and when we come back together, I am sporting my “got oxytocin?” t-shirt for all the class to see.

As we turn our attention to how oxytocin and its partnering hormones set up both mother and baby for a thriving start together in the postpartum period, I pass out plain, white baby t-shirts to each couple. I invite them to take them home and design their own “Got Oxytocin?” baby t-shirt. I ask them to create it as if the baby was asking the question of everyone who comes into the birthing space.

© Kyndal May

© Kyndal May

My intention is to have them continue to think about oxytocin’s value in labor; to remember how it interacts with and is inhibited by the other hormones and how they might best co-create a space that supports the free-flow of the hormone. And most of all, because their canvas is the baby t-shirt, they are mindful how it benefits not only the mother but also the baby.

Each time I have used this activity, the response has been very positive. The first time, it was met with surprising enthusiasm and every couple chose to participate. Two weeks later, they returned with their amazingly creative t-shirts using everything from paint, to iron-on transfers, crochet to tie-die. One couple even reconstructed their t-shirt into a bowling shirt complete with buttons, color panels, collar and nametag. It was clear all of them not only enjoyed the activity, they enjoyed doing it together as a couple. A few commented that the activity provoked them to imagine their baby’s personality.

At least one couple took their baby t-shirt to their birth as a reminder to everyone who entered to support their efforts to create a safe and private birth space. Many couples commented how meaningful it was to them to have the t-shirt as a memento from the class in their baby book.

It has been a while since I have done this kind of an activity in class, but a new idea came to me last year. As we approached the holiday season, it seemed the perfect time of year to try it out.

© Kyndal May

© Kyndal May

At the end of class one, I handed each couple 2 clear plastic tree ornaments – one round and one in the shape of a heart. These ornaments can be opened and filled with paint, confetti or, in the case of the photo here, a piece of paper with some writing on it. I asked each couple to think of some way they might represent oxytocin or what oxytocin means to them and put it into the ornament. The objective is to work together to identify what is especially oxytocin producing for them. Once they do that, they’ll find a creative way to represent it and put it in the ornament that will then become their personal “mistletoe”.

They are invited to hang their “oxytocin ornament” and each time they walk under it, it will remind them to stop and spend a little time in an embrace — which we know, if they will hold for 10 seconds or more and do it 8 times a day, is a wonderful way to increase their own oxytocin levels.

Ornament music

© Kyndal May

This first group brought their oxytocin ornaments back and I had just a moment to photograph just a couple at the break. The first one is filled with berries that represent gooseberries for the couple who met a health store called “Gooseberries.”
Another couple filled theirs with sheet music as each of them is very musical and plan to use music as a comfort measure in their birth. One couple filled their ornament with small birthday candles to represent candlelit moments and another filled theirs with layers of colored cake decorations – each color representing something about their relationship. Overall, the project was met with positive interest and one couple said they enjoyed it so much they found themselves giggling through the process which became a very playful experience them.

Early in my teaching career one of the moms in class brought a gift to give everyone at the closing class of the session.   She told us all, “The way Kyndal talked about oxytocin, I just felt it was a ‘wonder-product’. It can contract the uterus and bring milk down, it can bond people to each other and more…maybe even get stains out of the carpet. So, I thought everyone should have their own bottle of oxytocin.” She passed out massage oil in tiny bottles with a label claiming the contents to be “oxytocin” and thus began an long tradition of sending each couple home with their own personal bottle of “oxytocin”.

I have since shifted my parting gifts but I revisit that one now and again as it was a long-running favorite. You can see more of the “Got Oxytocin” baby t-shirts by visiting my site.

Maybe you would like to incorporate some of the ideas listed here in your childbirth classes as you cover the hormones of labor.  If you do, please consider coming back to Science & Sensibility and sharing how it goes.  We’d love to hear from you. – SM

About Kyndal May 

© Kyndal May

© Kyndal May

Kyndal May, MFA, LMP, CD(DONA), BDT(DONA), LCCE, is a storyteller and facilitator; a confidence and commUnity builder for expectant parents, doulas and childbirth educators. She has been an active, private practice childbirth professional since 1995. Teaching her own curriculum, first in Seattle, WA and now in Boise, ID, she has well over 2000 hours of teaching experience and has attended nearly 300 births. A Licensed Massage Practitioner, she incorporates her background in bodywork and movement into her classes to facilitate awareness and help her students discover their own way to labor and birth. She refers to her Confident Birthing Childbirth Class as an ‘informed choice’ class and her unique education platform is used by educators in the United States and abroad.

She is a Lamaze Certified Childbirth Educator, a DONA Certified Birth Doula and Birth Doula Trainer offering advanced doula trainings in loss and communication. She serves as the consumer member of the Idaho State Board of Midwifery and on the DONA International Board of Directors as the Western Pacific US Regional Director.

Kyndal’s photography has been published in The Essential Homebirth Guide, Birth Ambassadors: Doulas and the Re-emergence of Woman Supported Childbirth in the United StatesA frequent speaker at professional conferences, her session, The Doula’s Field Guide to Birth Photography is available online through DONA International’s webinar series. To view more of her birth photography, visit her website at: www.kyndalmay.com

Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Series: BABE - Brilliant Activities for Birth Educators, Uncategorized , , , , , , ,

A Tale of Two Births – Comparing Hospitals to Hospitals

December 9th, 2014 by avatar

By Christine H. Morton, PhD

Today, Christine H. Morton, PhD, takes a moment to highlight a just released infographic and report by the California Healthcare Foundation that clearly shows the significance of birthing in a hospital that is “low performing.”  This is a great follow up post to “Practice Variation in Cesarean Rates: Not Due to Maternal Complications” that Pam Vireday wrote about last month. Where women choose to birth really matters and their choice has the potential to have profound impact on their birth outcomes.   – Sharon Muza, Science & Sensibility Community Manager.

An Internet search of “A Tale of Two Births” brings up several blog posts about disparities in experience and outcomes between one person’s hospital and subsequent birth center or home births. Sometimes the disparity is explained away by the fact that for many women, their second labor and birth is shorter and easier than their first. Or debate rages about the statistics on home birth or certified professional midwifery. Now we have a NEW Tale of Two Births to add to the mix. However, this one compares the experiences of two women, who are alike in every respect but one – the hospital where they give birth.

Screen Shot 2014-12-08 at 5.15.04 PM

 

The California HealthCare Foundation has created an infographic drawn from data reported on California’s healthcare public reporting website, CalQualityCare.org. In this infographic, we meet two women, Sara, and Maya who are identical in every respect – both are the same age, race, and having their first baby, which is head down, at term. However, Sara plans to have her baby at a “high-performing” hospital while Maya will give birth at a “low-performing” hospital. “High performing” is defined as three or more Superior or Above Average scores and no Average, Below Average, or Poor scores on the four maternity measures. “Low performing” is defined as three or more Below Average or Poor scores on the four maternity measures.

Based on the data from those hospitals, the infographic compares the likelihood of each woman experiencing four events: low-risk C-section, episiotomy, exclusive breastmilk before discharge, and VBAC (vaginal birth after C-section) rates (the latter one of course requires us to imagine that Sara and Maya had a prior C-section).

First-time mom Sara has a 19% chance of a C-section at her high-performing hospital, while Maya faces a 56% chance of having a C-section at her low-performing hospital. These percentages reflect the weighted average of all high- and low- performing hospitals.

Screen Shot 2014-12-08 at 5.15.22 PM

 

The readers of this blog will no doubt be familiar with these quality metrics and their trends over time. Two of these metrics (low risk C-section and exclusive breastmilk on discharge) are part of the Joint Commission’s Perinatal Care Measure Set. The other two – episiotomy and VBAC are important outcomes of interest to maternity care advocates and, of course, expectant mothers.

Hospitals with >1100 births annually have been required to report the five measures in the Joint Commission’s Perinatal Care Measure Set since January 2014, and these metrics will be publicly reported as of January 2015.

Childbirth educators can help expectant parents find their state’s quality measures and use this information in selecting a hospital for birth. In the event that changing providers or hospitals is not a viable option, childbirth educators can teach pregnant women what they can do to increase their chances of optimal birth outcomes by sharing the Six Healthy Practices with all students, but especially those giving birth in hospitals that are “low-performing.”

You can download the infographic in English and en Español tambien!

About Christine H. Morton

christine morton headshotChristine H. Morton, PhD, is a medical sociologist. Her research and publications focus on women’s reproductive experiences, maternity care advocacy and maternal quality improvement. She is the founder of an online listserv for social scientists studying reproduction, ReproNetwork.org.  Since 2008, she has been at California Maternal Quality Care Collaborative at Stanford University, an organization working to improve maternal quality care and eliminate preventable maternal death and injury and associated racial disparities. She is the author, with Elayne Clift, of Birth Ambassadors: Doulas and the Re-emergence of Woman Supported Childbirth in the United States.  In October 2013, she was elected to the Lamaze International Board of Directors.  She lives in the San Francisco Bay Area with her husband, their two school age children and their two dogs.  She can be reached via her website.

Babies, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Newborns, Push for Your Baby , , , , , ,