Wednesday, November 18, 2015

Natural Induction?

I am going to go straight to the point. There is no such thing as a natural induction. There I said it. Non pharmacological inductions,certainly. To actively bring on labor is induction no matter what method is being used. In cases of healthy full term mothers carrying healthy babies,the body simply will not go into labor before it's ready. No method of induction is without risk. There are times when potential benefits will outweigh potential risks and that is when induction is the ideal choice for a mother and her baby.
Here are some of the claimed methods of natural induction:

Castor Oil: This is a laxative. The logic behind using this as a method of induction is that it triggers contractions of smooth muscles in the intestines which will trigger the tightening of uterine muscles. Research shows this is successful in about 50% of women. Realistically would you want diarrhea on top of contractions? Or just end up suffering stomach cramps and excessive pooping without bringing on labor!?

Membrane Stripping: A care provider will often do this during a cervical exam. They use a gloved finger to make a sweeping motion inside the cervix to detach the membranes from the cervix. This is thought to bring on labor in the next 48 hours. Side effects of this procedure are usually some spotting and cramping. On occasion premature rupture of membranes can occur (PROM).

Evening Primrose Oil: EPO is used to ripen the cervix, but there is little proof that it induces labor. The only studies regarding EPO are about consuming it orally. There are no studies about the safety of EPO used vaginally. It has not been found to shorten pregnancy or labor.

Black Cohosh: Black cohosh is an herb that is thought to bring on contractions. There are no reliable studies with evidence supporting this. Women with issues with estrogen should avoid black cohosh as it behaves similarly to estrogen.

Red Raspberry Leaf Tea: This tea, not to be mistaken for raspberry flavored tea is used as a uterine tonic. Some women drink it throught pregnancy and some wait until closer to full term. Red raspberry leaf tea may cause Braxton Hicks contractions in some women, while harmless this can be uncomfortable.

Pineapple: Pineapple is a prostaglandin, which will soften the cervix. For this to work large amounts of the pineapple and core must be eaten. Canned pineapple and store bought pineapple juice will not work. The jury is out on whether or not labor will start soon after doing this. If you love pineapple, maybe it's not the worst idea out there.

Sex: Semen is a prostaglandin and may help soften the cervix  Good sex, I know a full term pregnant woman can have trouble with this, with an orgasm for the woman can help move things along. Orgasms trigger uterine contractions,so maybe an orgasm could bring on labor contractions.

Spicy Food: Spicy foods trigger prostaglandins in the digestive process,which is thought to encourage labor. Extremely spicy foods can cause an endorphin rush. There is little evidence to back this claim up,but if heartburn isn't an issue in your pregnancy, why not hit up the Indian buffet?

I made this list starting with the most aggressive and risky methods of induction and ended with things that are harmless and even fun. Relax and enjoy your pregnancy. If the need to induce comes up bring these up with your doctor if you want to skip the Pitocin. You are in charge of your body and birth, there is no expiration date for pregnancy. No one has stayed pregnant forever. 



Wednesday, November 11, 2015

As Your Doula

I work for you.  I will give you all kinds of information about your birth options.  I will talk to you about your goals for your birth.  I will do research about anything I do not know, and come back to you with all the evidence I can find.  I will be there for you if you need to ask any questions during your pregnancy.  I will be almost as excited about your impending labor as you are.  I will wait anxiously by the phone for the call that might come in the middle of the night to come and join you while you are in labor.  I will come to your house, if you want to keep laboring at home.  I will follow you to the hospital or meet you as you arrive. I will hold your hand and tell you that everything is going normally, if it is.  I will decode any medical-speak you don’t understand and make sure that you are making informed decisions about your care.  I will squeeze your hips and try all my tricks to help you stay as comfortable as possible during your labor. If you ask me a third time, I will run to get the anesthesiologist to give you your epidural.  I’ll suggest position changes and help you move into them.  I will make you go to the bathroom every hour during labor. I will be there with you the entire time.  I will help guide you through the entire process, and I will love every minute of it.

I want for you to have the birth that you want to have.  I don’t care if you get an epidural; I still have ways that I can help you. If you don’t want an epidural, I know how to get you there too.  I want you to leave your birth feeling fulfilled.  I want you to feel like you accomplished something, because having a baby is a MAJOR accomplishment no matter how it happens.  I want you to feel like you were supported in every decision you made along the way, and that you had all the information to make each one.   I want for you to be happy with your birth, exactly how it happened, no matter if it was to plan or not.  I want so much for you to completely exhilarated and excited about your birth, so much so that you can’t wait to tell the story to anyone that will listen. 

I believe that birth is amazing.  There is nothing more exciting than getting to watch a new baby come earthside.  Getting to be a part of that process is what makes the job of a doula so rewarding.  I believe in this work and its value.  I believe that this job makes a difference not only in the lives of the women we serve, but also in all those that we touch through our service: the nurses and other hospital staff, the physicians, the midwives, the family members, and the friends. I believe that one birth at a time, I am making a difference in the way that birth is viewed and approached.  Most of all, I believe that this work is my passion.


Doulas make a difference.  Doulas everywhere want to change birth one mother at a time. Doulas are evidence-based. 

Wednesday, November 4, 2015

What's Gravity Got to Do with It? Delayed Cord-Clamping Evidence

I was recently at a birth where the mom didn’t even request delayed cord-clamping, but the OB did it anyway.  I asked him why he waited, and his response was, “Why not? There’s great evidence that it is beneficial.” I almost hugged him, but stopped short when I realized that he was wearing a sterile gown and covered in birth goo. 

Delayed cord-clamping is a BIG issue that many parents don’t even talk to their provider about or even put into their birth plan.  There have been numerous studies published on the benefits of delayed cord-clamping, so much so that it really doesn’t make sense that it isn’t common practice.  Though, as we know, there is a lag of YEARS between research and policy change. 

Most recently, we have been hearing about moms who are being forced to choose between immediate skin-to-skin contact with their baby and delayed cord-clamping, based on the misguided theory that a baby must be lower than the placenta in order to get the blood from it.  We find this extremely interesting considering so many facts and research that states that this is NOT the case at all. 

A long time ago (1969), this gravity interference theory was a commonly held misconception.  So much so, that there was a real dearth of research even looking into the idea.  But, that really is no longer the case at all.  There has been a Cochrane Review out since 2010 that discusses the ridiculousness of thinking that a baby must be lower than a placenta to receive the 25-40% of the baby’s blood that could be left in it.  Even older than that is Mercer & Skovgaard’s publication analyzing the physiology of cord clamping and blood transference.  More recently (2012)Mercer & Erickson-Owens published an article calling for a change in practice with regards to umbilical cord clamping.

What is our take on the issue:
1.      There is ample evidence to support the fact that delayed cord-clamping is a GREAT idea.
2.      Gravity is NOT an issue, and thinking so means you are misinformed.

3.      We need to DEMAND delayed cord-clamping and specifically discuss it not only in the office setting before birth, but also during labor, and immediately following the birth! 

Wednesday, October 28, 2015

Eat, Drink, & Birth!

It’s been 4 days since the American Society of Anesthesiologists put out a bomb of a press release saying that women in labor would benefit from a light meal!  This is HUGE news from the group who has always been the major stumbling block preventing eating in labor.  We could not be more excited that they finally realize that making women essentially run a marathon on an empty stomach is NOT a good idea. 

Lamaze International has been trying to push this change for years, and the great Sharon Muza even wrote this amazing article pointing out that just because they released a statement on the fact that research supports this does NOT mean that there has been a policy change for anesthesiologists as of yet.  There has always been evidence supporting the fact that women should be allowed to eat and drink during labor.  There has always been push back from childbirth educators & doulas who KNOW the research and have never understood the policy’s lack of reflection of this research.  It’s also important for you to understand that there is a typical time lag of YEARS between the publication of research and revision to evidence-based policies. 


This is what we want you to know: We, as the Doula Group of Evansville will be pushing for change here locally.  We WANT the local hospitals to practice evidence-based medicine and be on the cutting edge of putting policies in place that reflect that.  We firmly believe that evidence-based practice is the best thing for both mothers and babies when it comes to childbirth and immediately afterward.  We WILL be asking the anesthesiologists that we encounter what they plan to do regarding eating during labor every. Single. Time. We see them.  We want to see change happen NOW, not years from now. 

What can you do? Push for change for yourself! Bring the evidence up in your appointments with your provider.  Send a letter to the hospital talking about how you would like this evidence to be put into practice immediately.  If you don't know who to contact or what to say, let us help you. We love to help; We're doulas after all! 

Thursday, October 15, 2015

Carson's Birth Story (Abby's 2nd Delivery)

As I (Abby) proofread and prepare this post, I cannot help but giggle at how much I have changed! I hadn't been a doula very long when I wrote this, and I sure have learned a TON. My outlook on not only birth, but life and profession have all changed considerably. I submitted this to a birth story contest sponsored by Lamaze in 2012, and received 2nd place prize! Read on to find out why.

I have been meaning to sit down and type this out since the day that Carson was born, but, ya know, two kids and all of that. I think I’d like to start by saying that my labor and birth experience with Carson was a life-saving experience. Not in a physical way, but in an emotional way. It has permanently changed the way I live and view the world!
Throughout my pregnancy and for several months before, I seemed to just be going through the motions each day. Taking my life one day at a time, not really doing or feeling anything, just trying to get from sun up to bed time.  I’d not always been that way, and I’d honestly say the beginning of this feeling was at the time of my miscarriage in August 2008. At that time, I had “known” for several years that my fertility was very poor due to polycystic ovary syndrome. So when I found out that I was pregnant, I was obviously surprised, but also terrified, and sad because by the time I knew I was pregnant, I was having a very long, “lingering” miscarriage. It seemed to go on forever, though it was just a few weeks. After that, it seemed I couldn’t really think of anything else besides having a baby. Fast forward a year later, still no pregnancy. The first seemed to be a fluke. In comes Clomid, but that is another post. Two cycles later, YAY! Baby! After an uneventful pregnancy that went post dates, and an OB that scared me into getting induced when I didn’t need to be, who THEN preceded to mishandle my induction and delivery in such a way that my daughter and I both experienced physical trauma, bring on the postpartum depression. I had hoped for a natural birth, and what I got was the furthest thing from it. And the baby that I had seemed to cry uncontrollably, inconsolably, for hours. This was July 2010. August came, and we found out that my husband’s grandmother had stage IV cancer. Devastating. She was the glue of the family. By this time we also found out our daughter had severe digestive food allergies and sensitivities. A lot on our plates to say the least. But it was December 2010, that dealt the heaviest blow: My mom, my best friend, whom I saw every day and lived only blocks away my whole adult life, passed away suddenly after a massive heart attack. I pretty well turned my feelings off at that point. I found out I was pregnant in March and was shocked and so scared. I didn’t think I could handle anything else, especially without my mom to support me through it, and my daughter was barely 10 months old! If there was anything left to feel, they went to the closet after Grammy’s death in March, my Grandmother’s late stage cancer diagnosis in July, which was preceded by my husband’s grandfather’s death (Grammy’s husband) in July as well.
Now, I know that got windy, but it’s so important to the story. My kids and my births are so very important to me!!! I would do ANYTHING for my kids (including endure that horrid induction all over again if I had to.) I think that is why Carson’s birth was so important. I thought being pregnant was the last thing I needed that May of 2011. But God knew it was just what I needed to heal.
I had a severe diastasis recti during pregnancy (having babies very close together, and babies that grow very quickly can cause large spread in the two columns of abdominal muscles, causing no support and organs to “sag” directly against the skin.) I was uncomfortable, afraid to have another experience like my first, chasing a toddler, irritable uterus (constant and incessant Braxton Hicks) and not really dealing at all with all of the heartbreak of the years past. Toward the end of my pregnancy, I began to worry incessantly about going over too far and requiring another induction. My 24 week ultrasound had revealed a baby that would have been estimated to be about 12lbs at birth (97%) and because my daughter had a shoulder dystocia charted, my doctor was concerned that I wouldn’t be able to birth my second one. However, she was willing to let me try to labor and birth (this is the only true way to diagnose a shoulder dystocia-in labor) At 39 weeks 3 days, I agreed to a membrane sweep to avoid a real induction. By 39 and 5, I thought I had an infection in my uterus, and we packed up and went to triage that night. I didn’t feel contractions, I felt soreness and irritability. I had been 5 cm for about two weeks, with a bulging bag of waters. Nothing was happening, no infection, baby was fine, so home we go in the middle of January with an ice storm coming. We know sooner get on the interstate than contractions start and are about 6 minutes apart, all the way home. This continues for about an hour at home, so we head back to the hospital and call my doulas! I was in labor! Hoorah! Me and my crew roll in there and start my antibiotics (Group B strep) AND NO CONTRACTIONS on the monitor. UGH….My fear of the hospital had really taken over at that point, it was obvious. But I knew if I left they would begin again. I had to get out of my own head. So we walked the halls at 1 am, all four of us J no real pattern began, still 5 cm. I decided to bounce on the birth ball and use the breast pump that my doulas recommended. After about 15 minutes, I got a good pattern going and away we went! Around 7:30 am I was breathing through contractions and loving every minute of my natural labor! When they moved me to a room at that time, they checked me and I was 8cm and 100%. Yes! Total cake walk so far. I sat in the recliner and listened to my Ipod while my support team laughed at me for yelling over my music in the headphones and had snacks. But, I was at another stall. I walked the halls, and pumped some more, and the pattern picked back up. I knew at that time that my mind had to get past what was going on, and I needed to intensify things to avoid Pitocin. I asked my doctor to rupture my membranes since they had been bulging for quite some time. Well, it was a good idea, until she couldn’t rupture them with the hook. I had a very tough sac, and I could feel the snag and tug, but they wouldn’t burst! She at that time used a fetal heart electrode and they finally trickled! But after all that action, I back slid to 6 cm. (however, my team decided that would get in my head as well, and decided not to tell me about it-great decision!) Away I went with the walking and pumping again!  It was about 11am when they checked me again and admitted the back slide, and explained that I was now back to the 8cm. I felt so spiritual, I had intense feelings, period. The tears flowed with the music “Dark Before The Morning” by Josh Wilson was on repeat, and I prayed, a lot. I have never been high, but I would guess that is what it felt like. Hyper sensitive, more awake than I’ve ever experienced. It was then that I got very fearful. Why was baby not descending? Why was it taking so long? Was my child stuck again, was I facing the same trauma as I was with my first. At that time, I was very withdrawn, I was doing big work, and couldn’t string my sentences together. I could only say “I’m afraid baby is stuck” My team took it as fear of my previous labor getting to me, and encouraged me by saying “This is not Mallory’s birth” and “this is a different pregnancy, different doctor” but what I meant was that intuitively, I knew baby should’ve been born already. I knew something was holding things up. I had been laboring on the birth ball and standing by the bed at that point. Things were intense, I was almost ready to push, but I didn’t feel the need to…my doctor asked if I’d be willing to change positions to encourage baby to turn. I agreed to get on the bed and try the squat bar, but not much change. I tried all fours, but this killed my diastasis. What would I do then if baby was stuck? That had been my plan to dislodge! My OB suggested I lay on my side and put my foot on the squat bar. At that point she discovered a second bag of waters and asked if she could rupture it. When she did, WHOOOO! There was that urge to push I wanted! But baby wasn’t really coming after several pushes, and it turns out I was right: baby was stuck, the same way as my first. But my OB handled it like a champ! (my babies try to be born occiput right; OB #1 didn’t bother to see this and just cut me and sucked her out sideways, fracturing her collar bone and causing my a 3rd degree tear when I birthed the shoulders) My doctor manually turned my baby as she cheered me on: “Push Abby, this baby girl wants you to push!” (No one knew the gender, but I believed her haha) “This beautiful baby girl has some hair for you, Mom!” Then finally, she said “ABBY, REACH DOWN AND BIRTH YOUR BABY!” And I did. I hooked baby’s armpits with my fingers and pulled baby onto my chest. I hugged so snuggly I thought baby would suffocate. I NEVER felt so spiritual and ALIVE. My whole body tingled with delight! I rubbed baby, and the nurse lifted the blanket to check if the cord had stopped pulsing so my husband could cut it. It was then that she said, “Only one problem with this baby girl, It’s a BOY!” We had all just went with the girl thing! My 8lb 20in handsome little cube of love was the reason for all of this emotion, all of this release. He made it possible for me to feel so powerful, awe struck and intensely AWARE of my body and feelings. He was the miracle that I needed. He was my recovery, my band-aid, he was what I found when I searched my soul. I had no stitches, Baby Boy Moore had no trauma, and we went home 24 hours later to the most beautiful big sister in the world. My birth experiences were and are as different as my kids have turned out to be. And each experience has changed my life for the better.

Wednesday, August 19, 2015

Top 10 Craziest Pieces of Parenting Advice.

Having a pregnant woman around suddenly attracts all the pregnancy and parenting experts,right? Most of the advice is well intended,but out of date. This a list of incorrect,outdated,and just plain weird advice for pregnant women and new parents.

"Once your friends and relatives become aware of the fact that you are pregnant, you will be the recipient of all sorts of advice and suggestions from them. While this advice will be offered with the best of intentions and from the kindliest of motives, pay no attention to it at all. No matter how many babies your Aunt Minnie had, this has no bearing on you nor does it establish her as an authority. It is often difficult not to listen, but you should politely indicate that you get your advice from your doctor. Listening to the horrendous tales of your friends' obstetrical experiences is apt to be an upsetting pastime."
- Frederick H. Goodrich, Preparing for Childbirth: A Manual for Expectant Parents. London: George Allen and Unwin Ltd., 1967,.

1.Don't raise your arms above your head or you will cause a nuchal cord (umbilical cord wrapped around baby's neck).
2. Don't look at ugly people or your baby will be ugly. Crazy,eh?
3. Don't look at animals or you will give birth to one.  
4.Don't hold your baby,you'll spoil him if you hold them too much.
5. Cats can steal the breath of the baby
6. Dang,cats are at it again. Don't hold a cat while pregnant or it will steal the baby's soul.
7. Let the baby cry. They need to learn to self-soothe. Whatever that even means!
8.You need to drink milk in order to make milk. How ever did we survive before people starting milking cows?! 
9.Don't hug or kiss your baby. Again with the spoiling here. It is infact,impossible to spoil a baby.
10. Tickling a baby's feet makes them go crazy.

As you can see most of the things on this list seem down right ridiculous. Parenting and pregnancy rules are ever changing. Trust yourself, there is no definitive manual, we are equipped with all we need to birth and parent if we just stop listening to all the drivel out there. 

Tuesday, August 11, 2015

Revolutionizing Childbirth in an Intervention-Driven Society

Despite a decrease in the rate of premature birth, other areas of maternity care in America continue to suffer.  The United States continues to fall short on some significant quality and cost concerns. Fatality, intervention, depression, and cost rates are up, while satisfaction with care is down. This post is an in-depth description of the causes of these problems, like the cascade of medical intervention, a lack of awareness and acknowledgment sub-par maternity care, and deficient healthcare coverage. Also covered in this text are some suggested solutions. Providing risk-appropriate care, encouraging evidence-based practice through education and support of expectant women and families, and ground-level requests for maternal-fetal centered care are only a few of the ways that the United States can begin to put itself in among other industrialized countries. Grassroots education by doulas and childbirth educators and offering risk-appropriate maternity care are two of the most highly prioritized steps because controlling these issues will create a positive domino effect.
The process of giving birth has changed considerably over the course of humanity’s existence.  Women have come quite a long way from the times of laboring in a cave and wrapping a newborn in a pelt, particularly in the United States of America.  The cave is replaced with luxurious birthing suites and the finest medical technology on the ready 24 hours a day, 7 days a week.  Animal pelts have been exchanged for perfectly breathable swaddling blankets made from a blended fabric specially formulated to replicate the feeling of the womb.  Women and children that would not have survived during Paleolithic times are protected from complications with life-saving medications and procedures.  It all sounds so positive and beautiful, as long as no one looks too deeply.  Americans spend a fortune on maternity care, but save fewer lives than countries with lower intervention rates.  The emotional health of American families is also suffering, with rates of postpartum depression and negative emotional and developmental impacts on children increasing as well. Over the past 12 years, there has been a 56% increase in the amount of surgical births in the United States, and a sharp incline of births in which Pitocin was administered (Coeytaux, F., et al, 2011, p 1).  While there are no studies proving better outcomes, data exists showing misusing these procedures caused maternal and infant mortality rates to rise.   Many states have banned or refused to license the same midwives that delivered babies at home over the last century.  Maternity and postpartum care cannot be considered a success in the U.S. until spending and fatalities are controlled and citizens are once again in charge of their own healthcare.
The Detriment of Medical Overreach
            According to the CDC, about 23% of pregnant women underwent induction of labor in 2010, with 32.8% of women giving birth via cesarean in that same year (Martin, J., et al, 2012, p 4). Inducing labor in a pre-eclamptic mother can save the life of both herself and her unborn child. Performing an emergency cesarean is necessary to preserve the health of a fetus when the umbilical cord has prolapsed, or the fetus has begun to show signs of true distress. Over time, people have developed technology to make giving birth safer for mothers and children. However, the rates at which both of these procedures are occurring are considerably higher than recommended by multiple organizations, and are expensive-both emotionally as well as economically.  

Induction/Augmentation of Labor
Induction of labor is the act of artificially forcing labor to begin. Augmentation is the act of altering an already present labor process. Induction and augmentation may be done with several different methods.  Sometimes medications like prostaglandins are used to thin and dilate the cervix, or a synthetic oxytocin called Pitocin is used. A provider may artificially rupture the membrane that contains the amniotic fluid (breaking the water) in an attempt to intensify contractions, or insert a balloon catheter into the cervix to encourage effacement and dilation (the thinning and opening of the cervix). None of these procedures are without risk. Any time that an object is inserted into the vagina, there is a risk of transferring bacteria and encouraging infection. Synthetic prostaglandins have been linked to uterine hyperstimulation with maternal vomiting, diarrhea and fever, while amniotomy is associated with fetal distress and injury, umbilical cord prolapse, and possible bleeding from the placenta, and all of those risks increase the likelihood of a necessary cesarean section as treatment (Tenore, J., 2013). Labor induction has been strongly linked to an amplified risk of cesarean.  This is even more likely if induction methods are used before the cervix is favorable for birth.

Cesarean Section
            Surgically removing a fetus from the uterus is called a cesarean or c-section.  It is estimated that 1.5 million women have cesarean sections annually, and that number is on the rise (Guise, 2010). It is the most common surgery in the United States, with just over 32% of women birthing via cesarean (Martin, et al., 2012). This is considerably higher than the recommended rate of <15% by the World Health Organization (2015).  While cesarean birth began as a means to save lives, it is used too frequently to schedule convenient birth times, to choose a child’s birth date, or even to just relieve a mother that may be ready to end her pregnancy discomforts. There is some information attributing rising cesarean rates to the fear of pain and/or the toll vaginal birth takes on a woman’s body. An online survey of 752 American women found that those who were more fearful of birth were four times more likely to opt for elective surgical birth (Stoll, et al., 2013). Maternal risks of cesarean include hysterectomy, cardiac arrest, longer hospital stays and readmissions, anesthetic complications, blood clots or loss/transfusion, infection, and death, while fetal risks of cesarean section include respiratory distress, increased NICU stays, and increased development of asthma, autoimmune disease+, obesity, food allergies, Type 1 diabetes, and more (Childbirth Connection, 2012). The same review from Childbirth Connection stated that “data conflict but suggest that more women may experience PTSD or PTSD symptoms after cesarean delivery in general and unplanned cesareans in particular” (2012). This is an unacceptable side effect for a woman for one of the most important days of her life.

Increased Financial Costs
            The cost of maternity care in the United States is out of control. Susan Brink (2013) offers a wonderful explanation in her article written for USNews.com:
The economic issues of maternity care are huge. The present system of fee-for-service payments, in which physicians and hospitals are paid for every service they provide, encourage more intervention rather than less: a C-section is more profitable to doctors and hospitals; every dose of pain mediation has a profit incentive; and drugs to induce and speed up labor can add to the bottom line…. If insurers begin to use bundled payments—one set fee for pregnancy, rather than a payment for each service—the financial incentives will begin to move toward rewarding low-cost care and high-quality results (p 2).
            With Medicaid covering 48% of all births, medical overreach via induction and cesarean section is costing tax payers millions nationwide (Howell, E., et al, 2013). Both Medicaid and private insurers are getting a poor return on their investment because maternity care plays such a major role in the healthcare system. Maternity care charges exceed those for any other condition, and cesareans are the most common operating room procedure in the U.S. (Andrews, R., 2006).

Increased Fatality
A maternity related death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. In September of 2010 the United Nations placed the United States 50th in the world for maternal mortality — with maternal mortality ratios higher than almost all European countries, and rising over the past several years (World Health Organization, 2010). The leading causes of maternal morbidity were listed as hemorrhage, blood clots and cardiovascular conditions that were all considered preventable. The CDC (2014) released a comparative report in 2014 stating that infant mortality rate was about 6.1 per 1,000 live births, placing America 26th in the world (p 2).
These numbers are staggering and tragic. In a country with full access to medical technology, clean facilities and water, and the best healthcare that money can buy, American women and their unborn children are dying at alarming rates and something must be done to get childbirth back on track.
Transforming Childbirth in America

Increasing Awareness
One issue surrounding the maternity care crisis in America is the lack of acknowledgment that there is a problem. This has changed recently with the proletarian movements of organizations like BirthNetwork, Improving Birth and The International Cesarean Awareness Network. These groups promote informed decision making, mother-friendly maternity care, and educational/emotional support. Membership is mainly driven by birth workers and experienced families who are hungry for change. Meetings and avocation help to bring evidence-based care to the forefront, making both mother-friendly care a standard.  Admitting there is a problem is the first step.

Offering Education & Support
The ins and outs of childbirth are no longer common knowledge. What you used to learn from animals in the barn, an older sister, neighbor or friend, is not provided anymore. Due to lifestyle and occupational changes over time, many women have not witnessed birth prior to their own. Providers and medical staff cannot carry the burden of teaching every family all that they need to know about pregnancy, birth, and postpartum periods, along with keeping everyone safe and healthy. Staff will also likely have other patients to attend to during labor, and cannot be expected to be present throughout the birth process of every patient.

Childbirth educators. A person that teaches new parents what to expect during pregnancy, birth, and the early weeks of parenthood is called a childbirth educator or CBE. The CBE should have experience in the field at minimum, though many are trained and certified. Organizations like CAPPA, Lamaze, and International Childbirth Education Association (ICEA)    all train and certify childbirth educators. Classes vary on the needs of the family and the style of the educator. Some may be a one day workshop course, while others may be weekly meetings lasting several months.  The main goals of these classes are to cover signs of labor and what to expect, pain management techniques, information on making informed decisions about health care, how to properly care for postpartum mothers and newborns, and generally minimizing fears for the inexperienced family.

Doulas. A doula is a woman who is trained to assist another woman during childbirth and who may provide support to the family after the baby is born, depending on her training. A birth doula focuses on emotional, physical and educational support during the birthing process, while postpartum doulas focus on support during the early weeks following the birth. Both jobs are essential to the health and well-being of a mother and her family. Recent Cochrane Reviews (2003) show that while continuous labor support was essential to positive outcomes during birth, the best results occurred when women had continuous labor support from a doula with a 31% decrease in the use of Pitocin, 28% decrease in the risk of C-section, 12% increase in the likelihood of a spontaneous vaginal birth, 9% decrease in the use of any medications for pain relief, 14% decrease in the risk of newborns being admitted to a special care nursery, 34% decrease in the risk of being dissatisfied with the birth experience. This huge benefit is another key to unlocking the puzzle of cost and safety issues (p 4).

Making Alternative Methods Safe

Birth Centers. A birth center is a facility for giving birth that focuses on family-centered care. Family and staff work together to make informed decisions. Birth centers offer a more natural approach to care in that they don’t usually do routine interventions. Recent studies have found that “for women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes” (Benatar, S., et al, 2013). Also, with a projected savings of nearly $1,163 per birth center birth, it is imperative that these facilities are made available to more women (Howell, E., et al, 2013).This is an approximate $11.6 million per year savings to the Medicaid program. (Howell, E., et al, 2013).

            Legalizing homebirth. While the number of out-of-hospital births is increasing, still about 99% of births in the U.S. occur in hospitals (MacDorman, M., 2014). The issue with this this number of non-homebirths is that these births are largely attended by obstetricians- professional surgeons. These providers are not trained in minimizing intervention of the birth process, they are trained how to properly handle any medical emergencies that may arise. However, giving birth is a normal, non-emergent event in the majority of cases. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician. Hiring surgeons to attend births has contributed to the rise in cesarean and labor induction rates in the U.S. due to their lack of training in the field of normal birth. This is compounded by the fact that midwives who are trained to attend standard birth have been banned in many states. Banning certified professional midwives, or CPMs, has actually created more risk. Without access to safe midwifery assistance, some families choose to give birth unattended, at home.  After observing nearly 17,000 cases, a recent study has confirmed that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies (Cheyney, M., et al, 2014). In her review of this study, CNM Geradine Simkins (2014) writes: “Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system” (p. 3). Creating the availability of midwifery care to all low-risk families can help Americans lower mortality rates and costs.

            Vaginal birth after cesarean section. Although many governing organizations recommend vaginal birth after cesarean for most cases, America has a nearly 90% repeat cesarean rate (CDC, 2012). A recent review of studies found “stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans” (Guise, 2010).  This is unnecessary surgery with needless risk to the mother and to the child, facilitated by gratuitous spending. In order to gain control over spending and fatality rates, regulating the availability and safety of vaginal birth after cesarean is essential. The American Academy of Obstetrics and Gynecology recently released guidelines to encourage VBAC, reducing unnecessary cesarean sections.

 Continued Healthcare Reform
            Creating coverage of homebirth midwives, doulas, and childbirth educators is essential. Doing so would save tremendous amounts of money by way of benefits of these providers that have already been discussed above. This is not just an issue that varies from individual to individual. With nearly half of all births paid for by Medicaid, the program could cut costs remarkably by paying for preventative care with appropriate education and support (Howell, E., et al, 2013). A group of midwives, obstetricians, and other stakeholders brought together by the not-for-profit Childbirth Connection, published a consensus document calls for policies allowing women to choose where to give birth, whether by midwives, family physicians, or obstetricians (Carter, M.C., et al., 2010). Notably, consumers are beginning to demand such choices. Childbirth Connection, the American College of Obstetricians, and the American Medical Association have identified the services that should be covered, and these services include a care facility that is appropriate for the patient’s maternal-fetal risk.  In spite of this advice, out-of-hospital birth is still very difficult and even impossible for some women to access which forces them into a care facility that is more invasive and more costly. Sometimes these women choose to give birth at home unattended by medical staff.

Certified Professional Midwife Ina May Gaskin (2013) offers a vivid summation of how childbirth may feel for women in the U.S.:
Where the techno-medical model of birth reigns, women who give birth vaginally generally labor in bed hooked up to electronic fetal monitors, intravenous tubes, and pressure-reading devices. Eating and drinking in labor are usually not permitted. Labor pain within this model is seen as unacceptable, so analgesia and anesthesia are encouraged. Episiotomies (the surgical cut to enlarge the vaginal opening) are routinely performed, ….Instead of being the central actor of the birth drama, the woman becomes a passive, almost inert object - representing a barrier to the baby's eventual passage to the outside world. (p. 156).
American citizens cannot be gratified with this level of care. It is important that a higher level of service is demanded, expected, and fought for. The number of deaths occurring daily must be lowered. The amount of spending on birth must decrease. Both of these goals can be achieved. One of the first steps is to provide access to appropriate care for every birthing woman, whether that be an obstetrical surgeon, doula, childbirth educator, homebirth midwife, or other care provider that supports vaginal birth after cesarean. If each woman is able to access care that is appropriate for her case, labor augmentation and cesarean rates will inadvertently come down as well. With fewer augmentation and cesarean cases, maternal and fetal mortality rates will decrease. The snowball that is maternity care reform can start with only one snowflake. The time is now.





posted by: Abby Moore, Birth Doula














Resources
Andrews, R. (2006). The National hospital bill: The Most expensive conditions by payer. HCUP    statistical review 59. Rockville, MD: Agency for healthcare and research quality.

Benatar, S., et al, (2013, October). Midwifery Care at a freestanding birth center: A Safe and

effective alternative to conventional maternity care. Health Services Research, 48(5), 1750-68.

Brink,S., (2013, August 22). Reinventing Childbirth Classes: Low-Cost Care, High-Quality
 Results. US News & World Report,  p 2.
Carter, M.C., et al. (2010).  2020 Vision for A High-Quality, high-value maternity care system.
 Women's Health Issues. 20, (1), pp 7-17.
Cheyney, M., et al., (2014, Jan/Feb). Outcomes of care for 16,924 planned home births in the
United States: The Midwives Alliance of North America statistics project, 2004 to 2009. Journal of Midwifery & Women’s Health, 59, pp 17–27.
Childbirth Connection (2012). Vaginal or cesarean birth: What is at stake for women and
 babies? New York: Childbirth Connection. 
Coeytaux, F., Bingham, D., & Strauss, N. (2011) Maternal mortality in the United States: A         Human rights failure. ARHP Contraception Journal, (March 2011).
Gaskin, I.M., (2003). Ina May's guide to childbirth. New York: Bantam Books.

Guise, JM., (2010, June). Vaginal birth after cesarean: new insights on maternal and neonatal

outcomes. Obstetrics & Gynecology: 115(6), pp 1267-1278

Hodnett E.D., Gates S., Hofmeyr G.J., Sakala C. (2012). Continuous support for women during  childbirth. Cochrane database of systematic reviews, (10), 1-2. DOI:     10.1002/14651858.CD003766.pub4.
Howell, E., et al, (2014). Potential Medicaid cost savings from maternity care based at a freestanding birth center. Medicare and Medicaid Research Review. 4, (3). p 1.
MacDorman, M.F. (2014). Trends in out-of-hospital births in the United States, 1990–2012.
 NCHS data brief, 144. Hyattsville, MD: National Center for health statistics.

Markus, A., et al, (2014). Potential Medicaid cost savings from maternity care based at a

            freestanding birth center. Medicare and Medicaid Research Review. 4(3).

Martin JA, et al, (2012). Births: Final data for 2010. National vital statistics reports; 61(1).
 Hyattsville, MD: National Center for Health Statistics.
Midwives Alliance, (2014, January 30). New studies confirm safety of homebirth with midwives
            in the U.S., Midwives Alliance of North America. pp 1.

Stoll, K., et al. (2013). Vicarious Birth Experiences and Childbirth Fear. Journal of Perinatal

            Education, 22(4): 226–233.

Tenore, J.L., (2003, May 15). Methods for cervical ripening and induction of labor. American

            Family Physician. 67(10). pp 2123-2128.

World Health Organization, (2015). WHO statement on cesarean section rates. p 2.




Wednesday, July 29, 2015

Correlation, Causation, & Skepticism

I recently read this article about mother’s weight gain during pregnancy and connection with childhood obesity, and I just can’t keep my Medical Anthropologist mouth shut.

Title: When mom gains too much weight during pregnancy, her child is more likely to be obese

Researchers in Greece: “conducted telephone interviews using a standardized questionnaire collecting information on the mother's age at pregnancy, amount of weight gained during pregnancy, pregnancy exercise level, smoking status, alcohol consumption and the body mass index of the child at the age of eight.”

And they came to the conclusion: “that the amount of weight gained throughout pregnancy, the   level of physical activity and smoking status was strongly associated with obesity in children. Moderate exercise during pregnancy was found to lower the risk of a child becoming overweight or obese in childhood, even after adjusting for the other maternal and child characteristics.”

So what’s the big deal?
First I want to say that while there MIGHT be a correlation between pregnancy weight gain and childhood obesity, that certainly does not mean there is a causal relationship between the two.  Said another way: Gaining too much weight in pregnancy might NOT cause childhood obesity.

In my professional opinion, there are so many other factors that could contribute to childhood obesity that were not looked at in this study.  Things like lifestyle, diet, current activity levels, genetics, and so many more that were not considered.  Perhaps moms who gain excess weight in pregnancy are more likely to be overweight in the first place and to continue that same lifestyle after pregnancy thus passing it on to their offspring.  Additionally, this was a retrospective study that asked mothers to recall very specific information about their pregnancy 8 years after the fact.  I have a 7 year old, and I honestly have a really hard time remembering specifics about my pregnancy with her. 

This is the problem with inflammatory headlines like this.  While they might get a lot of attention, the specious connections they are touting are not always accurate or whole pictures of what is actually happening and the risks involved. 

The point: Don’t freak out over every new claim that blames pregnant mothers for the outcomes of their children.  It isn’t always the mother’s behavior when their child was in utero that has long term effects. While that certainly is part of the picture, the whole picture is much more complicated than a simple headline can explain.



Wednesday, July 15, 2015

The Birth of Avery.

This birth story is shared with permission. Saturday, July 11 marked the three year anniversary of the first birth I attended as a doula.

I met Avery's mother the month before he was born. Another doula referred me to her. I called her as soon as I read the message, I was calling to set up an interview, doing all the things just as they were supposed to be done. Whatever that even means. Her mom answered: "the doula is on the phone!!!!" Wait what!? I am not your doula yet, you have to interview me! I didn't say that,but that's what went through my head. We set up a meeting for the next day, I was in a hurry, she was dues soon and we had much to do. I jabbered like a crazy person at our first meeting, going around in circles about this and that. She was young. Sixteen in fact. I had questions, who is in charge at the birth. Her? Her mother? I needed answers! Not really,but I harassed more seasoned doulas anyway.

I jumped a mile any time my phone made a peep. Is is Jme? Is she in labor? The day before the birth she called me to say her OB wanted to induce. I panicked. What's wrong? Is everything ok!? I raged and punched a wall a few times after we got off the phone. What kind of doctor wants to induce a perfectly healthy woman? The baby is fine. The mother is fine. Leave.Her. Alone. After I drove myself crazy for a while. I got myself to sit down and shut up. It's her birth,not mine. I am there to support,not run the show. 

The induction was set for the next day. I had to get myself together and be prepared for a potentially very long birth. I was scrambling to figure out what to put in my doula bag. I was flat broke so I couldn't by any gadgets or any "official" doula tools. I feel very silly about all this now, as I don't really use anything from my bag these days. I packed my honey bear,Moby wrap, a sandwich,phone charger,and my manuals from my doula training. I was ready as I could get. I didn't sleep at all. I was up two hours before my alarm. 

I rode to the hospital with Jme and her family. I noticed she was having contractions the whole time we were in the car. This was very exciting! Maybe her labor would take off and there would be no need for induction. Labor picked up right away, after checking in and getting settled in a room. The nurse came in and broke her water, and we were off. I was officially at my first birth. Labor picked up steadily and a stream of visitors was in and out all day. Jme labored beautifully, she was in her own space, immune to the chaos going on around her. There wasn't a lot for me to do and I didn't know what to make of that. Shouldn't I be DOING something? The answer was no, as a doula I don't always have to be doing something. Sometimes my presence is enough. Eventually she was laboring on the birthing ball and I was doing the doula's bread and butter-the double hip squeeze. At that precise moment I was a doula. Doing doula things. 

As the day went by Jme was caught up in labor, she wasn't saying a much and the contractions were requiring all of her attention. She wasn't responding to all of the commotion in the room, hearing Avery's heartbeat on the monitor was meditative for her. I noticed that she was shaking through each contraction, I whispered "are you feeling pushy?" Yes. She was. Then what I like to call the baby swat team swooped in. Doctor,tech,more nurses. It was a bright sunny afternoon,what's that spotlight doing there? Avery was earthside after very little time pushing, he wasn't Avery yet. The name hadn't been decided yet. Avery? Alekzander? Every family member had an opinion, everyone wanted to hold him. 

A mother,baby,and a doula were born that day. Though it took me a bit longer to not be the over excited new doula. 

Wednesday, July 8, 2015

Birth Doulas: How Support Could Change Childbirth in America

Birth Doulas:
How Support Could Change Childbirth in America
That first moment, when a woman and her newborn lock eyes and a child imprints upon its mother is unforgettable.  That beautiful, intense, instantaneous love that a mother feels for a person that she is only first meeting, but whom she has "known" for much longer, is incomparable.  The birth of a child is an experience like no other in a woman's life.  Ensuring that this occasion is as positive an event as possible should be taking precedence in society, should it not?  Sadly, American culture has begun to devalue mothers and the childbirth process, treating it as an everyday occurrence.  The emphasis once put on its importance seems to have waned.
Several factors have contributed to society's desensitization of the effects of birth on mothers, infants, families and even society itself.  One of those reasons is how birth has changed over time.  Birth used to happen at home, where a woman was comfortably surrounded by those that loved her, and attendant that knew how to deliver children this way-a way mentally and physically safe and healthy.  Now majority of births are occurring in hospitals, with very expensive and impersonal care that is designed to make the jobs of medical staff simpler, not to better accommodate a birthing woman or her unborn child.  A certified professional midwife named Ina May Gaskin (2003) wrote, “Most Americans are unaware that women ever die from cesarean operations, particularly when those surgeries are scheduled, rather than emergencies…Few people have any way of knowing that most maternal deaths take place in hospitals or that unnecessary surgery can actually cause a death” ( p. 288).  Another factor is the increased usage of pain medications (such as epidural analgesia), scheduled births, like inductions of labor (choosing a baby’s birthdate), augmentation of labor (using medical intervention to speed up the labor process), and cesarean sections.  This creates the feelings of a well-planned and uncomplicated event-but that is not the case at all.  Each of these choices comes with risks to both mother and child.  All too often these risks are under-explained, and their severity is underestimated.
High Mother and Infant Mortality Rates
The general public would likely be shocked to know the reality of death in childbirth. Americans take solace in the mere thought of living in such a privileged society.   Rachel Ward is the director of research at Amnesty International, a human rights organization.  Ward is the author of Deadly Delivery: The Maternal Health Care Crisis in the USA, which was published in 2011, and she understands the need for these facts to be brought to light.  Ward (2011) found that the World Health Organization’s recommended rates are nearly half as much as the current U.S rates, since there has been a sharp rise in cesareans and inductions performed in the past 25 years. (p.78).  Drug-induced labors are an estimated 23%, and the national cesarean rate at 32%.
Many organizations agree that interventions are too high, yet attempts to get them down have been unsuccessful.  Ward went on to elaborate on the risks of these interventions. In summation, she found induction of labor is related to higher risk of hemorrhage and cesarean sections in primigravida mothers (2011).  Cesareans carry their own set of significantly increased risks when compared to spontaneous vaginal birth, such as hysterectomy, kidney failure, pulmonary embolism, infection, and death (p. 78).
Rachel Ward is not alone.  Published by Francine Coeytaux, Debra Bingham, and Nan Strauss, Maternal Mortality in the United States: A Human Rights Failure (2011) also refers to the overuse of technology in childbirth.  Over the past 12 years, there has been a 56% increase in the amount of surgical births in the United States, and a sharp incline of births in which Pitocin was administered.  While there are no studies proving better outcomes, data exists showing misusing these procedures caused maternal and infant mortality rates to rise.  America is a country where access to medical care is just as big an issue as the over exposure to procedures where pregnancy and birth are concerned.  
                Moreover, these interventions are also quite expensive, and are contributing to higher maternity care costs across the board.  The same study describes how these interventions aren’t just limited to maternity care.  Performing inductions and cesarean sections when they are not advisable to improve outcomes leads to higher risk of hysterectomy (and further expenditures) in the future.
A Birth Doula’s Ability to Reduce Intervention
A birth doula is a professional support person for women and families before, during, and immediately after childbirth. A doula is trained and educated in methods of physical and emotional comfort, and has information to help women make informed decisions about maternity care. A doula may be a lay person, have taken special training, and/or be certified through organizations like ICEA, CAPPA, and DONA. While some effects are immeasurable, many clinical studies have found that doulas have a major impact on outcomes for both mother and child. 
Hodnett, Gates, Hofmeyer and Sakala (2012) showed continuous labor support to be effective in reducing the need for interventions such as pain medications/epidural analgesia, labor induction or augmentation with synthetic oxytocin (Pitocin), vacuum extraction and forceps deliveries (pp. 1-2).  All of which carry hazards to both mother and child. Risks range from mild, like chills, to more life-threatening problems like shoulder dystocia, brain damage, and hemorrhage.  Lower incidences of abuse, postpartum depression, and generally shorter, uncomplicated labors were also reported. Mothers in the study reported more pleasant feelings about their birth experiences in the doula attended group.  Perhaps more importantly, there are no known risks to mother and/or child from doula attended births.  Dr. John H. Kennell, MD is one of the founders of Doulas of North America.  Dr. Kennell (1998) once said, “if a doula were a drug, it would be unethical not to use it.”
Conclusions and Future Study

            Citizens of the United States are spending more money than necessary on maternal/fetal healthcare.  There is also a needless and preventable amount of maternal and fetal mortality/morbidity.  By providing continuous labor support to mothers and families, both costs and risks of injury and death can be driven down.  It is advisable for doulas to become an integral part of the maternal/fetal support team for each birthing woman, for the sake of cost and safety. Heidi Rinehart is a former obstetrician for Amnesty International, she says, “What works is not flashy, not expensive, but it’s human intensive” (as cited in Deadly delivery: the maternal health care crisis in the US, 2010, p. 92).

Wednesday, July 1, 2015

Informed Consent in Maternity Care

Informed consent is the process where a healthcare provider discusses any procedure before it happens with a patient.  This includes discussing all the risks, benefits, and alternatives with the patient.  Informed consent is not only a discussion, but also typically involves some paperwork.  Some of this paperwork is signed during the pre-registration process, and even more is signed while you are in labor depending on the procedures that are being suggested for intervention or augmentation. 

So what’s the big deal about informed consent in maternity care? Not all providers are equal when it comes to the informed consent discussion.  We’ve even seen some providers who are absolutely horrible at it, even performing procedures without ever getting consent.  This has recently come to a BIG discussion in the birth community, with the case of a California woman who clearly did not consent to episiotomy while her provider proceeded to cut her. This woman is now suing her doctor for assault and battery in a landmark case!

Here are some great links for informed consent in maternity care:
1.      Research paper on informed consent & access to evidence-based research
2.      North American Registry of Midwives statement oninformed consent
4.      Use of the word ALLOWED when it comes to informed consent
5.      What the American Congress of Obstetrics & Gynecology has to say about informed consent

We always encourage our clients to do research about the procedures that might be suggested to them during pregnancy and birth.  We also encourage clients to be prepared for the informed consent conversations that will inevitably come up during the course of their care. The best way that you can approach conversations with your provider is by remembering the acronym B.R.A.I.N.

Benefits
Risks
Alternatives
Intuition
Nothing

Ask these questions:
What are the benefits of this procedure?
What are the risks?
Are there any alternatives?
What is my intuition saying?
What happens if we do nothing?

As your doulas, we can also help you by talking about the research that we have done. We regularly try to keep up with the maternal medicine research that is constantly evolving, and we can tell you what we’ve found.  What we can’t do, is have the conversation with your provider for you or make the decision for you.


We want to help you make the best decisions for your care.  We want to make sure that the most recent evidence-based research is being used in your care as well.  We want you to have the best birth experience ever, but as doulas it is not our place to make decisions for you.  You have to be an active participant in your care, and being an informed consumer is one step along that path.  Providers have an ethical responsibility to utilize good informed consent procedures, but you also need to be a good healthcare consumer.  Being a good consumer means asking questions and making sure