Pediatricians’ Practices and Attitudes Regarding Breastfeeding Promotion
Richard J. Schanler, MD*; Karen G. O’Connor‡; and Ruth A. Lawrence, MD§
Pediatrics 1999;103;e35
ABSTRACT. Objective. Public awareness of the benefitsof breastfeeding is expected to increase during and after the national,federally funded Best Start BreastfeedingPromotion Campaign. It is anticipated that this will resultin more breastfeeding-based interactions between families and pediatricians. The American Academy of Pediatrics conducted a survey of its members to identify their educational needs regarding breastfeeding to assist in the design of appropriate information programs. Method. An eight-page, self-administered questionnaire was sent to 1602 active Fellows of the American Academy of Pediatrics. Results. The response rate was 71%. Breastfeeding, as the exclusive feeding practice for the first month after birth, was recommended by only 65% of responding pediatricians; only 37% recommended breastfeeding for 1 year. A majority of pediatricians agreed with or had a neutral opinion about the statement that breastfeeding and formula- feeding are equally acceptable methods for feeding infants. Reasons given for not recommending breastfeeding included medical conditions with known treatments that did not preclude breastfeeding. The majority of pediatricians (72%) were unfamiliar with the contents of the Baby-Friendly Hospital Initiative. The majority of pediatricians had not attended a presentation on breastfeeding management in the previous 3 years; most said they wanted more education on breastfeeding management. Conclusion. Pediatricians have significant educational needs in the area of breastfeeding management.
This study is one that is actually quite humorous to those of us who work with women who are nursing and have an issue that takes them to the average pediatrician. We understand not only the lack of information or education a pediatrician has regarding breastfeeding, but also the level of influence they still have on the breastfeeding relationship. Ironic that a non medical issue is one that parents still seek out medical opinions for.
This study cited that even though the big boy club of the AAP themselves promote breastfeeding as the best form of infant nutrition and encourage the infant to be fed that way, the very members of this association are failing miserably at conveying correct information to their patients parents. If the hospitals are not screwing up the relationship fairly quickly in the postpartum period, then the doctors then do their own lack of encouragement.
This study was timed to ascertain the physicians influence on breastfeeding as federally funded Best Start Breastfeeding Promotion Campaign was launched. “This campaign is targeted initially at 10 states to raise public awareness of breastfeeding through pre- and postnatal parent counseling and media promotion. Increased public awareness is expected to increase breastfeeding-related interactions between families and physicians.” They wanted to know how many of the doctors in the areas were going to be supportive of this endeavor and if they needed to do anything to help make this more likely.
The good news is this study was to “to assess breastfeeding attitudes, knowledge, and management skills of pediatricians, as well as awareness of their hospitals’ breastfeeding promotion activities. Results from this survey are expected to help in the design of appropriate breastfeeding education programs for physicians.” The bad news is the majority of the doctors definitely need more education in this area!
The conducted this study by first giving a survey to the physicians- mostly located in urban areas. The solo and group practices had better breastfeeding initiation and continuation than the clinic physicians. Tragically, only 65% of the pediatricians’ recommended exclusive breastfeeding to new parents during the early weeks of their infants’ births. 13% recommended formula supplementation while actually 2% said formula feeding was ideal. Although the AAP takes a stand on duration of exclusive breastfeeding being recommended for at least six months only 63% made any recommendation regarding duration. And only 31% made the recommendation that AAP suggested. But to be commended are the 61% who suggested the ideal time of at least one year.
Establishing breastfeeding and bonding time with the infant in the early hours after birth is a known factor in helping to increase breastfeeding success. Yet the doctors varied in their initial recommendation to do so. Only 44% recommended that the mom initiate breastfeeding in the first half hour after the birth. Only 59% suggested that demand feeding be established. Almost a quarter of the physicians were not opposed to formula or water be given to the breastfed infant. And keeping the mom and baby together by rooming in was equally divided in the study.
The use of pacifiers was only discouraged by a fourth of the doctors until breastfeeding was established. And the introduction of solids was not at the AAP recommendation either. Many recommended solids at a much younger age than 6 months. As this study states, “These infant feeding practices are known to impede successful breastfeeding and may be unnecessary.”
It was no surprise that in an office several people could be called on for phone consultations to assist new parents with breastfeeding questions. Only 76% of the time it was the doctors- who have proven they were not following suggested guidelines. Fewer than a quarter actually had lactation consultants. And few even knew how or if the staff that supplied information had ever been trained in the area of breastfeeding. Is it no wonder that misinformation was being handed out?
Only 58% of the actual physicians themselves had ever had any education regarding breastfeeding. The younger physicians (under 45 years of age) were more likely than the older physicians. And the female physicians had more training than their male counterparts. And yet although they mostly said they wanted to learn more and had not had sufficient training, 77% said they felt competent to manage common breastfeeding problems. Based on their lack of training or education in the area, it makes you wonder other areas they feel competent managing where they may also lack training and expertise.
It is no wonder that only 60% of the pediatricians had children of their own who were breastfed! Those with no personal experience were more likely to not recommend breastfeeding if the moms had common problems like breast or nipple problems- this was at 37%!
It is also no wonder that few hospitals are meeting the standard of Baby-Friendly Hospital Initiative since 72% of the doctors were unfamiliar with this initiative as well as the Ten Steps to Successful Breastfeeding statement. How can they be supportive and help promote these ideals if they are unaware of what they recommend? More then half of the doctors were unsure if there was a written policy regarding breastfeeding and if there was one what was stated within it.
The study stated, “These data suggest that the lack of clear recommendations may lead to confusion when parents question physicians about breastfeeding.” I find this an understatement. It also uncovered that very few pediatricians were even seeing their patients’ parents prenatally- where good information regarding breastfeeding could be conveyed.
The study was effective in uncovering the strong need to get the pediatricians on board with promoting breastfeeding. Helping parents prepare, initiate, be successful and continue to breastfeed is certainly an area where pediatricians can make a huge difference. But we need to get them up to speed on how to do this and it begins with more education.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Tuesday, October 13, 2009
Does Income Affect Breastfeeding.... Does a Mom's BMI?
Maternal Variables Influencing Duration of Breastfeeding Among Low-Income Mothers
Anne Chevalier McKechnie, RN, IBCLC, RLC, Audrey Tluczek, PhD, RN, and Jeffrey B. Henriques, PhD
ICAN: Infant, Child, & Adolescent Nutrition June 2009
This is my review of their study….
Who breastfeeds longer? The study was performed on low income moms. The lack of long term breastfeeding is highest in this group. What the findings showed was that moms who had a high body mass index also fed for a shorter period of time. And the moms who fed longer were also moms who breastfed more exclusively. Younger moms did not nurse as long as the older moms in this study as well.
The study was done in hopes to figure out how to improve the outcomes for breastfeeding moms to nurse for a longer period of time. It stated, “US Department of Health and Human Services established the following goals for breastfeeding by the year 2010: a 75% rate of initiation, a 50% rate of breastfeeding for 6 months, and a 25% rate of breastfeeding for 12 months.“ They set a goal to lengthen the duration of breastfeeding and to help moms exclusively breastfeed.
So, let’s look at this study. It makes sense that if you begin weaning- and weaning meaning putting anything in the baby’s mouth besides the breasts- that the breastfeeding duration will be shortened. Many mothers do not realize that sucking needs are normal and should be met at the breasts as often as possible as to increase milk supply. Instead they begin using a pacifier too quickly and too often and wonder why their milk supply dwindles. They also think that just one bottle will not make any difference to their breastfeeding relationship. It does. One bottle quickly becomes more and soon others are feeding the baby and we are trying to pump to keep our supply going when nursing would automatically do that.
Poor women are more susceptible, I suspect, since often they are forced into the work environment to survive and our government assistance offers them free formula in order to feed their baby instead of a stipend to stay home and nurse. When my own daughter qualified for the WIC program I was amazed out how often she was encouraged to take the formula they offered and start supplements sooner. So, I was not surprised to find this study also showed, “Many mothers in low-income populations participate in Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs, and numerous studies have shown that these mothers are less likely to breastfeed as compared with nonparticipants of WIC programs.”
I believe these women are also often encouraged to start solids sooner. The concern I am sure may be that the women themselves have poor nutrition, thus breast milk is compromised. But instead of providing the mom with better nutritional guidelines, the suggestion is made that she offer her infant something that is less nutritious than nursing her baby. This study indeed showed how, “the highest risk for poor health, tend to have the lowest breastfeeding rates.”
The other part of this study looked at how the B.M.I. of women affected their breastfeeding relationship with their babies. “Obesity may also adversely affect breastfeeding in several ways. First, mothers with a BMI at or above 30 kg/m2 may experience hormonal patterns that interfere with milk production.30-32 Second, the infants of obese and overweight mothers may have physical difficulty latching onto the breast.31 Finally, an elevated BMI may indirectly interfere with the initiation and duration of breastfeeding because obesity is also associated with complications of pregnancy and delivery, cesarean delivery, poor maternal self-esteem, maternal depression, and low socioeconomic status. A recent study34 found that mothers with a BMI ≥25 kg/m2 were more likely to have discontinued breastfeeding before 6 months than normal-weight mothers.”
I tried to think about how this factored into the relationships of moms and babies I had worked with over the years. Indeed I saw more women who were considered overweight having complications with their pregnancies. These complications did lead to more surgical births as well as inductions and the edema that inductions sometimes caused in the moms causing latch issues initially. I have not seen the hormonal shift issues but certainly can see where an out of balance hormonal issue can cause milk production issues as well. But recently I had a client who is obese have real issues with her third baby. She found herself unable to successfully breastfeed outside of her own home environment due to how she had to work to latch her daughter onto the breast. It was not something she could do easily or even the least bit discretely.
New moms are concerned with body image as their breasts are larger but their bellies are still on the post pregnancy form- and therefore they want to hide their bulges and are learning to manage the new larger breasts. This makes them uncomfortable initiating breastfeeding in many situations outside of their home. Part of this is how we make women feel about their bodies in general in the USA and how we make breastfeeding a sexual act instead of a natural one. But certainly not feeling good about our bodies makes us not feel good about some of the natural body functions we may have as well. Our environmental support systems are certainly lacking in regards to support for breastfeeding.
This study had a hypothesis of, “Mothers within a low-income population who chose exclusive breastfeeding would likely (a) continue breastfeeding longer than mothers, who chose partial breastfeeding, (b) be of an older age than mothers who chose partial breastfeeding, and (c) have a lower BMI than mothers who chose partial breastfeeding.”
The other factor that was mentioned in this study was age. The younger moms seemed to lack the support of their community in breastfeeding and therefore initiated breastfeeding less as well as length of time of breastfeeding was limited.
The study concluded with this statement, “Breastfeeding is a complex issue with lifelong consequences for both mother and infant. This study found that factors, such as exclusive breastfeeding, older maternal age, and lower BMI, were associated with longer breastfeeding duration. These findings move us closer to understanding the unique needs of low-income, WIC, breastfeeding mothers and support the notion that maternal readiness and capacity for breastfeeding are influenced by dynamic biopsychosocial processes.”
I wonder if we had more pictures of younger moms nursing their babies in ads, women who overweight were nursing their babies, and moms in general nursing in more public areas in ads and government promotional materials, if we would increase these numbers for both initiating breastfeeding as well as duration of nursing exclusively. I wonder if we increased awareness to the communities of the benefits of breastfeeding if we would see the support change in the communities to support all women and babies in breastfeeding.
When as a lactation educator I am still counteracting the negative and detrimental things that are being done in the hospitals to sabotage breastfeeding, in the WIC offices to undermine the moms and in the communities that still want to banish women and their nursling to the bathrooms to nurse, if BMI and socioeconomic conditions are just a drop in the bucket as to why breastfeeding numbers are dwindling in the US.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Anne Chevalier McKechnie, RN, IBCLC, RLC, Audrey Tluczek, PhD, RN, and Jeffrey B. Henriques, PhD
ICAN: Infant, Child, & Adolescent Nutrition June 2009
This is my review of their study….
Who breastfeeds longer? The study was performed on low income moms. The lack of long term breastfeeding is highest in this group. What the findings showed was that moms who had a high body mass index also fed for a shorter period of time. And the moms who fed longer were also moms who breastfed more exclusively. Younger moms did not nurse as long as the older moms in this study as well.
The study was done in hopes to figure out how to improve the outcomes for breastfeeding moms to nurse for a longer period of time. It stated, “US Department of Health and Human Services established the following goals for breastfeeding by the year 2010: a 75% rate of initiation, a 50% rate of breastfeeding for 6 months, and a 25% rate of breastfeeding for 12 months.“ They set a goal to lengthen the duration of breastfeeding and to help moms exclusively breastfeed.
So, let’s look at this study. It makes sense that if you begin weaning- and weaning meaning putting anything in the baby’s mouth besides the breasts- that the breastfeeding duration will be shortened. Many mothers do not realize that sucking needs are normal and should be met at the breasts as often as possible as to increase milk supply. Instead they begin using a pacifier too quickly and too often and wonder why their milk supply dwindles. They also think that just one bottle will not make any difference to their breastfeeding relationship. It does. One bottle quickly becomes more and soon others are feeding the baby and we are trying to pump to keep our supply going when nursing would automatically do that.
Poor women are more susceptible, I suspect, since often they are forced into the work environment to survive and our government assistance offers them free formula in order to feed their baby instead of a stipend to stay home and nurse. When my own daughter qualified for the WIC program I was amazed out how often she was encouraged to take the formula they offered and start supplements sooner. So, I was not surprised to find this study also showed, “Many mothers in low-income populations participate in Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs, and numerous studies have shown that these mothers are less likely to breastfeed as compared with nonparticipants of WIC programs.”
I believe these women are also often encouraged to start solids sooner. The concern I am sure may be that the women themselves have poor nutrition, thus breast milk is compromised. But instead of providing the mom with better nutritional guidelines, the suggestion is made that she offer her infant something that is less nutritious than nursing her baby. This study indeed showed how, “the highest risk for poor health, tend to have the lowest breastfeeding rates.”
The other part of this study looked at how the B.M.I. of women affected their breastfeeding relationship with their babies. “Obesity may also adversely affect breastfeeding in several ways. First, mothers with a BMI at or above 30 kg/m2 may experience hormonal patterns that interfere with milk production.30-32 Second, the infants of obese and overweight mothers may have physical difficulty latching onto the breast.31 Finally, an elevated BMI may indirectly interfere with the initiation and duration of breastfeeding because obesity is also associated with complications of pregnancy and delivery, cesarean delivery, poor maternal self-esteem, maternal depression, and low socioeconomic status. A recent study34 found that mothers with a BMI ≥25 kg/m2 were more likely to have discontinued breastfeeding before 6 months than normal-weight mothers.”
I tried to think about how this factored into the relationships of moms and babies I had worked with over the years. Indeed I saw more women who were considered overweight having complications with their pregnancies. These complications did lead to more surgical births as well as inductions and the edema that inductions sometimes caused in the moms causing latch issues initially. I have not seen the hormonal shift issues but certainly can see where an out of balance hormonal issue can cause milk production issues as well. But recently I had a client who is obese have real issues with her third baby. She found herself unable to successfully breastfeed outside of her own home environment due to how she had to work to latch her daughter onto the breast. It was not something she could do easily or even the least bit discretely.
New moms are concerned with body image as their breasts are larger but their bellies are still on the post pregnancy form- and therefore they want to hide their bulges and are learning to manage the new larger breasts. This makes them uncomfortable initiating breastfeeding in many situations outside of their home. Part of this is how we make women feel about their bodies in general in the USA and how we make breastfeeding a sexual act instead of a natural one. But certainly not feeling good about our bodies makes us not feel good about some of the natural body functions we may have as well. Our environmental support systems are certainly lacking in regards to support for breastfeeding.
This study had a hypothesis of, “Mothers within a low-income population who chose exclusive breastfeeding would likely (a) continue breastfeeding longer than mothers, who chose partial breastfeeding, (b) be of an older age than mothers who chose partial breastfeeding, and (c) have a lower BMI than mothers who chose partial breastfeeding.”
The other factor that was mentioned in this study was age. The younger moms seemed to lack the support of their community in breastfeeding and therefore initiated breastfeeding less as well as length of time of breastfeeding was limited.
The study concluded with this statement, “Breastfeeding is a complex issue with lifelong consequences for both mother and infant. This study found that factors, such as exclusive breastfeeding, older maternal age, and lower BMI, were associated with longer breastfeeding duration. These findings move us closer to understanding the unique needs of low-income, WIC, breastfeeding mothers and support the notion that maternal readiness and capacity for breastfeeding are influenced by dynamic biopsychosocial processes.”
I wonder if we had more pictures of younger moms nursing their babies in ads, women who overweight were nursing their babies, and moms in general nursing in more public areas in ads and government promotional materials, if we would increase these numbers for both initiating breastfeeding as well as duration of nursing exclusively. I wonder if we increased awareness to the communities of the benefits of breastfeeding if we would see the support change in the communities to support all women and babies in breastfeeding.
When as a lactation educator I am still counteracting the negative and detrimental things that are being done in the hospitals to sabotage breastfeeding, in the WIC offices to undermine the moms and in the communities that still want to banish women and their nursling to the bathrooms to nurse, if BMI and socioeconomic conditions are just a drop in the bucket as to why breastfeeding numbers are dwindling in the US.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Saturday, October 10, 2009
Melia Gives Birth
Melia had her first baby using pain medication- I can't remember the details- hopefully she will share them in the comments... She then took my childbirth class and hired one of the LOL doulas and had a home birth. This time she hired a local doula- an excellent one I might add- and took the Birthing Again classes that I teach. They chose to give birth at Athens Regional using the wonderful midwifery group that supports women there. I read her birth story and asked if we could please post it here to share with you. She happily agreed!
Sunday, September 13, 2009
Birth Story of Noah Told By His Mom
My version of Noah's birth story
-by Lindsay
Noah's due date was August 20th, 2009. Throughout my pregnancy I kept thinking/hoping he'd be late so I could attend my brother, Mark's, wedding on August 22nd. Maybe all my pep talks worked because he stayed put! Then, on Monday August 24th I went to my final prenatal appointment. My midwife, Margaret, said I was about 1-2 cm dilated and 80% effaced. She could feel my belly contracting and thought I might be in early labor. They did a non stress test to check out Noah's heart beat and track my contractions. It went just fine. I left the office thinking I'd probably be back for another appointment the following week.
Wednesday, August 19, 2009
Parts of the Puzzle that Make for a Good Outcome
Recently a local childbirth educator made a comment that students in her classes had the average cesarean rate of consistently 10-12%. I thought wow that is great- I have never kept statistics on my students. I have kept statistics on my doula clients- over the last year my primary cesarean rate has been 8% and all of the cesareans- not including planned ones for things like placenta previa- but including women who had previous cesareans had only been 12%. But it made me think of all of the pieces of that go into the puzzle that makes for a "good" outcome. I realize "good" is a subjective word- so for the sake of this blog article, I will classify "good" as non interventive or at least having only the interventions you as a consumer choose.
Often times a couple who chooses our classes- certainly different than the "normal" hospital "how to be a good patient" classes. So they are usually looking for a different approach- perhaps in an attempt to have "their" birth experience- not the hospitals or their care providers. They are usually open to hearing new ideas that will help expand the ideas they are already developing on their own.
Often times a couple who chooses our classes are not choosing the "normal" birth experience and therefore has either chosen a care provider who is open to stepping outside of the "norm" or soon figure out from the class and their own exploration that the provider they have chosen will need to either get on board or they will need to find a new one.
Often times a couple who chooses our classes are not reading "What to Expect When You are Expecting," or "The Girlfriends Guide to Pregnancy and Birth." They are reading books like "Birthing From Within" and "Ina May's Guide to Childbirth." They are refusing to believe the view that you follow protocol even when it is not what you want.
Often times a couple who chooses our classes are considering their support team carefully. They either surround themselves with family and friends who are on the same page- or they choose to hire a doula. The added support of a doula is definitely documented in numerous studies to make a real positive difference in birth outcomes.
So I choose to believe that my classes- our classes at Labor of Love offer one more piece of the exploration process for a couple to consider in their journey to parenting. My mom used to tell me if you take credit for all of your kids positive characteristics, you must also take credit for the bad ones. I choose to be happy about the characters of my children- and will praise them- hoping that I did influence them but fall just short of claiming credit!
My advice is to prepare for your birth as much as you prepared for other important, life changing experiences in your life up to this point. Choose your care provider carefully. Choose your support team carefully. Choose how you educate yourself carefully. Blend all of this together and you will likely have a "good" birth experience and one where you can take full credit for the choices you made along the way.
Often times a couple who chooses our classes- certainly different than the "normal" hospital "how to be a good patient" classes. So they are usually looking for a different approach- perhaps in an attempt to have "their" birth experience- not the hospitals or their care providers. They are usually open to hearing new ideas that will help expand the ideas they are already developing on their own.
Often times a couple who chooses our classes are not choosing the "normal" birth experience and therefore has either chosen a care provider who is open to stepping outside of the "norm" or soon figure out from the class and their own exploration that the provider they have chosen will need to either get on board or they will need to find a new one.
Often times a couple who chooses our classes are not reading "What to Expect When You are Expecting," or "The Girlfriends Guide to Pregnancy and Birth." They are reading books like "Birthing From Within" and "Ina May's Guide to Childbirth." They are refusing to believe the view that you follow protocol even when it is not what you want.
Often times a couple who chooses our classes are considering their support team carefully. They either surround themselves with family and friends who are on the same page- or they choose to hire a doula. The added support of a doula is definitely documented in numerous studies to make a real positive difference in birth outcomes.
So I choose to believe that my classes- our classes at Labor of Love offer one more piece of the exploration process for a couple to consider in their journey to parenting. My mom used to tell me if you take credit for all of your kids positive characteristics, you must also take credit for the bad ones. I choose to be happy about the characters of my children- and will praise them- hoping that I did influence them but fall just short of claiming credit!
My advice is to prepare for your birth as much as you prepared for other important, life changing experiences in your life up to this point. Choose your care provider carefully. Choose your support team carefully. Choose how you educate yourself carefully. Blend all of this together and you will likely have a "good" birth experience and one where you can take full credit for the choices you made along the way.
Thursday, July 30, 2009
Lamaze Six Healthy Birth Practices
Lamaze has done a great job with this ...
Common sense tells us and research confirms that the Six Lamaze Healthy Birth Practices featured in these video clips and print materials are tried-and-true ways to make birth as safe and healthy as possible.
Check out this page for some great video clips and even some printable material!
This is definitely worth your time to check this out!
Common sense tells us and research confirms that the Six Lamaze Healthy Birth Practices featured in these video clips and print materials are tried-and-true ways to make birth as safe and healthy as possible.
Check out this page for some great video clips and even some printable material!
This is definitely worth your time to check this out!
Sunday, July 26, 2009
The hardest part of being a doula- part 2
I have written before about being on call being a difficult issue for doulas. Many times I get a call from someone wanting to be a doula. But besides the erratic schedules, the need for excellent childcare and a supportive partner- it is essential they understand the idea of being on call. We are on call "officially" for the due month- which is 38 weeks to 42 weeks- but of course if a mom goes prematurely we make sure she has a doula, even if her primary is not available. But there was a conversation today that I wanted to share with you.
When you are a doula, you may be hire months in advance of the woman's due month. We have folks who hire us as early as 12 weeks- we will not accept a retainer prior to this time. But things come up sometimes unexpectedly. I am not talking about illness or family emergencies- I mean things like a friend's wedding, a special concert, a last moment opportunity for a vacation, etc. But in Labor of Love's business workings- we ask that when you are hired by a couple, you are fully available during her due month- meaning those things you want to do that arise are back burnered to the mom in labor. The exception to this is of course if when you are hired- you enlighten a couple to a possible date conflict within their due month and they hire you irregardless- knowing you will have a back up in place when that special event occurs.
Well we discussed as a group today the idea of a couple hiring the group- not a specific doula. We came by this idea based on two things. First since this is a difficult if not the most difficult part of doula work it would make our lives so much easier if we knew specific days we would be on call and days we could be free to do other things without worry about not being there for a mom. Second,we get couples all the time who attend the Meet the Doula Tea and say they would be be happy with any of us.
But as we discussed the logistics of offering this as a potential service at a lower rate than the average doula in our group, we realized it benefited us as doulas but was not in the best interest of the couples. Already moms often have no idea who will be the care provider on call when they go into labor. In fact there are several groups who now share call with other groups- meaning you will not have ever even met the doctor who shows up to catch your baby- he or she has never read your birth plan- has no idea what your birth ideals are- and really is not that concerned about it. Their job is to show up and catch your baby and make medical decisions for you but is not invested in your birth experience outside of that.
Often times a woman will even entertain the idea of induction with all of those risks in order to get her preferred doctor. Although that is not guaranteed either since often inductions go longer than expected and the shift change of on call changes too. The last thing we would want is someone to consider an induction to get their favorite doula who would be on call. The risk of induction is somehow out weighed by the familiarity of desire for those who will attend her. This is awful.
Continuity of care is something we offer. We will stay with you during the duration of your labor- no matter how long. I talked with a doula with another group in town recently who has small children- she said she would not be able to attend a mom irregardless of the length of her labor... she said she would call another "fresh" doula in place. We may call in help to allow us a power nap with the mom still fully supported- at no additional cost to the mom- if her labor went unusually long- but that is rare. We have found we make 97% of our births- the other 3% are covered during those rare occasions when an emergency arises for the primary doula- by a back up doula. The fantastic thing about our company is we have several wonderful doulas who folks get to have met at the teas we do bimonthly.
Penny Simkin was quoted in a publication the IHS Provider page 155 "Doulas “hold women” by supporting them emotionally during their pregnancy, labor, and birth. The doula meets with her expectant mother one or more times before the birth and discusses the mother’s expectations or ideas of what the birth will be like, and issues of importance, such as pain medication preferences or infant feeding choices. During these meetings the doula supplements information the mother has learned in prenatal classes and explores misinformation she may have gleaned from what she has heard or read. The doula empowers the client to eat well, observe healthy lifestyle practices, and exercise, all to prepare for a healthy and positive birth experience. A doula may use this time to enhance communication within the woman’s support network, including family and partner, and/or may give advice about how to communicate effectively with the medical staff.
During early labor, the doula and her birthing partner stay in close contact until the mother needs additional support, at which time the doula will join her, meeting the mother at her birth place. She will then stay throughout the entire labor and birth and for up to two hours during the postpartum period. She will talk about normal contractions with the mother and will provide an objective viewpoint. Knowledge of what is normal replaces fear of the unknown. The doula listens to the mother and responds to her needs. The presence of the doula, who is calm and committed to the mother’s well-being, counteracts the effects of elevated stress hormones (adrenaline and noradrenaline), which are released when the mother becomes anxious, fearful, or insecure. A trusting, relaxed mother is able to continue producing oxytocin, which then keeps the labor in its normal rhythm, with the perception of pain diminished greatly. Most importantly, the doula lessens the anxiety of the laboring woman with quiet reassurance and enhancement of the unique talents and strengths the laboring mother brings to the birth."
And at Labor of Love we agree."She will then stay throughout the entire labor and birth and for up to two hours during the postpartum period."
That relationship, "supporting them emotionally during their pregnancy, labor, and birth." is essential and one we are not willing to compromise by having a varying and rotation of doulas on call for the mom. We love having a well established relationship built prior to the labor and birth. We love the phone calls, the personal talks, the emails along the journey.
So, although it would make our lives easier- we realized it would not be easier for the moms themselves. We want to be the consistent,non variable support to couples in their labor and birth. We want them to know we will do our very best to be with them- the doula they selected as their primary- and insure that is our goal. If it makes our life a bit more difficult, then so be it- we love the work we do. For us it is our calling. We love being with women in birth. We feel blessed to do it. Our families are understanding although it is difficult for them at times. But if they love us and they understand our work is in our hearts and gives us that which we need- they support us none the less.
So, know where our hearts are- with you... for you... in support of you.
When you are a doula, you may be hire months in advance of the woman's due month. We have folks who hire us as early as 12 weeks- we will not accept a retainer prior to this time. But things come up sometimes unexpectedly. I am not talking about illness or family emergencies- I mean things like a friend's wedding, a special concert, a last moment opportunity for a vacation, etc. But in Labor of Love's business workings- we ask that when you are hired by a couple, you are fully available during her due month- meaning those things you want to do that arise are back burnered to the mom in labor. The exception to this is of course if when you are hired- you enlighten a couple to a possible date conflict within their due month and they hire you irregardless- knowing you will have a back up in place when that special event occurs.
Well we discussed as a group today the idea of a couple hiring the group- not a specific doula. We came by this idea based on two things. First since this is a difficult if not the most difficult part of doula work it would make our lives so much easier if we knew specific days we would be on call and days we could be free to do other things without worry about not being there for a mom. Second,we get couples all the time who attend the Meet the Doula Tea and say they would be be happy with any of us.
But as we discussed the logistics of offering this as a potential service at a lower rate than the average doula in our group, we realized it benefited us as doulas but was not in the best interest of the couples. Already moms often have no idea who will be the care provider on call when they go into labor. In fact there are several groups who now share call with other groups- meaning you will not have ever even met the doctor who shows up to catch your baby- he or she has never read your birth plan- has no idea what your birth ideals are- and really is not that concerned about it. Their job is to show up and catch your baby and make medical decisions for you but is not invested in your birth experience outside of that.
Often times a woman will even entertain the idea of induction with all of those risks in order to get her preferred doctor. Although that is not guaranteed either since often inductions go longer than expected and the shift change of on call changes too. The last thing we would want is someone to consider an induction to get their favorite doula who would be on call. The risk of induction is somehow out weighed by the familiarity of desire for those who will attend her. This is awful.
Continuity of care is something we offer. We will stay with you during the duration of your labor- no matter how long. I talked with a doula with another group in town recently who has small children- she said she would not be able to attend a mom irregardless of the length of her labor... she said she would call another "fresh" doula in place. We may call in help to allow us a power nap with the mom still fully supported- at no additional cost to the mom- if her labor went unusually long- but that is rare. We have found we make 97% of our births- the other 3% are covered during those rare occasions when an emergency arises for the primary doula- by a back up doula. The fantastic thing about our company is we have several wonderful doulas who folks get to have met at the teas we do bimonthly.
Penny Simkin was quoted in a publication the IHS Provider page 155 "Doulas “hold women” by supporting them emotionally during their pregnancy, labor, and birth. The doula meets with her expectant mother one or more times before the birth and discusses the mother’s expectations or ideas of what the birth will be like, and issues of importance, such as pain medication preferences or infant feeding choices. During these meetings the doula supplements information the mother has learned in prenatal classes and explores misinformation she may have gleaned from what she has heard or read. The doula empowers the client to eat well, observe healthy lifestyle practices, and exercise, all to prepare for a healthy and positive birth experience. A doula may use this time to enhance communication within the woman’s support network, including family and partner, and/or may give advice about how to communicate effectively with the medical staff.
During early labor, the doula and her birthing partner stay in close contact until the mother needs additional support, at which time the doula will join her, meeting the mother at her birth place. She will then stay throughout the entire labor and birth and for up to two hours during the postpartum period. She will talk about normal contractions with the mother and will provide an objective viewpoint. Knowledge of what is normal replaces fear of the unknown. The doula listens to the mother and responds to her needs. The presence of the doula, who is calm and committed to the mother’s well-being, counteracts the effects of elevated stress hormones (adrenaline and noradrenaline), which are released when the mother becomes anxious, fearful, or insecure. A trusting, relaxed mother is able to continue producing oxytocin, which then keeps the labor in its normal rhythm, with the perception of pain diminished greatly. Most importantly, the doula lessens the anxiety of the laboring woman with quiet reassurance and enhancement of the unique talents and strengths the laboring mother brings to the birth."
And at Labor of Love we agree."She will then stay throughout the entire labor and birth and for up to two hours during the postpartum period."
That relationship, "supporting them emotionally during their pregnancy, labor, and birth." is essential and one we are not willing to compromise by having a varying and rotation of doulas on call for the mom. We love having a well established relationship built prior to the labor and birth. We love the phone calls, the personal talks, the emails along the journey.
So, although it would make our lives easier- we realized it would not be easier for the moms themselves. We want to be the consistent,non variable support to couples in their labor and birth. We want them to know we will do our very best to be with them- the doula they selected as their primary- and insure that is our goal. If it makes our life a bit more difficult, then so be it- we love the work we do. For us it is our calling. We love being with women in birth. We feel blessed to do it. Our families are understanding although it is difficult for them at times. But if they love us and they understand our work is in our hearts and gives us that which we need- they support us none the less.
So, know where our hearts are- with you... for you... in support of you.
Saturday, July 25, 2009
ACOG changes their tune on inductions
We know that inductions can lead to two problems- babies who were truly not ready and due date guesses that were wrong- leading to a baby who needs help and therefore earns a stay in the nursery or NICU. Or a mom whose body was not ready and her body did not comply with being forced into labor and therefore her failed induction led to a surgical birth by cesarean. I adore the Cochrane Datebase of evidence practiced medicine. And I adore Medscape which reports new guidelines by the medical societies set up by their specialties- the ACOG guidelines have now changed regarding inductions. I wonder if this was due to the ever increasing premature infants that are being born across the US and also the escalating cesarean birth rates.
So read ahead the newest guidelines regarding induction:
July 23, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, "Induction of Labor," in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.
Benefits vs Risks of Labor Induction
For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.
The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.
"There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut," coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. "And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home."
Recommendations Based on Sound Evidence
Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.
The bulletin authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents to identify pertinent English-language articles published between January 1985 and January 2009. Although articles reporting results of original research were given priority, review articles and commentaries were also consulted, as were guidelines published by organizations or institutions such as ACOG and the National Institutes of Health. However, abstracts of research presented at symposia and scientific conferences were excluded. Expert opinions from obstetrician- gynecologists were used when reliable research evidence was not available.
Indications for Labor Induction
Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.
Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.
When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.
The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.
Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.
Clinical Recommendations
Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:
* For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
* When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
* Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
* For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
* For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
* In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
* The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.
An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.
As a proposed performance measure, the guidelines authors suggest that the percentage of patients in whom gestational age is established by clinical criteria when labor is induced for logistic or psychosocial indications.
"A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," Dr. Ramin concluded. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."
Obstet Gynecol. 2009;114:386- 397.
Authors and Disclosures
Journalist
Laurie Barclay, MD
Laurie Barclay, MD, is a freelance writer and reviewer for Medscape.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
So read ahead the newest guidelines regarding induction:
July 23, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, "Induction of Labor," in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.
Benefits vs Risks of Labor Induction
For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.
The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.
"There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut," coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. "And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home."
Recommendations Based on Sound Evidence
Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.
The bulletin authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents to identify pertinent English-language articles published between January 1985 and January 2009. Although articles reporting results of original research were given priority, review articles and commentaries were also consulted, as were guidelines published by organizations or institutions such as ACOG and the National Institutes of Health. However, abstracts of research presented at symposia and scientific conferences were excluded. Expert opinions from obstetrician- gynecologists were used when reliable research evidence was not available.
Indications for Labor Induction
Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.
Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.
When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.
The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.
Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.
Clinical Recommendations
Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:
* For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
* When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
* Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
* For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
* For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
* In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
* The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.
An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.
As a proposed performance measure, the guidelines authors suggest that the percentage of patients in whom gestational age is established by clinical criteria when labor is induced for logistic or psychosocial indications.
"A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," Dr. Ramin concluded. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."
Obstet Gynecol. 2009;114:386- 397.
Authors and Disclosures
Journalist
Laurie Barclay, MD
Laurie Barclay, MD, is a freelance writer and reviewer for Medscape.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Tuesday, July 21, 2009
Real Savvy Women
A few years ago I had the pleasure of being a part of a PBS special show about doulas. Here is the link you can view and enjoy!
I was interviewed a few years ago with a client who I have been the doula for two times previously. Here is a video online you can access to see it! http://www.realsavvymoms.com/season-5/episode-2/doulas/
If the link stops working above- then go to
Real Savvy Moms is the location of the video- I wish I could upload it but it won't upload here- so go to this link- click on watch videos on the left hand sidebar. Then click on pregnancy. Then in the section at the top in the middle- it says search by topic. Put in Doulas. Then click on Doulas. The segment has Penny Simkin in it as well as me!
It is the video we usually show at our teas. Hope you can figure this convoluted way of finding it to watch it.
I was interviewed a few years ago with a client who I have been the doula for two times previously. Here is a video online you can access to see it! http://www.realsavvymoms.com/season-5/episode-2/doulas/
If the link stops working above- then go to
Real Savvy Moms is the location of the video- I wish I could upload it but it won't upload here- so go to this link- click on watch videos on the left hand sidebar. Then click on pregnancy. Then in the section at the top in the middle- it says search by topic. Put in Doulas. Then click on Doulas. The segment has Penny Simkin in it as well as me!
It is the video we usually show at our teas. Hope you can figure this convoluted way of finding it to watch it.
Friday, July 10, 2009
New Educational Tools
A great new resource! Childbirth Preparation videos
This is a collaboration by InJoy Birth & Parenting Videos in partnership with Lamaze International and brings the Six Lamaze Healthy Birth Practices to life. Check them out!
This is a collaboration by InJoy Birth & Parenting Videos in partnership with Lamaze International and brings the Six Lamaze Healthy Birth Practices to life. Check them out!
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