Friday, November 20, 2015

Why $175-$200 is not too much for an eight hour, private/independent, childbirth education class.

Often, childbirth educators are asked why their fees for private/independent childbirth education classes are so high – meaning over $100.  After all, hospitals generally charge less for the same service.  What is the difference?  Here’s some fuel to help you when these discussions arise:

Quality of educator
The quality of the educator may be the same for either the hospital based childbirth education class as the private class.  Hospitals tend to require nurses to teach the childbirth classes, and there may or may not be a further requirement for those nurses to be certified childbirth educators.  Is certification as a childbirth educator necessary?  Absolutely!  In nursing school, the nurses learn about complications of labor and birth but very little about a “normal” or physiologic birth.  They also do not focus on adult learning or nonpharmacologic pain relief.  Some hospitals pay for their employees to become certified, while private educators must pay for their own certification.  Certification is not easy or cheap, and so being certified shows dedication to the field and to competency.  So regardless of what type of class is chosen, the best quality of the childbirth educator is that of certification.

Teaching Tools
An educator working in the hospital setting may have a large variety of models, charts and DVDs to help in the teaching process.  These items have been purchased by the hospital.  However, the private educator must purchase her own models, charts and DVDs and also be responsible for purchasing new ones when the material becomes outdated.

Education Curriculum
Educators follow a curriculum either written by them or for them.  In a hospital setting, often the curriculum is approved by educational committees, and follow the policies and procedures set forth by the hospital.  This curriculum may or may not reflect the most current evidence-based research.  Private/independent educators who keep current as to the latest research may constantly update their teaching curriculum to reflect this latest research.

Colateral Expenses
Both the hospital educator and private/independent educator may spend money on expenses such as child care,  and gas for the car driven to and from the location of the class.  One expense item that hospital educators don't have and private/independent educators may have is location to hold the class.  Some locations can be obtained free of charge while others are a rate by hour.  Private/independent educators who teach in their clients' homes or in their own homes do not have this expense.

Hospital childbirth education classes are rarely profitable for a hospital, due to the low cost charged.  That is why for more and more hospitals today, childbirth classes have been shortened to two short days or one day in an effort to become more sustainable.  By shortening the length of the childbirth education classes, a limit to the amount of information given to expectant parents is imposed. Not only, then, is information limited but also time for practicing relaxation or breathing techniques or even viewing DVDs that can further reach the variety of adult learners. 

So for $60, a hospital may provide a childbirth education class.  Parents need to assess the qualifications of the educator and the quality of the class itself.  In serious consideration of  the options available in the community for childbirth education, a private/independent childbirth education class does have significant benefits.

Thursday, November 19, 2015

How a Kim Kardashian pregnancy could help maternity care

Perhaps it is because I get news alerts delivered to my in box about pregnancy or childbirth.  Or perhaps there really ISN'T anything else in the world to talk about than Kim Kardashian being pregnant.  Whatever it is, I am somewhat weary of Kim and her pregnancies.

What if Kim actually took her opportunity as an expectant parent to do something positive for maternity care?

What if she not only talked about the aches and pains and morning sickness of pregnancy, but also highlighted for women what can be done to lessen these discomforts of pregnancy?

What if she focused not on her 40+ lb weight gain but on what a healthy diet looks like for expectant women?  What optimum exercise looks like?

What if she went to childbirth education class and chronicled her learning about pregnancy and childbirth?  

What if she promoted childbirth education?  Not just one organization, but education as a whole?

What if she also promoted going to infant care, infant feeding/breastfeeding classes, postpartum classes, and researched postpartum mood and anxiety disorders?

What if Kim Kardashian actually used her fame to change the way society looks at maternity care?

Somehow, I believe her legacy would mean a whole lot more than it does right now.

Tuesday, November 17, 2015

Bullies in the Birth Profession: Shining light on a dirty little secret

I recently read the article "I loved being a midwife but bullying, stress and fear made me resign." The things that the midwife/author said evoked such a feeling of sadness.  As I began to consider the phenomenon of bullies, I understood that bullies are in every part of life.  But there is a part of me that asks, "Why maternity care?  We are better than that!".

Identifying the Bully Tactics
While bullies exists in nearly every part of life, the way in which bullies work varies.  In a 2009 article in the Journal of Perinatal Education, Susan Hodges says this about bully tactics: 

Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient's self-esteem while enhancing the abuser's sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a “patient.” Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

Work place bullies
As the coordinator of one of the first hospital-based doula programs in the United States in the
mid-1990s, I experienced first hand bullies in the workplace.  A nurse manager would say things to me like (after a difficult labor ending in a cesarean), "Well, your doulas didn't do their magic this time." or "Don't let your doulas whisper in the labor room, I know they are talking about me."  As Hodge points out, we are socialized to see health care professionals as trustworthy and demonstrating professional behavior.  No one would expect a nurse manager in labor and delivery to act with such disdain. Or at least I didn't.

Peer bullies
Bullying takes place between midwives, childbirth educators, doulas, lactation - really anyone in any profession!  Fellow birth researcher from Australia, Carolyn Hastie wrote about how peer bullying can take a dark turn:

"Jodie was one of those 'bright young things' that older, cynical midwives knowingly smile at each other about and comment how they were like that once. Enthusiastic, passionate about her work, talented and committed to learning as much as she could about her chosen profession, Jodie was equally committed to improving the situation for the women and babies in her care. Jodie went to every conference and workshop possible within the limitations imposed by shift work and rosters. Those of us who knew Jodie were aware of the difficulties she experienced as she sought to influence practices and improve care for women and their babies in the institution in which she worked. Instead of support, interest and encouragement from the institution and its management, Jodie met hostility, criticism and intimidation. Comments such as 'what would you know, you are only a new graduate, I've been doing it this way for "x" number of years' were common responses to her suggestions and ideas based on her rapidly accruing knowledge. Jodie developed a deep sense of isolation and despair. Gradually her confidence was shattered. Continued criticism and disparagement led her to doubt her value and abilities."

Bullies to patients/laboring women
Verbal and physical abuse of laboring women is a reality.  Examples of bullying in the birth room includes beginning procedures without informed consent, not stopping the procedure when asked for information by the laboring mother or her support team, misrepresentation of medical situations, and threats such as "if you don't do this, your baby will die."  In a true bully situation, this lack of informed consent and listening to the patient may contribute to the high rate of interventions and traumatic birth experiences, according to Hodges.

Side effects of bullying
Some adults who are targets of bully tactics can compartmentalize such behavior and deal successfully with it.  Others may experience physical illness, psychological depression and permanent debilitation, such as what happened with Hastie's story of Jodie the midwife.

But the side effects of bullying can be much more wide spread.  According to an article in The Clinical Teacher, the UK's NHS has shown that bullying can undermine the effectiveness of the workplace environment, and have serious implication on the delivery of care.

What can you do?
First, be aware of the behaviors of a bully.  If you witness a bully scenario between a health care person and patient, remind the patient that they have the right to change nurses or other health care person.  If you are a childbirth educator or doula who typically sees women prior to them going into labor, let them know about the rights of childbearing women and also about informed consent. Additionally, become familiar with the Mother-Friendly Childbirth Initiative from the Coalition for Improving Maternity Services - particularly the portions that deal with normalcy of the birthing process, empowerment and autonomy.  Lastly, find out about any grievance policies involving the parties.  Reach out to administrators or organizational governing bodies for assistance.

If you are the object of a bully situation, be mindful of your actions, your words and your tone. Do not antagonize the bully, stay with the facts and after the interaction, have someone with whom you can debrief. Bullies practice their behavior for many reasons including cultural, social, family and personal history or the desire to have power over persons perceived as weaker.  Understand the difference between bullying and harassment plus identify strategies that work for you to get you through the situation(s).  Take care of you.

Monday, November 16, 2015

Empowering Expectant Women vs Social Media Shaming of Weight Gain

A study from the Centers for Disease Control and Prevention, released Nov 5, 2015 says that nearly half of mothers in the United State gain too much weight during pregnancy.  The study involved over 3 million US women who were pregnant during 2012-2013.  Only 46 states (including the District of Columbia) of the 50 states were included in the study. 
It is logical to see that increased gestational weight gain contributes to larger babies as well as prolonged loss of pregnancy weight during the postpartum period.  Some studies go farther to implicate obesity as a complication of pregnancy, carrying with it the increased need for interventions.

Is this empowering women to eat a healthy diet or using social media to shame American
women for their food choices?  If the latter is true, how are American women expected to know nutritional parameters for pregnancy?  This type of information is not typically included in a prenatal office visit.  If childbirth education classes are encouraged or suggested, few classes include such information.

As with many news features that indicate a crisis in American prenatal health care, it seems that many of these media perceived crises could be solved to a large extent with comprehensive, evidence-based childbirth education.  Ideally, childbirth education classes should include not only the typical anatomy and physiology of pregnancy, labor and birth but also basic nutrition, fluid intake and exercise tips.  In today’s “drive through and eat” mentality, it might well be advisable for educators to once again include nutrition and exercise within their curriculum.

An unofficial poll of childbirth educators showed that while 100% felt that including nutrition and exercise was extremely important in the education curriculum, one deterrent was shorter class length mostly due to classes being in the hospital setting. A second is that few if any prenatal care providers review nutritional and exercise suggestions with expectant parents.
So herein lies the conundrum: the medical community minimizes the exposure to expectant parents the information about optimal nutritional and exercise information and suggestions yet chastises the expectant parent for weight gain.  Not that every expectant parent who receives nutritional and exercise information will abide by it, but it will certainly increase the likelihood of compliance if they know the information in advance.  Follow-up with care providers with this type of information would only benefit the expectant parent and perhaps lower the perceived obesity in this demographic.

To read the entire study from the Centers for Disease Control and Prevention, click here:

Monday, November 09, 2015

The Research Says "this" But Why Doesn't Our Local Hospital Change the Policies? Discovering the Transtheoretical Model of Change.

No one argues the fact that research in birth and breastfeeding changes almost daily.  

New studies with new evidence dispute thoughts long held by many professionals, or validate the thoughts long held by others.  A major conundrum occurs when evidence shows that long held beliefs are no longer valid - especially those beliefs that have impacted hundreds of thousands of expectant families!

Case in point is the new study from the American Society of Anesthesiologists.  In the November 6, 2015 press release, the American Society of Anesthesiologist stated the following:

“Women traditionally have been told to avoid eating or drinking during labor due to concerns they may aspirate, or inhale liquid or food into their lungs, which can cause pneumonia. But advances in anesthesia care means most healthy women are highly unlikely to have this problem today and when researchers reviewed the literature of hundreds of studies on the topic, they determined that withholding food and liquids may be unnecessary for many women in labor.”

Many birth professionals have known anecdotally that aspiration of vomit by a woman with general anesthesia during a cesarean section is virtually non-existent with the increase usage of epidural and spinal anesthesia.

“Researchers also noted that no cases of death due to aspiration were reported in the United Kingdom between 2000 and 2005, compared to 1.5 cases per 1,000 during the 1940s.”

In reading this as a birth professional, many will rejoice that the researched evidence proves the anecdotal evidence.  Others will react more negatively and ask further, “What’s taken everyone so long?”

It is important to realize that the wheels of change move slowly in regular life, and much more slowly in the world of health and medicine.  New concepts or re-evaluated concepts must go through a research based vetting process on the world scale and often on the national and local scale as well. Once the concepts are more accepted, hospitals begin to take a look at them.  Policy changes go through many committees, including an obstetrics section committee. These committees are made up of nurses and physicians and managers, who also have full schedules.  Thus, those wheels of change also move very slowly by the very nature of the schedules of the members of the committees but also the gravity of changing major policies.  Once policies have been changed, implementing change often confuses or disorients some individuals.

The bottom line, change happens very, very slowly.

Another way to look at the reason for slow change is the Transtheoretical Model or Stages of Change developed by psychologists Prochaska and DiClemente in the late 1970s.  The Transtheoretical Model is designed for health promotion and fits perfectly in our scenario regarding offering food in labor.  The different Stages of the Model include:

  1. Precontemplation - In this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). People are often unaware that their behavior is problematic or produces negative consequences. People in this stage often underestimate the pros of changing behavior and place too much emphasis on the cons
    of changing behavior.
  2. Contemplation - In this stage, people are intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months). People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both. Even with this recognition, people may still feel ambivalent toward changing their behavior.
  3. Preparation (Determination) - In this stage, people are ready to take action within the next 30 days. People start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life.
  4. Action - In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. People may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.
  5. Maintenance - In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.
  6. Termination - In this stage, people have no desire to return to their unhealthy behaviors and are sure they will not relapse. Since this is rarely reached, and people tend to stay in the maintenance stage, this stage is often not considered in health promotion programs.  

It can indeed be frustrating to wait for change to occur.  But, as my grandfather used to say, “the squeaky wheel gets the grease”.  Therefore as dedicated birth professionals, keeping our anecdotally proven concepts in front of researcher and other professional will raise the likelihood of eventual adoption and adaptation.

Monday, October 26, 2015

Developing strength as a childbirth educator: pursuing a global view – Part 5

This is the final installment in this series.  I hope you have benefited from it!

All too often, birth professionals go through their careers with blinders on – blinders to the global view of birth and how that might impact their practice in their small little corner of the world.

There is a big birthing world out there, with rich history and a variety of cultural differences surrounding the birth experience.  Learning about these differences can enrich the classes and lives reached by your classes.  Plus, learning about differences within the US, North America and then outward, you can breathe new life into your classes, career and add strength!
Read a variety of articles. Begin here:
 ( – this 2015 article in the Huffington Post explores birthing traditions around the world in 11 countries.

Attend a variety of birth-related conferences.  Spread your wings and move from inside your comfort zone of your own certifying organization to a conference held by another organization!  For an ongoing and frequently updated calendar of professional conferences in 2016, click here:

For a view of birth with evidence-based statistical data, subscribe in YouTube to “Birth by the Numbers”, hosted by Boston University professor Eugene Declercq.  View the latest video here:

Thursday, October 15, 2015

The Lost Art of Vaginal Breech Birth

This is the trailer for the landmark new video.  It is a must-see for all birthing professionals!

See "Homeland" actor Morena Baccarin process her amazing pregnancy and vaginal breech birth.