Tuesday, August 21, 2012

The Technicalities of Teaching Childbirth Education Part 7: Robust Teaching Techniques

Somewhere in the deep recesses of the hospital, someone assumed that because a maternity nurse is a good maternity nurse, she’d also make a good childbirth educator.  As a maternity nurse who has been a Lamaze Certified Childbirth Educator for over 30 years as well as a childbirth educator trainer for CAPPAICEA and now Lamaze International, I can tell you unequivocally that assumption is untrue.  Not all childbirth educators are created equal.  I have known some great maternity nurses who have been less than good childbirth educators.  And I have known some lay persons who have studied and become tremendous certified childbirth educators.

I have assembled 10 key principles of teaching effective childbirth education classes, and am briefly addressing them in this blog.  In no particular order, they are:

  1. Know how to teach
  2. Preparation of a dynamic course lesson plan
  3. Being Organized
  4. Evidence-based knowledge base
  5. Learner Assessment
  6. Critical Thinking
  7. Robust teaching techniques
  8. Motivational skills for engaging students
  9. Compassionate listening 
  10. Problem solving

As a childbirth educator trainer for the past 12 years, I have observed a good number of new and budding childbirth educators as they “student teach”.  To be observed and be given constructive criticism on teaching childbirth education is only one of the MANY benefits of becoming certified.  And it can be one of the most valuable tools of the educational process!

Educating is not just passing along interesting information.  If that was the case, students would not nap during boring presentations in high school or college…..or childbirth class.  To be an effective educator, you must be part information disseminator and part actor.  Actor?  Yes, a performer.  Do the unexpected in unexpected ways - either through demonstration, presentation or through video.  Would you consider using the Bill Cosby monologue about birth as an opening of the first class?  Would you use different props, such as funnels, for describing the various types of labors?  Would you act our transition, including the emotional roller coaster and a bit of screaming or vocalization?

Various teaching techniques can include but are not limited to lecture, Power Point Presentations, handouts, work groups, buzz groups, graffiti sheets, visual aids such as charts or models, videos, homework/reading assignments, demonstration/return demonstrations, guest speakers, guided discussion, panel discussion, computer based learning, question/answer.

View the video below to see how this educator models teaching techniques to his students.

The use of acronyms such as COAT or TACO to remember the four elements to report once the mother's amniotic sac has ruptured also aids in information retention.  Similarly, relating the cervical dilation to foods, such as 1 cm = a Cheerio and 3 cm = the circumference of a banana ~ all lead to memory hooks.  A memory hook is taking something familiar and linking it to something out of character, which stimulates the brain to actively remember.

Teaching techniques, however, must be chosen based on the style of learner who is attending class.  An initial assessment of learning styles can be helpful in deciding which technique will be used to cover which subject during a class.  Needless to say, with all of this in mind, no two childbirth education classes will ever be taught exactly the same!

Robust and dynamic teaching techniques are vital to keep the learner's interest during each individual class session AND during the entire series.  Many childbirth educators complain because their students/clients do not attend the full class series.  While some students may give birth to their babies early, the most common reason for them to not complete the series is boredom.  With a little bit of performing and active learning/teaching techniques, you can enhance parents' childbirth education experience and help them have the most satisfying birth!

The second edition of "Innovative Teaching Strategies Handbook for Birth Professionals" is due out in December of this year.  You will find extensive information about learning and teaching techniques especially for those teaching about childbirth!

Monday, August 20, 2012

The Technicalities of Teaching Childbirth Education Part 6: Critical Thinking

Somewhere in the deep recesses of the hospital, someone assumed that because a maternity nurse is a good maternity nurse, she’d also make a good childbirth educator.  As a maternity nurse who has been a Lamaze Certified Childbirth Educator for over 30 years as well as a childbirth educator trainer for CAPPAICEA and now Lamaze International, I can tell you unequivocally that assumption is untrue.  Not all childbirth educators are created equal.  I have known some great maternity nurses who have been less than good childbirth educators.  And I have known some lay persons who have studied and become tremendous certified childbirth educators.

I have assembled 10 key principles of teaching effective childbirth education classes, and am briefly addressing them in this blog.  In no particular order, they are:

  1. Know how to teach
  2. Preparation of a dynamic course lesson plan
  3. Being Organized
  4. Evidence-based knowledge base
  5. Learner Assessment
  6. Critical Thinking
  7. Robust teaching techniques
  8. Motivational skills for engaging students
  9. Compassionate listening 
  10. Problem solving

The definition of critical thinking is a way to determine if assumptions are true, sometimes true, partly true, or inaccurate.  To experienced childbirth educators, the synonym of critical thinking could be teaching about informed decision making or informed consent.

According to the American College of Obstetricians and Gynecologist's Committee on Ethics and Informed Consent, "The ethical concept of "informed consent" contains two major elements: 1) comprehension (or understanding) and 2) free consent. Both of these elements together constitute an important part of a patient's "self-determination" (the taking hold of her own life and action, determining the meaning and the possibility of what she undergoes as well as what she does). Both of these elements presuppose a patient's capacity to understand and to consent, a presupposition that will be examined later."

The ACOG report also states:

Consent is based on the disclosure of information and a sharing of interpretations of its meaning by a medical professional. The accuracy of disclosure, insofar as it is possible, is governed by the ethical requirement of truth-telling. The adequacy of disclosure has been judged by various criteria, which may include the following:
  1. The common practice of the profession
  2. The reasonable needs and expectations of the ordinary individual who might be making a particular decision
  3. The unique needs of an individual patient faced with a given choice

But research in US maternity care, as reported by Childbirth Connection, does show that informed consent "fails to meet legal standards for providing adequate information and choice of care."  Childbirth Connection also identifies what informed consent means to the maternity care clients and family, what are the legal rights to "informed consent" and "informed refusal", and tips to help clients explore issues with caregivers.

How can parents identify what best practice in maternity care is so that they can become more informed about their options?  The Milbank Report is a foundational document which identifies evidence-based maternity care in the US.  Both professionals and maternity clients must understand that the routine care provided in their communities may not be best practice.  The Milbank Report is a guide map for understanding and intensifying informed consent.

One job of childbirth education is to assist maternity clients in identifying foundational concepts for informed decision making.  Unfortunately, sometimes this goes against community routine practice.  Our country must look more carefully at best practice so as to reduce cesarean rates, maternal mortality/morbidity rates and infant mortality/morbidity rates.  And whereas the US spends significantly more money for maternity care than many other countries, our data does not reflect the use of best practice.

It is past time to step up education - choose today 5 ways to promote informed consent during the week of Labor Day - your website, blog, Facebook, Twitter or in your own classes.  Yes, YOU can make a difference!

Thursday, August 16, 2012

Trial of Labor: A film about birth

View this trailer.  

Then, read their story and donate if you feel compelled.

The Technicalities of Teaching Childbirth Education Part 5: Learner Assessment

I have assembled 10 key principles of teaching effective childbirth education classes, and am briefly addressing them in this blog.  Part 5 in the Series is "Learner Assessment". Over the course of the next 10 blogs entries, I will address each one of these key principles so that you can enhance your own childbirth education classes!  Please read Parts 1-4! 

You feel great after teaching a childbirth class or a series.  You have effectively covered all of the topics in the timeframe allotted.  But your evaluations are less than stellar.  Why?

It is generally accepted that students know at the onset of the class what they are expected to learn.  Childbirth education is different because the reasons why students take our classes are different than, say college or high school.  Theoretically, in those situations, they WANT to take the classes.  Plus in a one day childbirth intensive or even in a weekly series, most educators do not work to understand what the students know already so as to identify gaps.

An initial assessment can be in the form of a half sheet of paper, with some open-ended questions such as listed below:

1.    1.  How did you hear about my CBE classes and what prompted you to register?

2.    Is this your first baby?    Who is your care provider?

3.    What are two topics that you would really like for me to address during class?

4.    Please order these styles of learning in the order in which you prefer to learn:
______Discussing with friends
______Reading books
______Filling out forms or worksheets

     5.  What do you hope to accomplish by taking this class?

These five questions can tell you a lot about your students, and can be filled out either before class if you do a pre-class mailing or at the break in the first class.  While not a true diagnostic assessment, these questions can give you a profile from which to base your class materials and the emphasis you place on certain topics. 

During the childbirth education course, you may take note of the types of questions asked by certain students.  Are they higher level questions, indicating pre-class reading or are they basic level questions?  This type of formative assessment helps you to form instructional techniques and guide the student’s learning.  This is an ongoing type of assessment and may change if the student is exposed to new reading lists or websites containing evidence-based information.   Also, as we teach to the learning style of the learner, an increased knowledge base is formed.

The last type of assessment is the summative assessment and is used by the student at the end of the class or series to assess the level of understanding the student has received.  Usually made in the form of the Likert Scale, the final assessment or evaluation may contain a scale of strongly disagree, disagree, neither agree or disagree, agree and strongly agree as answers to definitive questions.  It is vital for the educator to realize that this type of evaluation is very subjective and is influenced by a vast number of elements.  Many educators read but then discard the very best evaluation and the very worst, leaving all of those in the middle as learning tools.

If you do not use an evaluation in your childbirth education class, you will not be aware of how to improve the styles of teaching you practice and if they meet the needs of the learners.  Reconsider.  We, as educators, should never stop learning!

Wednesday, August 15, 2012

Evidence-based Care and Current Practice: Crossing the Great Divide

Be it published in the Journal of the American Medical Association, or a survey from the CDC, there is a gap in the United States between evidence-based practice and what is commonly seen in hospitals and termed current/best practice…or more correctly called current culture practice.

Obviously the facts about the relationship between high intervention rates and high maternal mortality/morbidity and infant mortality/morbidity rates bears repeating.  But the question is, is all of the repetition doing any good?  Since the above sets of rates keep rising, repetition is doing no good at all.

Over 2500 facilities (or approximately 82%) responded to the Center for Disease Control’s mPINC (Maternity Practices in Infant Nutrition and Care) Survey in 2007.  The results of the Survey found that a large portion of responding facilities used care practices that are not evidence based and interfere directly with breastfeeding.  Articles in JAMA, the British Journal of Obstetrics and Gynecology, the Journal of Pediatrics, JOGNN, the Journal of Perinatal Education,  and publications by WHO and UNICEF confirm that many “traditional” birth practices interfere with the body’s function during labor/birth, hormone releases, breastfeeding and skin-to-skin/bonding.  And yet, our national statistics for which traditional care or best practice is said to improve, remains humiliatingly poor.

The arguments are many.

“That’s the way we’ve always done it” is a resounding response when traditional practice is challenged. The same policies, procedures and practice guidelines have driven the care of facilities for years and to change would be a major consumption of time (time = $pay). 

Since it’s been working, why fix something that isn’t broken is another response.  After a lengthy review of the country’s statistical data, can one honestly say the system is not broken?

Mothers are not asking for change.  It is difficult for change to occur when Birth Plans are torn up infront of mothers and statements such as “This is just another plan for a section” are muttered.  It is difficult for change to occur when not only are childbirth education classes discouraged but ridiculed. It is difficult for change to occur when so many roadblocks to change stand in front of expectant parents.

There is not research to substantiate a change. Copious research is available in hard-copy print and online, including the WHO Joint Interregional Conference on Appropriate Technology for Birth, the Cochrane Database, the Baby Friendly Hospital Initiative, A Guide to Effective Care in Pregnancy and Birth, the aforementioned mPINC study through the CDC,  Impact of Birthing Practices on Breastfeeding 2nd Edition, and the new Optimal Care in Childbirth: The Case for a Physiologic Approach.  All of these mentioned (and many more) contain research evidence to support a change in maternity care.

We wouldn’t know where or how to begin.  Itemized clearly on the website for Childbirth Connection (www.childbirthconnection.org) are the amazing blue print  and tools for transforming maternity care!  Additionally the US Surgeon General placed a call to action in January of 2011 to make breastfeeding easier and raise the breastfeeding rates – how better to do this than to improve a woman’s chances of breastfeeding through prenatal education and labor care practices conducive to breastfeeding? 

According to “Transparency in Maternity Care: Empowering Women to Make Educated Choices” (Journal of Perinatal Education 2008 Fall; 17(4): 8-11), “In 2001, the Institute of Medicine (IOM) published a report wherein they called for an overhaul of the U.S. medical system and identified transparency as one of the 10 necessary steps to achieve system-wide improvement. The IOM (Institute of Medicine) report states:  In 2006, The White House released an executive order calling for increased transparency in health care.”   So far, The Birth Survey has been able to shine some light on maternity care practices in the US so that expectant parents are not in the dark about local health care practices. 

What can one person do? In one corner of the community?

1 1.  Put together a FAQ sheet of books, journal articles and website addresses that support improving US maternity care, including the Health Birth Practices . Carry copies with you everywhere.  Hand them out to clients in childbirth education classes, doula clients and lactation clients.

2.    Be an advocate for education in your community.  Sponsor small but frequent workshops with guest speakers.  Invite local health care professionals.

3.    Have a birth movie night – show exciting movies such as “the Business of Being Born”, “More Business of Being Born”, “Pregnant in America”, “Orgasmic Birth”, or “Doula The Ultimate Companion”.  Have your local library order these movies to have in their collection.

4.    Start a Birth Book Club, inviting both professionals and parents to give their opinions on current birthing books.

5.    If you have a Facebook page, promote news articles and journal articles that focus on evidence-based maternity care.

6.    Call local attention to national/international celebrations you can use to help spread the word.  World Breastfeeding Month (August) is another great event on which to focus attention!

7.    Don’t give up and don’t think that a small contribution is too small.  Apathy and complacency is the worst enemy to any cause.  Be a voice.  Be a conduit.

Tuesday, August 07, 2012

World Breastfeeding Week - Lamaze Calls Out Breastfeeding Barriers to Support Continued Rise of Breastfeeding Rates in the U.S.

Welcome to the World Breastfeeding Week Blog Carnival!  From August 1-7, we'll be featuring breastfeeding experts sharing their expertise about breastfeeding and breastfeeding issues.  Each day will bring something new!  Day 6 features a personal interview with Lamaze International President, Michele Deck.

Yesterday, August 6, I had the privilege to speak to Michele Deck, Lamaze International president and childbirth educator. We talked at length about World Breastfeeding Week/Month and what part Lamaze is playing.
“I am encouraged and thrilled to see the breastfeeding trends moving up.  Lamaze is dedicated to support of all breastfeeding mothers, especially those without cultural support.  Lamaze isn’t just about childbirth education – Lamaze Certified Childbirth Educators can also act as breastfeeding support.  Social media such as Facebook can help educators promote their services – the educators shouldn’t underestimate their power!”

Breastfeeding rates across the country continue to climb, with nearly 77 percent of moms initiating breastfeeding - the largest annual increase over the previous decade - and increases in breastfeeding at six and twelve months, according to the Centers for Disease Control and Prevention (CDC) report, “Breastfeeding ReportCard – United States, 2012.” The report comes on the first day of World Breastfeeding Week (August 1-7), and National Breastfeeding Month (August), annual events dedicated to raising breastfeeding awareness and removing the barriers to breastfeeding, both in the United States, and worldwide.

“This encouraging increase shows that the evidence around the benefits of breastfeeding is compelling to pregnant women, and the health care providers and hospitals that care for them,” said Deck. “Scientific research shows breastfeeding helps ensure babies are well nourished, protected against disease, and given the best chance to develop optimally. What women need most often is good information and support to get breastfeeding off to a good start, and to help them reach their breastfeeding goals.”

According to the CDC report, there are also national improvements in hospital maternity care practices that support breastfeeding; however, the indicators show that there is room for improvement to ensure moms are getting the quality care that can help them reach their breastfeeding goals. Valuable resources and information for expecting parents, like Lamaze’s Push for Your Baby (www.PushForYourBaby.com), are aimed at giving expecting parents the tools to push for the best care practices for moms and babies, including those that support breastfeeding education and awareness.

“While breastfeeding is natural, it doesn’t always come naturally,” said Deck. “Many moms have difficulties establishing breastfeeding and some of this may be due to birth practices that aren’t the best for moms and babies. Pregnant women can help to push for the best birth and breastfeeding experiences by using childbirth education to understand the most common barriers and how to navigate them.”

In honor of breastfeeding awareness, Lamaze calls out the following top five breastfeeding barriers within the first 24 hours of birth to help expecting moms prepare for the best breastfeeding experience:

1.   Unnecessary birth interventions:  While there are many unknowns during the birthing process, women can seek maternity care practices backed by science that can make birth safer and healthier. Fetal monitors, confinement to bed, artificially starting or speeding up labor and cesarean surgery can make birth more difficult and lead to a harder start for breastfeeding. For example, women whose babies are delivered by cesarean surgery can face a delay before the mature milk comes in. Pregnant women can find more information about reducing these and other challenges in childbirth by visiting Lamaze’s Push for Your Baby resources at: www.lamaze.org/ChildbirthChallenges

2.    Separating mom and baby: Abundant evidence shows that mother-baby, skin-to-skin care beginning right after birth and continuing uninterrupted, for at least one hour, or until after the first feeding for breastfeeding women, helps mothers, babies and breastfeeding. Skin-to-skin care helps a mom feel more confident, respond more quickly to her baby’s needs, reduces stress and makes breastfeeding easier. There are also clear benefits for babies: they breastfeed sooner, longer and more easily, they cry less, have more stable temperatures and blood sugar levels, have lower levels of stress hormones, and adjust more easily to life outside of the womb.[i]

3.    Use of pacifiers or other artificial nipples before breastfeeding is well established: Does the hospital nursery use pacifiers or bottle-feed babies without need? It’s an important question for expecting parents to ask. Studies show that early pacifier use may interfere with breastfeeding, and could decrease mom’s ability to exclusively breastfeed and reduce the duration of breastfeeding. Artificial nipples should be avoided until breastfeeding is well established (after about four weeks).

4.    Supplementing breastmilk with formula: Breastmilk is best for babies. Formula simply does not provide the added nutritional and health benefits of breastmilk that’s naturally packed with antibodies, and should not replace formula unless there is a compelling medical reason to do so. Even the few days following birth are vitally important. The breasts produce a vital substance called colostrum, which protects the baby from illnesses and provides important nutrients.

5.    Lack of postpartum breastfeeding support: Many new moms need breastfeeding support after hospital or birth center discharge. Support may include: a home visit or hospital postpartum visit, referral to local community resources, follow-up telephone contact, a breastfeeding support group, or an outpatient clinic. This is a good time for a mom to talk about any challenges she may be having, and get the help she needs to give her baby the healthiest start.

"While breastfeeding decision-making can spark controversy among moms, improving breastfeeding awareness is not about passing judgment,” said Deck. “It’s about considering the scientific evidence and giving women the support they need to achieve their breastfeeding goals.

“Lamaze has a mechanism in place.  Our short and long term goals include promotion of breastfeeding.  We’ve been involved in conversations with the March of Dimes and the U.S. Surgeon General.”

As part of World Breastfeeding Week, Lamaze International partnered with the world’s leading dedicated juvenile products retailer, Babies“R”Us®, to host in-store events nationwide, where new and expectant moms had the opportunity to learn valuable information and practical tips on how to prepare for a successful breastfeeding experience. The “Nursing Basics for New Moms” events took place on August 4 at 1:00 p.m. local time.

To find out more about breastfeeding in the workplace, Deck also offers a Q&A video on breastfeeding options for working women here:

About Lamaze International
Lamaze International promotes a natural, healthy and safe approach to pregnancy, childbirth and early parenting practices. Knowing that pregnancy and childbirth can be demanding on a woman’s body and mind, Lamaze serves as a resource for information about what to expect and what choices are available during the childbearing years. Lamaze education and practices are based on the best and most current medical evidence available. Working closely with their families, health care providers and Lamaze educators, millions of pregnant women have achieved their desired childbirth outcomes using Lamaze practices. The best way to learn about Lamaze’s steps to a safe and healthy birth is to take a class with a Lamaze certified instructor. To find classes in your area, or for more information visit: www.lamaze.org.

About Push for Your Baby
Push for Your Baby was created by Lamaze International to provide expectant parents with the support and information needed to push for the safest, healthiest birth possible. Knowing how to spot good maternity care is the key to getting it, and through Lamaze childbirth education classes, parents-to-be can get the tools needed to have the best birth day. For more information visit: www.PushForYourBaby.com.

[i] Moore, E. R., Anderson, G. C., & Bergman, N. (2012)). Early skin-to-skin contact for mothers and their healthy newborn infants (Review) Cochrane Database of Systematic Reviews.

Monday, August 06, 2012

World Breastfeeding Week - Common Problems

Welcome to the World Breastfeeding Week Blog Carnival!  From August 1-7, we'll be featuring breastfeeding experts sharing their expertise about breastfeeding and breastfeeding issues.  Each day will bring something new!  Day 6 features Mary Shay RN, MS, ICCE, IBCLC, a lactation consultant, talking about Common Breastfeeding Problems.

Some of the most common breastfeeding problems I see relate to the basics; positioning for one. Moms can read, twitter, blog and gain information from a variety of sources but when it comes to getting started, it’s the hands on practice that is important. Teaching a Mom to tuck the baby in close and to latch deeply and showing her how are so basic and yet easily missed and overlooked by staff. Misinformation about soreness and hurting in the beginning are common and teaching this isn’t so with good positioning and latching is surprising to new Mothers. The “Ah” factor and smile when good positioning and latch are done confirms the importance of this along with good milk transfer and baby’s out puts. It also prevents problems after discharge when home alone and growing in the role of Mother.

          Another important problem is routine hospital practices that separate Mom’s from their infants, not only in the first hours of life but in the days that follow. Skin to skin provides so many great benefits and getting the routines to change can be a challenge. The ways I have seen the staff grow and accept this is by doing a research project on our unit and encouraging staff to become certified in Skin to skin. As staff begin to understand and actually see the benefits (bonding, temp. control, stabilizing of blood sugar and weight) they accept this whole heartedly.

          As we celebrate World Breastfeeding Week, going back to the simple basics can be a good focus. It’s exciting to see the positive influences and changes that are coming from the support from so many places, the wave has started and it is sweeping across our nation. 

Mary Elliot Shay, RN, MS, IBCLC 
Mary is a certified lactation consultant at Upper Valley Hospital in Troy Ohio.  She has devoted most of her life to helping mothers breastfeed, in a variety circumstances.  Mary's knowledge base and devotion to breastfeeding has made her an invaluable asset to the community in which she lives.

Sunday, August 05, 2012

World Breastfeeding Week ~ Myths (and old wives tales) about Breastfeeding

Welcome to the World Breastfeeding Week Blog Carnival!  From August 1-7, we'll be featuring breastfeeding experts sharing their expertise about breastfeeding and breastfeeding issues.  Each day will bring something new!  Day 5 features Donna Walls RN, BSN, ICCE, IBCLC of Dayton, Ohio.

First, Happy World Breastfeeding Week, an opportunity to celebrate the joys of breastfeeding!

Second, we are going to dispel some of those myths that just won’t go away, like the size of the breasts determine the amount of the milk a woman can produce. In fact, the external size of the breasts have nothing to do with the ability to produce milk. Most women have one breast that is larger than the other and the smaller breast often makes a larger amount of milk.

Donna Walls RN, ICCE, IBCLC
Foods have always been a hot topic in lactation circles, usually lists of all the foods you can’t eat while breastfeeding. The truth is, there really isn’t any food that must be avoided. Spicy foods are often denied, but these foods form the basis of many cultures and do not cause concerns in those newborns. Those foods labeled “gas-forming” also have no real basis in fact to remove from the diet. Some infants may have a reaction to cow’s milk in the mother’s diet, but this is no reason to eliminate milk from all mother’s diets.

One of those myths that won’t go away is that babies need to nurse for long sessions to get the high-fat hind milk at the “end” of the feeding. Recent studies show that the milk fat is distributed throughout the entire feeding. Some very efficient babies nurse shorter periods with more milk fat in the foremilk. Mandating that mothers force longer feedings will not enhance weight gain and is a practice that is not supported by research. Encouraging baby-led feedings, feeding with cues for frequency and length of feedings, and not the clock, will provide the best nutrition. 
Many women worry about not having enough milk in the first days. New mothers need to be reassured that they have all the food their newborn needs right from the beginning. Colostrum is the first milk and is present in the breasts in the last part of the pregnancy and ready for the first feedings. An average feeding of colostrum is about 1 teaspoon, plenty to fill the newborn’s stomach which is about the size of a shooter marble. Early feedings are ensured when moms and babies spend lots of time snuggling skin to skin when babies can smell the milk.

Donna has been an RN for 32 years and for 30 years, has worked with expectant and new parents.  She is a certified childbirth educator, Lactation Consultant, and  has a Diploma in Herbal Sciences from Australasian College.  In 1995, she developed and opened the first Alternative Birth Center within a hospital setting in the state of Ohio.  Donna created the Early Lactation Care Specialist program because of her passion for babies, mothers and lactation.  She is an internationally known author and speaker, presenting workshops, programs and speaking at conferences. Donna also works with hospitals, helping to set up their Baby-Friendly Programs.  You can reach her at daswalls@aol.com.  

Saturday, August 04, 2012

World Breastfeeding Week ~ On my Heart, In my Soul, Through my Eyes

Welcome to the World Breastfeeding Week Blog Carnival!  From August 1-7, we'll be featuring breastfeeding experts sharing their expertise about breastfeeding and breastfeeding issues.  Each day will bring something new!  Day 4 features Misti Ryan from Bay Area Breastfeeding and Education, LLC.

Beads of sweat forming on her forehead and tears streaming down her face, a sweet momma looks up at me briefly in between long, loving gazes at her newborn.  No words were necessary as her face wore the expression of gratitude and elation.  We sit in silence for a moment listening to the rhythmic thup, thup, thup of that sweet baby at the breast.  I stroke baby’s soft, little head, careful not to disturb the latch that took so long to achieve.  Inside, my heart is floating, and relief floods my soul…

…and in that stillness, I am reminded of the weighty responsibility my work carries with it.  Time and time again I am invited into homes, entrusted with the management of one of baby’s most important basic needs.
Who am I?       
What makes me so special?       
I don’t carry a magic lactation wand or a pouch of latch dust.
          I am simply a lactation consultant who
simply loves moms,
          simply loves babies,
                   simply loves breastfeeding,
and has simple goals:
          meeting moms where they are,
 helping more babies get breastmilk,
helping more moms breastfeed.

Short of my family, nothing gives me more satisfaction than knowing I have helped one more baby get even one more drop of breastmilk, empowered one more mom to push through even one more feeding…

          …. respected the mom who decided whole-heartedly to throw in the towel, supported the mom that had no idea what to do when milk came in after the birth of her stillborn.

Where has our reverence gone? Despite recent efforts, our culture continues to struggle with promoting and supporting breastfeeding. 

·         Pregnancy and birth are perpetually medical-ized, squelching what should be a natural progression.

·         Well-meaning but erroneous information is passed along serving to confuse moms rather than encourage them.  

·         Younger generations have lost their models after decades of the suffocating marketing ploys of formula companies. 

The right message has been all but extinguished: Breastfeeding is not the best way to feed your baby…it is the way to feed your baby.  The tasks ahead are not for the faint of heart:

·         Normalize pregnancy and birth.

·         Standardize evidence-based breastfeeding education for health care providers.

·         Nurse in public to model breastfeeding.

What can you do today to promote and support breastfeeding?  Happy World Breastfeeding Week!

Eyes close, tiny fists open as baby falls off the breast, signaling a full tummy.  Momma wipes away a dribble of milk from the corner of the baby’s mouth.  “Thank you,” she says quietly, “I was going to quit.”  I think out loud, “It’s not me, it’s all you, momma.”

For baby, every drop counts…For momma, every minute is worth it.
Misti Ryan, BSN, RN, CCE, IBCLC, RLC
Co-Owner, Bay Area Breastfeeding & Education, LLC
International Board Certified Lactation Consultant (2011)
Labor and Delivery Nurse (1998)
Certified Childbirth Educator (1999)
Accredited La Leche League Leader (2004)
RTS Pregnancy Loss Bereavement Counselor (2004)
Certified Early Pregnancy Ultrasound Tech (2010)

Friday, August 03, 2012

World Breastfeeding Week ~ "Don't Sleep With Big Knives"

Welcome to the World Breastfeeding Week Blog Carnival!  From August 1-7, we'll be featuring breastfeeding experts sharing their expertise about breastfeeding and breastfeeding issues.  Each day will bring something new!  Day 3 features Kathleen Kendall Tackett Ph.D., IBCLC, RLC, FAPA, who has given us her permission to reprint this editorial.

 “Don’t Sleep with Big Knives.”:
Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

The City of Milwaukee launches
their most-recent
infant sleep campaign
On November 9, 2011, amid much fanfare and media attention, the city of Milwaukee unveiled their latest campaign to promote safe infant sleep. The images are disturbing to say the least—they were designed that way. "Co-sleeping deaths are the most preventable form of infant death in this community," Barrett said.  "Is it shocking? Is it provocative?" asked Baker, the health commissioner. "Yes. But what is even more shocking and provocative is that 30 developed and underdeveloped countries have better (infant death) rates than Milwaukee."  A campaign such as this has a noble goal: to prevent infants from dying. But does this type of campaign keep infants safe?  The tragic answer is “no.” In less than two months after this campaign was launched, two more infants had died in Milwaukee in what the press described as “cosleeping deaths.”

On January 3, 2012, WITI-TV, the affiliate Fox News in Milwaukee reported this:

One-Month-Old Infant Dies in Co-Sleeping Incident
Medical Examiner's Report Says Baby Was Sleeping On Floor with Three Other Children

The second death was of a 10-day-old infant who had died while sleeping with three other children on an adult bed.  Neither of these infant sleep locations was safe and should not be classified as “bedsharing deaths.” The sad take-away we can learn from these cases is that “simple messages,” may be headline-grabbing. But in the end, they do not communicate what parents need to know to keep their infants safe while sleeping.

In the same month as the Milwaukee campaign was launched, the American Academy of Pediatrics issued their new policy statement and follow-up technical report (American Academy of Pediatrics & Task Force on Sudden Infant Death Syndrome, 2011a, 2011b) on infant sleep-related deaths. In their press release, they stated that they were “expanding [the AAP guidelines] on safe sleep for babies, with additional information for parents on creating a safe environment for their babies to sleep.” 

When I first read through this statement, it didn’t seem to differ all that much from previous statements, particularly on the issue many of us are interested in—namely, their recommendations regarding bedsharing. That recommendation did not really change. But in reading the full statement, there were some interesting, and dare I say hopeful, developments.

The AAP Policy Statement (2011a) lists their Levels A, B, and C recommendations. A-Level recommendations are those with the strongest evidence. Number 3 of their Level-A Recommendations is that parents and infants room share, but not bedshare (p. 1031). They based their recommendation on the results of a new meta-analysis of 11 studies comparing 2,404 cases where infants died (28.8% of whom bedshared) with 6,495 healthy controls (13.3% of whom bedshared). They calculated the odds ratio and found that it was 2.89 (95% CI, 1,99-4.18).1  Based on their calculation, bedsharing increased the risk of SIDS by almost three times. But wait…..The authors noted that there was “some heterogeneity in the analysis” (p. 45). The heterogeneity in question referred to the fact that several of the studies included infant deaths that took place on a chair or couch (a situation that greatly increases the risk of infant death), not just those that took place in an adult bed with a non-smoking, non-impaired parent. 

Footnote: An odds ratio of 1.0 indicates no increased risk. Above 1.0 means increased risk. The higher the number, the worse the risk.

This issue has, of course, dogged the bedsharing debate for more than a decade. The authors themselves acknowledged that this was a difficulty (Vennemann et al., 2012).

Only recent studies have disentangled infants sleeping with adults in a parental bed from infants sleeping with an adult on a sofa. This is certainly a limitation of the individual studies and hence of the meta-analysis (p. 47).

But hopeful sign number 1: the AAP statement specifically differentiates between bedsharing and the broader term, “cosleeping,” which often includes all deaths that take place outside of a crib. I hope that this distinction will trickle down into future research studies.

And there’s more. Vennemann et al. (2012) noted that bedsharing was much more hazardous with a smoking mother (OR=6.27; 95% CI, 3.94-9.99) than a non-smoking mother (OR=1.66; 95% CI, 0.91-3.01).  So there was still some increased risk if an infant slept with a non-smoking mother. But remember that this analysis included studies where babies died on couches and chairs. The next analysis was by age of infant. For infants less than 12 weeks, the odds ratio was 10.37 (95% CI. 4.44-24.21).  But for older infants, 1.02 (95% CI, 0.49 - 2.12), i.e., no increased risk.  Another analysis looked at whether bedsharing was routine.  They found that if bedsharing was routine, the odds ratio was 1.42 (95% CI, 0.85-2.38).  If bedsharing was not routine, but happened on the last night, the odds ratio was 2.18 (95% CI, 1.45 - 2.38). The authors noted that the risk was NOT significantly elevated in the routine-bedsharing group (although I note that there does seem to be some elevation in risk, probably due to the studies that included couch sharing).

The next interesting issue is regarding their recommendations on chair or couch sharing with an infant. This has been a long-standing concern of mine due to the massively increased risk of infant death if parents fall asleep with infants on these surfaces. In fact, I have spoken with quite a few parents who routinely do this because they want to avoid bedsharing. Here’s what AAP says.

Because of the extremely high risk of SIDS and suffocation on couches and armchairs, infants should not be fed on a couch or armchair when there is a high risk that the parent might fall asleep (AAP, 2011a, p. 1033).

Further, they acknowledge—and seem to affirm—feeding babies in bed, but putting them in their own cribs for sleep.

Therefore, if the infant is brought into the bed for feeding, comforting, and bonding, the infant should be returned to the crib when the parent is ready for sleep (AAP, 2011a, p. 1033).  

Unfortunately, this statement does not acknowledge that it’s quite easy to fall asleep in bed: 70% of mothers in our study who fed their babies in bed said that they fall asleep there (Kendall-Tackett, Cong, & Hale, 2010). And many a new parent would argue that that is precisely the point. There needs to be some recognition of, and planning for, that contingency.  But other than that, I am happy to see this recommendation included.

The final point that I would like discuss is the role of breastfeeding in SIDS prevention, and how bedsharing has a role in sustaining breastfeeding. For example, Helen Ball (2007) found, in her longitudinal study of 97 initially breastfed infants, that breastfeeding for at least a month was significantly associated with regular bedsharing.

We, in the breastfeeding world, have been saying this for a very long time (Academy of Breastfeeding Medicine, 2008; McKenna & McDade, 2005; McKenna & Volpe, 2007). But now the SIDS researchers are saying it too. For example, Vennemann et al. (2009) found that breastfeeding reduced the risk of SIDS by 50%. (Yes, this is the same Vennemann whose meta-analysis was cited above.) Regarding breastfeeding, Vennemann et al. (2009) said the following.

We recommend including the advice to breastfeed through 6 months of age in sudden infant death syndrome risk-reduction messages (p. e406).

Peter Blair and colleagues (Blair, Heron, & Fleming, 2010) went further and highlighted the role of bedsharing in maintaining breastfeeding. (Peter Blair is also a co-author on Vennemann et al., 2012.)

Advice on whether bed sharing should be discouraged needs to take into account the important relationship with breastfeeding (p. 1119).

So I am hopeful that we may be reaching a possible accord on this issue. While the AAP will probably never come straight out and recommend bedsharing, it would be helpful if they acknowledged that it will likely continue, and that our role is to help all parents sleep as safely as possible--either with or near their infants. Such a statement is possible. I’d like to close with the words from the Canadian Paediatric Society (Canadian Paediatric Society & Committee, 2004/2011).

Based on the available scientific evidence, the Canadian Paediatric Society recommends that for the first year of life, the safest place for babies to sleep is in their own crib, and in the parent’s room for the first six month. However, the Canadian Paediatric Society also acknowledges that some parents will, nonetheless, choose to share a bed with their child…..

The recommended practice of independent sleeping will likely continue to be the preferred sleeping arrangement for infants in Canada, but a significant proportion of families will still elect to sleep together…….

The risk of suffocation and entrapment in adult beds or unsafe cribs will need to be addressed for both practices to achieve any reduction in this devastating adverse event (emphasis added).


Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA is a health psychologist, IBCLC, and Fellow of the American Psychological Association. Dr. Kendall-Tackett is Editor-in-Chief of Clinical Lactation, clinical associate professor of pediatrics at Texas Tech University Health Sciences Center, and owner of Praeclarus Press. More information on the mother-infant sleep debate can be found at http://praeclaruspress.com/sense-sensibility.html