ACOG: OB-GYNs to be a Resource for Breastfeeding Women

breastfeeding2The American College of Obstetricians and Gynecologists has issued an updated Opinion from their Committee on Obstetric Practice on the role of obstetric care providers in supporting breastfeeding. In it, ACOG states that the offices of obstetric providers such as ob-gyns should be a resource for breastfeeding women including clinical management, triage of common nursing challenges, and referrals to or availability of certified lactation professionals. ACOG notes that this level of support should be available through the first year and beyond for those who choose to continue nursing. The Opinion also states that many of the health benefits of breastfeeding increase the longer nursing continues.

In this update, ACOG provides more specifics on how providers are expected to support breastfeeding in their practice, at hospitals, and in the community. It even goes so far as to note how essential policies, such as paid maternity leave, availability of breaks and space to pump, and onsite childcare, are to breastfeeding success. Overall the Opinion highlights and expands the role of obstetric care providers in the initiation and continuation of breastfeeding:

The advice and encouragement of the obstetrician–gynecologist and other obstetric care providers are critical in assisting women to make an informed infant feeding decision.

This new Opinion replaces a previous 2007 document which stated that ACOG “strongly supports breastfeeding” and that ob-gyns and other maternity care providers “should provide accurate information on breastfeeding to expectant mothers and be prepared to support them.” The updated guidelines emphasize the importance of appropriate care for breastfeeding by ob-gyns saying,

Clinical management of lactation is a core component of reproductive health care.

and

Because lactation is an integral part of reproductive physiology, all obstetrician–gynecologists and other obstetric care providers should develop and maintain knowledge and skills in anticipatory guidance, physical assessment and support for normal breastfeeding physiology, and management of common complications of lactation.

ACOG Committee Opinion: Optimizing Support for Breastfeeding as Part of Obstetric Practice

Providers are now expected to know and do much more than provide accurate information and be ready to provide support for breastfeeding as the previous document stated. Additional care guidelines outlined in this new Opinion include:

  • Obtain a woman’s breastfeeding history during prenatal care
  • Communicate concerns or risks related to breastfeeding to the baby’s care provider
  • Engage family members in discussions regarding infant feeding to address their questions or concerns
  • Facilitate early and frequent milk expression in the case of preterm or “vulnerable” infants
  • Breastfeeding difficulties are correlated with a higher risk of postpartum depression and appropriate screening, treatment and referral are recommended
  • Skin-to-skin is associated with reduced need for formula supplementation and is feasible in the operating room following cesarean birth

ACOG has previously stated that care providers should support breastfeeding beyond providing appropriate care and information. Specifically, they suggest:

  • Providers support women as they integrate breastfeeding in their daily lives, including at work
  • OB-GYNs be in the forefront of policy efforts to enable women to breastfeed including education, hospital policies, community efforts and legislation
  • The offices of obstetric care providers should be a resource for breastfeeding through the first year of life and beyond

The Committee Opinion also provides a list of the Top Ten Hospital Practices to Encourage and Support Breastfeeding and discourages the distribution of formula distribution via “gift packs” noting that it is a barrier to establishing breastfeeding.

ACOG states that care providers should support an informed decision regarding breastfeeding and that women are “uniquely qualified to decide” if they breastfeed and for how long.

Overall, ACOG recommends:

  • Exclusive breastfeeding for the first six months
  • Continued breastfeeding thereafter so long as mutually desired by mother and baby

It seems that providers will be taking a page or two from doulas on how to support breastfeeding! We know how important it is to find out a woman’s background when it comes to nursing – her previous experience, level of knowledge, cultural influences and her concerns. Including her partner and other families members in the discussion is key; and it is encouraging to see ACOG recognize that, while women are the ones who nurse, partner and family support is key to breastfeeding success, however the woman defines it. Doulas also understand the importance of being a resource for nursing mothers and referring to certified lactation professionals when needed. That doulas were not mentioned as a resource for women in establishing breastfeeding is, of course, unfortunate. Overall, external supports received very little mention in the Opinion beyond recommending certified lactation consultants and including families members in discussions of feeding choices. Childbirth education is well known to increase breastfeeding rates and was also not mentioned. It is encouraging that ACOG recognized workplace and cultural challenges to breastfeeding in the U.S., and we can hope that future recommendations will address a wider range of support resources for nursing families including doulas.

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ACOG Updates: PROM, Preterm Labor, Magnesium Sulfate

The American Congress of Obstetricians and Gynecologists has recently updated two Practice Bulletins and a Committee Opinion on interrelated topics: Premature Rupture of Membranes, preterm labor management, and the use of magnesium sulfate to stop preterm labor. We have provided a summary of each highlighting the new recommendations as well as background on the topic.

Summary
All three documents have been updated to reflect a very specific change in the recommendations for the administration of corticosteriods to support lung development in the baby before birth. ACOG recommends a single course of corticosteriods between 24 and 34 weeks gestation. This change comes in part following the joint Obstetric Care Consensus document from ACOG and the Society for Maternal-Fetal Medicine on Perviable Birth released last year.

Premature Rupture of Membranes – Practice Bulletin Interim Update

Overview
ACOG states that the course of care when a woman’s water breaks before labor begins (the definition of PROM) should be determined based on an accurate assessment of gestational age, the status and progression of labor, infection and risks to mother and baby. Evaluation and counseling are the first course of action. The Practice Bulletin notes that Premature Rupture of Membranes occurs in approximately 8% of pregnancies and labor generally begins quickly after the water breaks. Infection is the most common complication of Premature Rupture of Membranes occurring in 15 -20% of cases. ACOG recommends hospitalization and surveillance (their word) of both mom and baby with PROM citing insufficient research to support “outpatient management”. Additional care guidelines include an initial period of fetal heart and contraction monitoring followed by periodic fetal heart tone monitoring. Induction of labor has been shown to reduce the length of labor, incidence of infection and admission to the Neonatal Intensive Care unit without increasing the risk of cesarean or vaginal operative delivery the Bulletin notes. Expectant management (allowing labor to progress on its own) may be acceptable, according to ACOG, if “clinical and fetal conditions are reassuring” and the mother is adequately counseled on the associated risks of prolonged PROM. There is insufficient evidence to support the administration of prophylactic antibiotics except in the case of patients who are GBS positive.

New Guidelines
ACOG has issued an Interim Update to this Practice Bulletin “to reflect a limited, focused change”. In this update, the guideline has been changed regarding:

Antenatal coricosteroids are now recommended for the following gestational ages:

  • Between 24 weeks, 0 days and 34 weeks, 0 days
  • May be considered as early as 23 weeks, 0 days for those at risk of preterm birth

Course of care in previable period (before 23 weeks, 6 days):

  • Antibiotics not recommended except to prolong the pregnancy when the patient has chosen expectant management
  • Tocolysis (medications to stop premature labor such as magnesium sulfate) not recommended

Management of Premature Labor – Practice Bulletin Interim Update

Overview
Preterm labor is defined as contractions which create cervical change between 20 and 37 weeks of pregnancy. Preterm labor does not always lead to preterm birth, with 50% of women hospitalized with preterm labor giving birth after 37 weeks (term). Preterm birth is associated with a number of risk factors including long-term impairment, neonatal and infant death. While bed rest has historically been recommended for preterm labor, ACOG notes that evidence does not support its effectiveness. The suggested course of treatment includes tocolytic drugs such as magnesium sulfate to stop contractions and corticosteriods to support the baby’s lung development. Magnesium sulfate is also administered for its benefits in supporting the baby’s brain health. Antibiotics are not recommended without clinical indication of infection.

New Guidelines
In this Interim Update, changes have been made to align with the PROM Practice Bulletin Interim Update:

  • Single course of antenatal corticosteriods for pregnancies between 24 and 34 weeks gestation at risk of preterm birth within 7 days
  • Antenatal corticosteriods may be considered as early as 23 weeks

The Management of Premature Labor Practice Bulletin has also been updated to recommend:

  • Considering an additional course of antenatal corticosteriods if the first course was given at least seven days ago, the risk of preterm birth remains and the pregnancy is less than 34 weeks along

Magnesium Sulfate Use in Obstetrics – Committee Opinion Interim Update

Overview
Magnesium Sulfate offers two benefits in the case of preterm labor – stopping contractions and reducing the incidence of cerebral palsy in babies. Magnesium sulfate and other tocolytic medications are often used to stop labor long enough for the administration of corticosteriods before birth. ACOG and the Society for Maternal-Fetal Medicine support the use of magnesium sulfate for up to 48 hours. The U.S. Food and Drug Administration advises against providing magnesium sulfate for more than five to seven days out of concern that long term exposure to magnesium sulfate can lead to neonatal bone demineralization and fractures. The Committee Opinion notes that these risks are associated with cases where the averaged exposure to magnesium sulfate was 9.6 weeks which is considered nonstandard use of this medication.

New Guidelines
The Committee Opinion on magnesium sulfate has been updated to reflect the changes to the Practice Bulletins on preterm labor and Premature Rupture of Membranes:

Magnesium Sulfate is recommended:

  • Between 24 and 34 weeks of pregnancy
  • When there is a risk of preterm birth within 7 days

Note: Practice Bulletins and Committee Opinions are guidelines for practitioners about specific conditions and care options for treatment. ACOG is clear that these recommendations do not dictate a specific course of care and that care providers should create a course of treatment based on the patient’s unique needs, the resources available to the provider, and any limitations based on where or how they practice.

— Adrianne Gordon, CD(DONA), MBA

References
Premature rupture of membranes. Practice Bulletin No. 160. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e39–51.

Management of preterm labor. Practice Bulletin No. 159. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e29–38.

Magnesium sulfate use in obstetrics. Committee Opinion No. 652. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e52–3.

Periviable birth. Obstetric Care Consensus No. 3. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e82–94.

Best of International Doula: A Critical Review of the ACOG Committee Opinion on Screening for Perinatal Depression

From time to time we like to share a full length article from DONA International’s members only quarterly magazine, The International Doula. In the December 2015 issue, Walker Karraa, PhD provided a critique of the American College of Obstetricians and Gynecologists Committee Opinion on perinatal depression screening. Dr. Karraa is a world renowned expert on perinatal mood disorders and was previously a DONA International certified birth doula. She is a researcher and advocate for maternal mental health and powerful voice in the birth community.

Her article is an in-depth analysis of the Opinion, and Dr. Karraa illustrates specific questions and insights about the recommendations. This review not only serves to help doulas better understand the complex world of screening and treatment of perinatal mood disorders, but it can also help us better analyze research and recommendations we read on other topics with a critical eye. The article ends with this important question,

My hope is that this article will strengthen our understanding of the current paradigm of perinatal mental health in the medical establishment and encourage our own self-reflection as birth professionals and advocates. Doulas continue to lead the way in advocacy for childbearing women in labor, birth and postpartum. How can we improve? — Walker Kaarra, PhD

Too little, too late
A critical review of the ACOG Committee Opinion on screening for perinatal depression

By Walker Karraa, Ph.D.

There are several reasons I wanted to share my thoughts on the recent ACOG Committee Opinion on screening for perinatal depression. First, I am a researcher. I have spent the last 15 years researching the suffering endured by women as a result of untreated perinatal mood and anxiety disorders. Researchers are trained to see problems, to methodically dissect the presentation of evidence and to question validity.

Second, I have also spent the last 15 years advocating for maternal health reform that includes maternal mental health. Lastly, I have direct experience with the life-threatening nature of untreated perinatal mood and anxiety disorders. As I write this, I am grieving the loss of a friend and fellow advocate to suicide. I am so critical of institutions that fail to adequately address maternal mental health because women die from mental illness that is untreated, overlooked, stigmatized and ignored.

Some of the most powerful images of women and motherhood are those held by the professional disciplines that lay claim to a special expertise in the field of reproduction — namely, medical science, clinical psychiatry and psychology.1
– Ann Oakley

Introduction
Oakely’s(1) observation, cited above, is a great reminder for us to examine the paradigm of motherhood constructed by the medical establishment and identify the gaps between authority and authenticity. Birth advocacy by definition is a tradition of critical analysis of institutionalized power.(2) Moreover, the international doula movement was founded on the principle of speaking women’s truth to medical power. Penny Simkin and countless other birth advocates have courageously shed light on the gaps between the medical establishment and a woman’s inherent abilities and needs in childbirth. It is from this perspective that I get my passion, as well. As a researcher, former DONA certified birth doula and author, I am trained to see the discrepancies in the maternal health policy for mothers who experience mental illness.

Here, at the intersection of the birth and the brain, I have spent the last 15 years wondering, questioning and grieving the loss of life and suffering at the hands of untreated perinatal mood and anxiety disorders.

Current paradigms of maternal health can also be understood through close examination of the published work and public statements of the medical establishment. Enter the American College of Obstetricians and Gynecologists’ (ACOG) latest committee opinion on screening for perinatal depression (3). Published in May of this year, ACOG’s Committee Opinion Number 631 regarding screening for depression and anxiety in the perinatal period, with the stated purpose “to increase awareness of depression and mood disorders in pregnant and postpartum women” recommends screening pregnant and postpartum women once during the perinatal period, replacing the previous 2010 opinion stating that screening was not recommended due to “insufficient evidence” (2). The change of opinion is noteworthy.

In this article I will first review the stated ACOG recommendations and the rationale used to support them, with careful attention paid to the quality of supporting evidence in the document. Secondly, I will review the screening instruments recommended and juxtapose current understanding of barriers to screening for obstetric providers.

Review of Recommendations
The four central recommendations from ACOG’s recommended screening for perinatal depression and anxiety are:

1. Screening patients “at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.”
2. “Closely monitoring” patients with risk factors for Perinatal Mood and Anxiety Disorders (PMADs), such as current depression or anxiety or a history of previous PMADs.
3. Clinicians should not rely solely on screening but must offer “appropriate follow-up and treatment when indicated,” including initiating medical treatment and referring patients to “appropriate behavioral health resources.”
4. “Systems should be in place to ensure follow-up for diagnosis and treatment.”

At first glance, the new recommendations appear progressive. However, upon closer examination, the document reveals anemic supporting evidence and impractical recommendations. The cited studies fluctuate among outdated studies, studies cited in the last opinion recommending against screening and absence of citations. Academic writing requires the presentation of a rationale based upon previously validated research that is most current.

Granted, the ACOG Committee Opinion was purposed to increase awareness. Nonetheless, it was published in a top-tier medical journal that requires rigorous peer-review and editorial scrutiny – including checking for the validity of the literature review. The lack of supportive evidence weakens the rationale for screening and in essence minimizes women’s mental health.

The organization of the opinion merits mentioning. The paper presents an abstract, then bullet-pointed recommendations, followed by the introduction, and then recommended screening tools. Standard protocol for peer reviewed manuscripts recommends an abstract (which includes a brief summary of findings), followed by an introduction to the topic and background information. (4) The paper is not a research study, yet it is published in a peer-reviewed research journal with the highest of standards for publication. Therefore, the layout itself was incongruous with the established protocol for peer-reviewed publication.

The inconsistencies in the research cited in support of the recommendations confuse and weaken the report. For example, the prevalence of depression in women is cited with a 20-year-old epidemiological overview article5, not a research study. The authors then cite a well-respected 2005 meta-analysis6 to support their one-in-seven prevalence; however ACOG used the same study in the previous ACOG 2010 opinion (7) against screening for PMADs.

The document notes deleterious effects of untreated PMADs, including maternal suicide: “maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality” citing a current and important study regarding maternal mortality8; but then uses another 20-year-old study9 to support their statement that PMADs are often unrecognized, when it is widely reported that as many as 50% of women with PPD go untreated (10).

The paper addresses the more recent evidence regarding comorbidity of symptoms of anxiety within perinatal mood disorders but fails to cite any, let alone recent, studies. In vague and somewhat simplistic language, the authors only direct: “It may be helpful to ask a woman whether she is having intrusive or frightening thoughts or is unable to sleep.” It may be helpful? Here ambiguity is juxtaposed by the equally vague and somewhat stigmatizing “intrusive or frightening thoughts.” The authors offered no context as to when or how to approach such thoughts and fail to note whether these questions are already included within any of the recommended screening tools, nor did they offer a suggestion as to what to do if a patient says “yes” and there is an indication of a psychiatric emergency. The absence of discussion regarding next steps protocol weakens the best practices necessary to initiate the recommendations, and weakens the strength of the opinion.

Screening tools
The weak language is further evidenced in how the committee described PMAD screening tools: “Several screening instruments have been validated for use during pregnancy and the postpartum period to assist with systematically identifying patients with perinatal depression” (p. 2). They then list seven validated screening instruments and direct the reader to a table listing the same information. Neither the in-line text nor the table references the authors of the instruments listed. It is common practice and professional courtesy to cite the authors of screening tools. However, this document does not. Secondly, there are no clear supporting resources given for how to access the tools, nor how to integrate them into a clinical practice during the perinatal visit. Third, the opinion does not review the symptoms of PMADs, nor reference the DSMV11 nor the ICD-10 (12) diagnostic criteria. Rather, the opinion offers: “Although screening is important for detecting perinatal depression, screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated; clinical staff in obstetrics and gynecology practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both” (p.2).

Be prepared to initiate treatment. What does that mean? A colleague of mine suggested that it would be like telling psychiatrists that they had to now be ready to assess preterm labor and initiate medical therapy to stop contractions. It is widely understood that the most common medical treatment intervention is psychopharmacology (13). Yet in this document, ACOG fails to note that the majority of women are resistant to taking medication without being offered a range of nonmedical based treatment options (14).

I was curious as to the training OB/GYN residents receive regarding psychopharmacology and PMADs. I reached out to ACOG Director of Media Relations and Communications Kate Connors, and asked about the standards for training. She shared: “There’s no specific amount of time that is dedicated to this training, but rather one of the educational objectives of the residency is the mental health care of women. Residents are taught to evaluate pregnant and postpartum women for wellness and mental health disorders. Also the objectives (as with all educational objectives) are matched to a progressive learning experience throughout the residency and competency rather than hours assessed. So, there is no one magic answer, but rather residents have to demonstrate proficiency and competency.” (Personal communication, July 7, 2015)

I query this: How does one demonstrate proficiency and competency without standardized learning? How do students prove they have learned the material without a formal assessment of their learning? It would be as if to say that you don’t have to take a driver’s test, nor complete the required hours of driver’s training, but just have to demonstrate you are proficient on the road. The gap between training and practice in screening for perinatal mood and anxiety disorders merits closer examination.

What is still more concerning is the recommendation, considering the practical application of proficient, competent clinical practice, of how often a provider should screen. I went back to Connors for a statement regarding the determination of screening once during the perinatal period, and received this official statement.

“OB/GYNs recognize that perinatal depression can be serious and debilitating. The Committee Opinion does not state that women should be screened once; it states that women should be screened at least once, with additional emphasis given to women with risk factors. Screening for depression is regularly part of perinatal visits and is an important way to help women get the treatment that is right for them.” (Personal communication)

The vagaries in language and the random recommendation of screening at least once during pregnancy illustrate the image of motherhood held by ACOG. The opinion suggests that ACOG compartmentalizes and marginalizes women’s perinatal mood disorders. The lack of substance in the opinion speaks to the lack of substance in ACOG’s appreciation for the issue and clinical intentions.

Having been on several organizational working committees, I wondered about the conditions under which the members of this committee were asked to perform. Was there an unreasonable deadline for the paper? Were committee members given appropriate time and resources to accomplish the work? Did leadership reach beyond past protocol for opinions to suggest new standards for transdisciplinary inclusion, such as insuring perinatal psychiatry literature was reviewed? Were there any perinatal psychiatrists on the committee? Was the peer-review process inclusive of perinatal psychiatrists? Questions linger as the opinion lives in publication as a representation of current opinion regarding obstetric practice and perinatal mental health.

Conclusion
Using Oakley’s (1) concept that we gain insight into the construct of motherhood through the lens of disciplines charged with their care, what might the ACOG recommendation detailed here illustrate? When the medical establishment demonstrates weakness in attention to academic detail, it reveals institutional (and possibly systemic) uncertainty, if not apathy. Most important, the ACOG recommendation to screen a woman at least once during the perinatal period may give license to providers to neglect women’s mental health throughout the rest of her life span, tethering a woman’s medical visibility and mental health care to reproductive events. The precedent set results in situations such as my own mother, whose lifelong depression was treated at the end of her life, by her oncologist. Who cares for mothers’ mental health after they are done birthing?

Perinatal mental health has yet to receive equal status in obstetric research and practice. The majority of maternal mortality research ignores suicide altogether — despite the fact that suicide is the second-leading cause of death for women in the postpartum period13-16 and that suicide accounts for more maternal mortality than hypertension and hemorrhage8, we have evidence in this document that the issue merits only loose, arbitrary recommendations and paltry evidence. The lack of academic rigor gives tacit permission to not address the most common complication in pregnancy and postpartum, promotes marginalization, fuels stigma and may institutionalize lack of appropriate care.

My hope is that this article will strengthen our understanding of the current paradigm of perinatal mental health in the medical establishment and encourage our own self-reflection as birth professionals and advocates. Doulas continue to lead the way in advocacy for childbearing women in labor, birth and postpartum. How can we improve?

——–
References
1. Oakley, A. (1993). Essays on women, medicine and health. Oxford, England: Edinburgh University Press.
2. Morton, C. H., & Clift, E. (2014). Birth Ambassadors: Doulas and the Re-emergence of Woman-supported Birth America. Amarillo, TX: Praeclarus Press.
3. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. (2015). Committee opinion No. 631: screening for perinatal depression. Obstetrics & Gynecology, 125, 1272-5.
4. Publication manual of the American Psychological Association. Washington, DC: American Psychological Association, 2001.
5. Weissman, M. M. (1995). Depression in women: implications for health care research. Science, 269, 799-801.
6. Gavin, N. J., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Garthlehner, G., & Swinson, T. (2005). Perinatal depression: a systematic review of prevalence and incidence. Obstetrics & Gynecology, 106, 1071-83.
7. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. (2010). Committee opinion No. 453: screening for depression during and after pregnancy. Obstetrics & Gynecology, 115(2, pt. 1), 394-395.
8. Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstetrics and gynecology, 118(5), 1056.
9. Whitton, A., Warner, R., & Appleby, L. (1996). The pathway to care in post-natal depression: women’s attitudes to post-natal depression and its treatment. British Journal of General Practice, 46, 427-428.
10. Mental Health America, Substance Abuse, and Mental Health Services Administration. (2009). Maternal depression making a difference through community action: a planning guide. Washington, DC: Government Printing Office.
11. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub.
12. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.
13. Marcus, S., Flynn, H., Blow, F., & Barry, K. (2003). Depressive symptoms among pregnant women screened in obstetrics settings. Journal of Women’s Mental Health (Larchmont), 14(4), 373-380.
14. Oates, M. (2003). Suicide: the leading cause of maternal death. The British Journal of Psychiatry, 183(4), 279-281.
15. Chang, J., Berg, C. J., Saltzman, L. E., & Herndon, J. (2005). Homicide: a leading cause of injury deaths among pregnant and postpartum women in the United States, 1991– 1999. American Journal of Public Health, 95(3), 471.

About the Author
WalkerWalker Karraa is a provocative thought leader in the field of maternal mental health and leadership. Her first book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, presents her research revealing the traumatic and transformational dimensions of postpartum depression. Dr. Karraa is a member of DONA International’s Advisory Council and serves on the board of the International Marcé Society for Perinatal Mental Health. She is a Research Fellow for the Center for Leadership Studies and Educational Research for the School of Advanced Studies at the University of Phoenix where she teaches qualitative research methods in the doctoral program. Dr. Karraa runs a perinatal research consulting practice, Postpartum Associates, Inc., and lives in Sherman Oaks, California with her two children.

Call for Speaker Proposals: 2016 Annual Conference

2016-01-14_1952In just six short months the international doula community will gather in Bellevue, Washington for ENGAGE, DONA International’s 22nd Annual Conference. The Conference Committee is now accepting submissions from those interested in providing a one hour concurrent session. This four day event from the oldest, largest and most respected international doula organization provides training, resources and networking for doulas both experienced and new, leaders in the birth community and experts in topics related to the childbearing year. New and experienced conference speakers are encouraged to submit proposals. The submission deadline is February 15, 2016.

Topics
The theme for this year’s conference is ENGAGE. DONA International seeks excellent presenters who can share knowledge, skills, inspiration, tips, resources and research in the following areas:

  • breastfeeding
  • labor
  • birth
  • business
  • cultural diversity
  • new and exciting research
  • other topics relevant to the field of childbearing

Session Details

  • 60 minutes in length
  • to be presented concurrently to other breakout sessions during the conference

Submission Process & Requirements
Interested speakers must submit all of the following for consideration in one document. Forms and details are provided in the Call for Speakers Proposal document.

  • Speaker Cover Page Form with:
    • Title of session
    • Brief narrative introduction
    • Brief description of 60 minute session
    • Brief description of teaching methods used
  • Resume or curriculum vitae
  • Conflict of Interest Disclosure

The speaker proposal deadline is February 15, 2016.

Selected speakers will receive an honorarium, one-day conference registration or generous discount to attend the full conference, and a complimentary copy of the session recording if recorded. Handouts and PowerPoint presentations from selected speakers will be due to the Conference Committee by June 1, 2016.

Need inspiration? You can see a list of selected sessions from past conferences and purchase past recordings on the DONA International website.

Board of Directors Update

With the start of 2016, there are several changes on your DONA International Board of Directors. We are saying goodbye (and thank you!) to some as well as welcoming new directors. We are fortunate to have many dedicated board volunteers who have served the organization for several years who are moving to new roles. We have several open positions so if you feel called to serve DONA International in a larger way, please let us know by emailing nominations@dona.org.

Leaving the Board of Directors
Our immense gratitude to two board members who have served the organization for a combined 14 years!

Uta Mattox, CD(DONA) has served on the Board of Directors twice. She served as a Regional Director from 2001 to 2005 and was again elected as the Southeastern US Regional Director in 2009, but just a few months later became the Director of Certification. She has led the certification and recertification process since 2009, managing a very vibrant committee of certification and recertification reviewers. Thank you, Uta!

Eva Bild, CD(DONA), BDT(DONA) has served as the Western Canada Regional Director since 2011. Our Regional Directors are important points of contact for our members and help ensure the organization is meeting the varying needs of members from all across the globe. Thank you, Eva!

New Additions to the Board of Directors
We welcome three new leaders to the DONA International Board of Directors:

Johanna D’Aleo, CD(DONA), PCD(DONA), Director of Certification. Johanna previously served as Treasurer before taking a short sabbatical from the Board of Directors.

Rachel Parris, CD(DONA), Western Canada Regional Director.

Sherri Wilkerson, CD(DONA), Director of Publications overseeing the International Doula magazine, eDoula e-newsletters and The DONA Doula Chronicles.

Experienced Directors in New Roles
The success of any organization comes from a balance of new ideas and energy with continuity of leadership. Organizational knowledge and experience in more than one aspect of the organization greatly help provide stability to a large, non-profit like DONA International. We appreciate these Directors for their willingness to take on new roles.

Sunday Tortelli, AdvCD(DONA), BDT(DONA), Past President. Sunday has served DONA in various roles for over ten years, including President, President Elect and Director of Publications. She will remain on the board through 2016 to provide her deep organizational knowledge and additional support to the larger leadership team.

HeatherGail Lovejoy, PCD(DONA), PDT(DONA), President. HeatherGail served as the Western Pacific US Regional Director from 2008 until 2014, when she assumed the position of President Elect.

Virginia Rivenbark, CD(DONA), President Elect. A former Regional Director for the Northeastern US Region, Virginia will remain in this role until December 31, 2016 and then become President of the Board of Directors for 2017.

Kyndal May, CD(DONA), BDT(DONA), Director of Education. Previously the Western Pacific US Regional Director beginning in 2014, Kyndal has served as the Interim Director of Education since March 2015.

Melissa Harley, CD(DONA), BDT(DONA), Director of Marketing and Public Relations. While this role is a new addition to the Board, Melissa has been a member of the board as the Southeastern US Regional Director since February 2015.

Open Positions
There are four open Regional Director positions on the DONA International Board of Directors. If you live in one of these areas and are interested in serving, please contact nominations@dona.org.

Western Pacific US Regional Director
Northeastern US Regional Director
Southeastern US Regional Director
Mexico Regional Director

Contact information for the Board of Directors, including State/Provincial/Area Representatives (SPARs), will be updated on the DONA International website shortly.

Best of The DONA Doula Chronicles 2015

As 2015 comes to a close, we thought we’d share the most popular posts from The DONA Doula Chronicles this year. If you’ve missed any of these articles, here’s your chance to catch up! Thank you for making 2015 the best year yet for DONA International’s blog.Best of 2015-2

Top 5 Posts in 2015

In the DONA Doula Chronicles, we cover a range of topics and offer a variety of post types from research to practice tips to news from DONA International. These five were the most popular in 2015:

Breastsleeping, New Word, Old Concept – This summary of a published commentary from Drs James J. McKenna and Lee Gettler proposing a new phrase for co-sleeping nursing families was our most popular post in 2015. This article also includes a video from Dr. McKenna, Director of the Mother-Baby Behavioral Sleep Laboratory at Notre Dame and multiple sources for doulas to obtain additional information about the relationships among co-sleeping, SIDS and breastfeeding.

DONA International Stands Against Informed Doulas Report – Director of International Development for DONA International, Ana Paula Markel, wrote this response on behalf of the organization to a report released by the General Nursing Council of Spain, which included defamatory and untrue accusations about doulas.

Certification Requirements for Birth Doulas Revised – Our third most popular article of the year was also the most widely read post about DONA International. This description of the new documentation and education requirements for birth doulas certifying with DONA International was big news for the doula community.

New ACOG Opinion on Exercise in the Childbearing Year – We’ve summarized several Committee Opinions, Practice Bulletins and policy statements from the American College of Obstetricians and Gynecologists to help doulas stay informed of the latest guidelines for ob-gyns. This post was the most popular of this type and the fourth most read overall providing a detailed summary of an Opinion on physical activity during pregnancy and postpartum including recommendations, warning signs and contraindications to help doulas share the latest information with our clients.

Nurses and Doulas Playing Nice for Optimal Birth – Guest posts provide additional perspective and expertise to share with our doula readers and it’s no surprise to see one rounding out the top five for 2015. This article from guest writer Barbara Hotelling addressed a topic that resonated strongly with us on how nurses and doulas can work together to better support families and one anothers roles.

We have great things planned for The DONA Doula Chronicles in 2016, so be sure you are following the blog to get new posts delivered right to your inbox. If you’d like to submit an article or have an idea for something we should cover in 2016, drop us a message at blog@dona.org.

With Gratitude,
Adrianne Gordon, MBA, CD(DONA)
Editor, The DONA Doula Chronicles

International Doula Features Article on Nitrous Oxide in Labor

Nitrous_Oxide_coverThe next issue of the International Doula features an article written by Catherine McGovern and Dr. William Camann titled “Nitrous Oxide for Labor Pain Relief.” Dr. Camann is Director of Obstetric Anesthesiology at Brigham and Women’s Hospital and Associate Professor of Anesthesiology at Harvard Medical School, so he brings an interesting perspective to this topic. Whether you’ve supported births where nitrous oxide was present, or you haven’t, you’ll find this an interesting discussion. Here’s a small snippet:

“One of the criticisms of nitrous oxide for labor use is that it does not have a high degree of efficacy. This is partly due to being compared to epidural anesthesia. At present, epidural anesthesia is the “gold standard” for labor pain relief, and no other technique compares to the quality of pain relief offered by an epidural (6). A more appropriate comparison for nitrous oxide would be with other non-epidural pharmacologic methods of labor pain relief, such as opioids. Nitrous oxide should not be considered as a replacement for epidurals, but rather as an alternative to the use of narcotic pain relief, or an adjunct to other non-pharmacologic techniques.”

You’ll also find articles about using keywords on your website, a review of ACOG’s Committee Opinion on screening for perinatal depression, and a recap of the 2015 DONA International Virtual Conference. Keep an eye out for the Winter issue in your mailbox in the coming weeks!

— Susan Troy, CD(DONA), Editor, International Doula

2015 Advanced Doulas Announced!

DONA International is proud to announce the inaugural Advanced Doula designees! At the 2015 virtual conference, a new credential was unveiled for veteran doulas. This year’s nominees were exactly what we expected from experienced DONA International doulas who are working, teaching, publishing, mentoring and learning in support of the growth and strength of the maternal-child field. Congratulations to the 2015 Advanced Doulas!

Advanced Doula CollagePenny Bussell Stansfield, BA(Hons), AdvCD(DONA), BDT(DONA), LCCE, CLC, LMT
Rina Crane, AdvCD(DONA), BDT(DONA), LCCE, FACCE
Rae Davies, BSH, BDT(DONA), LCCE, AdvCD(DONA
Jalana E. Grant, AdvCD(DONA), BDT(DONA), LCCE
Ann F. Grauer, AdvCD/AdvPCD(DONA), BDT/PDT(DONA), LCCE, FACCE, IBCLC
Linda M. Herrick, RNC, CCE, CLE, AdvCD(DONA), BDT(DONA)
Barbara A. Hotelling, MSN, WHNP, AdvCD(DONA), BDT(DONA), LCCE, FACCE, IBCLC
Brenda J. Lane, AdvCD(DONA), BDT(DONA), LCCE
Kathleen Lindstrom, AdvCD(DONA), BDT(DONA), CBE, FACCE
Jan S. Mallak, 2LAS, AdvCD/BDT(DONA), ICCE-CD-CPD
Krista Maltais, AdvPCD(DONA), ALC, CLC, BS Family Studies
Ana M. Martínez Delgado, AdvCD(DONA), CLE, LCCE
Kamala McCormick, Adv(CD)DONA), DFB, ICPFE
Molly Mendota, CLS, LCCE, AdvCD(DONA)
MaryBeth Nance, AdvCD(DONA), CLD(CAPPA), SBD(Stillbirthday)
Karen Palumbo, MEd, CCE, CBE, AdvCD(DONA), BDT(DONA)
Sally Riley, BS ED & PSY, AdvCD(DONA), BDT(DONA), CCE, CLE
Tammy Ryan, AdvCD/BDT(DONA), SpBT
Stacey Scarborough, ICCE, CLE, AdvCD/PCD/BDT(DONA)
Emily Shier, MS, Ed., AdvCD(DONA), BDT(DONA), PCD(DONA)
Julia Sittig, MSW, AdvCD(DONA), BDT(DONA), LCC
Kathy Malowe Stewart, BSN, RN, CPNP, IBCLC, LCCE, AdvCD/BDT(DONA), PCD/PDT(DONA)
Julie A. Thompson, AdvCD(DONA), BDT(DONA), PCD(DONA)
Sunday Tortelli, CCE, AdvCD/BDT(DONA), HBCE, LCCE, CLC, FACCE
Audrey Tyree, AdvCD(DONA), HBCE, CLS
Robin Elise Weiss, PhD, LCCE, AdvCD(DONA), BDT(DONA)
Linda Worzer, BME, IBCLC, AdvCD/BDT(DONA)

Learn more about this year’s designees including career highlights:

Advanced Doulas have achieved and maintained certification in good standing with DONA International for at least two consecutive certification periods (6 years) and during that time pursued additional training, certification or licensure in a related field, been published on a relevant topic, and made major contributions to advance the mission and purpose of DONA International, the recognition of doulas and/or the maternal-child field.

Applications for the Advanced Doula designation in 2016 will be accepted during International Doula Month (May) and recognized at the annual conference in Bellevue, WA. Additional eligibility information will soon be available on the DONA International website.

New ACOG Opinion on Exercise in the Childbearing Year

There have been a number of articles around the Internet lately about exercise during the childbearing year. They have come as a result of a recent Opinion by The American College of Obstetricians and Gynecologists Committee on Obstetric Practice on Physical Activity and Exercise During Pregnancy and the Postpartum Period. So what does the Opinion say and what should doulas know about the latest recommendations on exercise during pregnancy and the postpartum period? The DONA Doula Chronicles has you covered!

“…physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to continue or to initiate safe physical activities.” — ACOG Committee Opinion, Physical Activity and Exercise in Pregnancy and the Postpartum Period

What is considered physical activity or exercise?
exercise-969300_640At its base level, physical activity or exercise does not necessarily mean an hour long spin class. In the Opinion, ACOG defines physical activity more simply as any movement produced by the skeletal muscles. Exercise is outlined as repetitive body movements that are planned, structured and repeated to improve physical fitness. The Opinion goes on to say “physical fitness is an essential element of a healthy lifestyle…”

Benefits of Physical Activity
The health benefits of being physically active across the lifespan are well documented. The authors note that the benefits of exercise are indisputable and far outweigh the risks and that worldwide physical inactivity is the fourth-leading risk factor for early mortality. Their message is quite clear – we should be moving at all ages and stages of life.

Exercise increases aerobic capacity and improves or maintains physical fitness in pregnant and non-pregnant people. The Opinion mentions that observational studies have shown that exercise during pregnancy is correlated with lower rates of gestational diabetes, cesarean birth, vaginal operative birth (using forceps or vacuum extraction) and a shorter recovery after birth. For those with gestational diabetes, exercise can lower glucose levels and prevent preeclampsia. Exercise in pregnancy has also been shown to reduce overall weight gain. In the postpartum period, returning or initiating exercise supports a healthy lifestyle.

The Opinion notes that exercise in pregnancy is well tolerated by a healthy fetus. Vigorous exercise in the third trimester has been correlated with a slightly lower birth weight but was not associated with increased risk of fetal growth restriction.

General Exercise Recommendations for Pregnancy & the Postpartum Period
The following are the recommendations for healthy pregnant and postpartum people:

  • 20 – 30 minute sessions on most days of the week totaling 150 minutes per week
  • Aerobic exercise of moderate intensity, such as brisk walking
  • For those who were previously not active, exercise should begin gradually and increased over time
  • Activity should be adjusted as needed for medical reasons
  • Those who are highly active or routinely engaged in vigorous exercise, such as running before pregnancy, can continue that level of exercise so long as they remain healthy and discuss with their care provider how and when their physical activity should be adjusted
  • To prevent heat stress, particularly in the first trimester, ACOG recommends avoiding high heat and humidity, staying well hydrated and wearing loose fitting clothing
  • Pelvic floor exercises can begin very soon after birth
  • Nursing prior to exercise can reduce discomfort due to engorged breasts
  • Care providers should prescribe an individualized exercise plan for individual patients based on overall health, medical conditions and lifestyle

Contraindications to Exercise in Pregnancy
ACOG lists a number of conditions that are considered contraindicated to aerobic exercise in pregnancy. The health conditions listed as absolute contraindications include ruptured membranes, incompetent cervix, persistent bleeding in the second or third trimester, placenta previa after 26 weeks, premature labor and preeclampsia. In addition to these pregnancy related health conditions, ACOG also lists heart disease that impacts blood pressure or blood flow (hemodynamic), restrictive lung disease and severe anemia as absolute contraindications to exercise in pregnancy.

Exercise in pregnancy is potentially inadvisable, ACOG says, under additional circumstances listed as relative contraindications. No specific guidelines are provided on how care providers should weigh the potential risks of exercise in pregnancy when these conditions are present. Many of these relative contraindications are related to overall health, such as extreme morbid obesity, extreme underweight, history of extreme sedentary lifestyle, being a heavy smoker and orthopedic limitations. Existing health conditions that are poorly controlled, such as type 1 diabetes, hypertension, seizure disorders and hyperthyroidism are also listed as relative contraindications. Pregnancy related health conditions that ACOG recommends care providers consider as potential risks related to exercise are intrauterine growth restriction and unevaluated maternal cardiac arrhythmia.

Safe and Unsafe Physical Activities During Pregnancy
This section of the Opinion recommends avoiding contact sports, such as hockey and boxing, and activities with a high fall risk, such as off-road cycling and horseback riding, scuba diving, sky diving, hot yoga and hot Pilates.

Activities considered safe to begin or continue in an uncomplicated pregnancy include walking, swimming, stationary bike riding and low impact aerobics.

Modified yoga and Pilates are also considered safe so long as positions which may decrease venous return are avoided.

Jogging or running, strength training and racquet sports can be continued if these activities were routine before pregnancy and in consultation with a care provider. The Opinion notes that racquet sports where the risk of falling is increased due to changes in balance brought on by pregnancy should be avoided as much as possible.

Warning Signs
ACOG states that exercise during pregnancy should be discontinued and the care provider consulted if any of the following conditions arise:

  • Vaginal bleeding
  • Regular painful contractions
  • Leakage of amniotic fluid
  • Labored breathing before beginning the activity
  • Dizziness
  • Headache
  • Chest pain
  • Muscle weakness that affects balance
  • Pain or swelling in the calf

The Committee Opinion on Physical Activity and Exercise in Pregnancy and the Postpartum Period also includes a scale for evaluating exertion in exercise as well as recommendations for special populations which address obesity and competitive athletes. The Opinion also notes ACOG’s position on bed rest stating, “bed rest is not effective for the prevention of preterm birth and should not be routinely recommended.”

Sources
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Physical-Activity-and-Exercise-During-Pregnancy-and-the-Postpartum-Period

New Obstetric Care Consensus: Periviable Birth

The American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) released their third joint consensus statement last month, this one addresses care during the periviability period – between 20 weeks and 25 weeks 6 days gestation. These infants require life saving interventions immediately after birth for survival. Recent research shows that treatment and outcomes have varied across hospitals for these very premature infants. This new consensus statement provides guidelines for treatment and decision making for newborn care in the case of periviable birth to increase consistency in care across the U.S. and improve care providers’ ability to predict outcomes in these cases.

The Obstetric Care Consensus on Periviable Birth recommends:

● Transfer to a hospital with advanced levels of neonatal or maternal care before birth when appropriate and feasible.
● Practitioners consider multiple variables that may affect survival and outcomes for the newborn when counseling parents. This recommendation applies to counseling before and after birth on both short-term and long-term outcomes.
● Counseling for the family from a multidisciplinary team including maternity care providers and neonatologists with follow-up counseling when new information is available about the mother or baby’s condition.
● In counseling patients, providers should talk to parents about their goals, specifically whether they wish to optimize survival or minimize suffering.
● Create a predelivery plan with the family and adjust it as additional information becomes available. A stepped approach should be used for care and interventions that is harmonious with the infant’s condition and the parents’ wishes. The specific situation should direct what interventions are offered and conducted including resuscitation.
● Specific interventions based on the clinical situation and family preferences.

The impacts of interventions on the mother’s health should also be considered, the authors note. Periviable infants are more likely to be born via cesarean using a vertical incision which presents risks for future pregnancies. The statement notes that even cesarean birth using a low transverse incision for periviable birth has a greater risk of uterine rupture in subsequent pregnancies.

This document also addresses “individualized compassionate care” for the infant in cases where the decision is made not to offer resuscitation saying, “A decision not to undertake resuscitation of a liveborn infant should not be seen as a decision to provide no care, but rather a decision to redirect care to comfort measures.” Compassionate care recommendations include minimizing discomfort, keeping the baby warm and allowing the family as much time with their infant as they wish.

The new recommendations are a result of research conducted at 19 neonatal intensive care centers to develop a tool to better predict outcomes for infants born during the previable period. The tool, developed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network uses birth weight, gestational age, sex, plurality and exposure to antenatal corticosteroids rather than previous methods which relied on gestational age and birth weight alone. The use of additional clinical data should allow for more accurate prediction of outcomes and help care providers and families better determine the appropriate care and interventions in periviable births.

For those doulas with particular interest in periviable birth, the Obstetric Care Consensus statement details the research findings including survival rates, morbidity rates and the variation in care for periviable birth, particularly those occurring before 25 weeks gestation. Detailed recommendations for care providers regarding how to counsel families on their options are also included.

-Adrianne Gordon, CD(DONA), MBA

Sources

http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Periviable-Birth

http://www.medscape.com/viewarticle/853110

http://www.ajog.org/article/S0002-9378(15)00905-9/abstract