Respectful maternity care: the problem and suggested solutions

Guest  post by Donna Walls, RN, BSN, CLC, ANLC with intro by jess fedenia, clc

 

Donna Walls’s, RN, BSN, ICCE, IBCLC, ANLC unmedicated births were sort of a fluke.

“I remember being horribly afraid of someone sticking a needle in my back,” she recalls.

The “glorious” feelings of confidence and joy were unexpected consequences, but thinking back, Donna says, “Boy, I am sure glad I [gave birth that way.]”

In all other aspects of parenting, Walls credits growing up in the 1960s for becoming a self-described Granola Mom.

“When everything went ‘back to nature’, that was a big influencer for me,” she says.

As a nurse, Walls was always drawn to maternity care and supporting breastfeeding as the natural progression after giving birth.

It felt thorny to her when babies were taken to the transition nursery immediately after birth and later given back to their mothers.

This ritual sent the message that “We (as in the staff) can take better care of your baby than you (as in the mother) can.” That never sat right with Walls.

Then, one pivotal moment in particular, Walls on duty in the transition nursery, walked by a baby only a couple of hours old.

“He was frightened,” Walls begins. “His lip was quivering and he was splayed out underneath the warmer. He was so frightened. It just affected me.”

After that, Walls galvanized to change the culture in this hospital. She worked very hard alongside a physician colleague to open a birth center within the hospital. In 1995, Family Beginnings at Miami Valley Hospital in Dayton, Ohio was unveiled, offering families an option where birth wasn’t pathologized and where mothers and babies were honored as dyads. (Birthing at Family Beginnings remains an option for those in the Dayton area today.)

The center was designed to look like a home. There was no nursery for babies to be separated from their parents. When mothers came in to labor, the staff would pop in bread to bake, a special touch of aromatherapy.

Freshly baked bread, though enticing, wasn’t the number one reason families signed up to birth here. Instead, they chose Family Beginnings because they didn’t want their babies taken away from them, Walls reports.

Walls has since retired from her work in the hospital, but respectful maternity care remains forward in her mind and in her advocacy.

She graces us with reflections on respectful maternity care in her guest post this week on Our Milky Way. Read on!

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As a nurse in maternity for over 40 years, I have too often witnessed what I refer to as the “empty vessel theory”. Women are regarded as merely a container for the fetus and care providers merely the technician to remove it, usually as quickly as possible. I have often been saddened when the emotions and spirituality of birthing are disregarded or even mocked. This miraculous process is a rite of passage with all the inherent pain, joy, lessons and connections needed to begin the journey into parenting. My hope is that through discussions and activism, we can reach a point where the birthing family is honored and all newborns are brought into the world with love and respect.

Photo by João Paulo de Souza Oliveira: https://www.pexels.com/photo/gray-scale-photo-of-a-pregnant-woman-3737150/

Respect is “showing regard for the feelings, wishes, rights or traditions of others”. Concerningly, there is an abundance of anecdotes from patients and caregivers that demonstrate how maternity care practices are often disrespectful, sometimes even abusive.

Disrespectful care encompasses racial inequity, lack of confidentiality, physical and/or emotional abuse, denial of care or provision of substandard care, lack of informed consent or coercion or condescending communications. This type of care occurs in all countries around the world, to all demographics of women and their families. Fortunately, disrespectful care has drawn the attention of many health organizations, including the World Health Organization, and steps are being taken to stop disrespectful, abusive care practices.

Examining the intersection of maternity care and human rights has been a recent topic in many maternal and infant care advocacy groups as well. We cannot assume that hospital admission for an appendectomy is equal to admission for the birth of a baby. This is because  the scope of the process of birthing impacts a person, a family, a community and a nation which is not so of a surgical procedure.

Most women and families expect they will receive safe, inclusive, compassionate care and trust their caregivers to provide prenatal, intrapartum and postnatal care with honest communication and respect for their needs and choices. Provision of safe care should look beyond the basics of preventing maternal, fetal or neonatal morbidity or mortality and consider how to support the family’s human rights– rights inherent to all people, without discrimination, regardless of age, nationality, place of residence, sex, national or ethnic origin, color, religion, language or any other status. (White Ribbon Alliance, 2020)

Photo by Dipu Shahin DS: https://www.pexels.com/photo/baby-in-pink-and-white-blanket-4050647/

The first stated right is to be free from harm and mistreatment, yet we find continuing cases of physically and emotionally abusive treatment of pregnant and birthing women. Secondly is the right to competent, culturally sensitive care for both mother and newborn.  Next is  the right to companionship and support, and lastly the right to meet the basic life-sustaining needs of the dyad, including breastfeeding support for the newborn.

The first step toward respectful care is choosing  healthcare providers who value open, honest communication and who will discuss options and listen to the family’s needs and concerns. WHO defines respectful communication as communication which  “aims to put women at the centre of care, enhancing their experience of pregnancy and ensuring that babies have the best possible start in life.” (WHO, 2018)

Other components of respectful communication include the use of positive body language, active listening, the use of non-judgmental language, assuring patient privacy and honoring physical and emotional needs.  Respectful communication can begin with simply referring to the person by the name they prefer. If it is not documented, ask.

Another important step is selecting the birthing place. (Niles, 2023) Most care providers practice at one to two hospitals or birth centers. Choosing the birthing environment is an important decision in creating a birth experience which is in line with the family’s expectations and goals. Research and discussions with childbirth educators, lactation care providers and other families can give insights into common or routine practices at that institution. Will the family’s requests be honored? Will questions be answered with open and honest informed consent? Will the birthing and breastfeeding practices support their goals? These are all questions that need to be answered before a birthing place decision is made.

Creating an environment of respectful care in the birthing place is foundational. It is care that assures women and their families will be regarded as capable of making decisions. Making decisions which respect the values and unique needs of the birthing woman can only be made when patient autonomy– the right of patients to make decisions about their medical care without their health care provider trying to influence the decision–  is recognized.

Photo by Rebekah Vos on Unsplash

Individuals often comment on birthing in the hospital as a time when you lose all modesty; however, it is possible to follow protocols that set a standard for assuring privacy and modesty which can positively impact the birth experience. Simple steps like not discussing patient history or current conditions in front of others (without the patient’s permission), being mindful of covering intimate body parts (or culturally sensitive covering) whenever possible, asking permission before touching or knocking (and waiting for a response) before entering the room are a huge part of maintaining patient dignity. It cannot be overstated that any cultural requirements for modesty must be respected at all times.

More on respect in health care on Our Milky Way here, here and here.

Other recommended resources 

The International MotherBaby Childbirth Initiative (IMBCI) A Human Rights Approach to Optimal Maternity Care

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth: Report of a Landscape Analysis

 

Efforts to curtail dubious marketing practices of commercial milk formula industry

The commercial milk formula (CMF) industry uses marketing tactics similar to those of the tobacco, alcohol, and ultra-processed food industries.

Photo Credit: Boston Public Library
Date: ca. 1870–1900 https://ark.digitalcommonwealth.org/ark:/50959/3b591d51p Please visit Digital Commonwealth to view more images: https://www.digitalcommonwealth.org.

Earlier this winter, the Lancet published a three-paper series outlining the multifaceted and highly effective strategies used by commercial formula manufacturers to target parents, health-care professionals, and policy-makers.

“The industry’s dubious marketing practices—in breach of the breastfeeding Code—are compounded by lobbying of governments, often covertly via trade associations and front groups, against strengthening breastfeeding protection laws and challenging food standard regulations,” the Lancet summarizes.

Two new publications corroborate WHO findings on the digital marketing of commercial milk formulas in Mexico:

In another recent publication, Pediatricians’ Reports of Interaction with Infant Formula Companies, the authors found that: “Of 200 participants, the majority reported a formula company representative visit to their clinic (85.5%) and receiving free formula samples (90%). Representatives were more likely to visit areas with higher-income patients (median = $100K versus $60K, p < 0.001). They tended to visit and sponsor meals for pediatricians at private practices and in suburban areas. Most of the reported conferences attended (64%) were formula company-sponsored.”

The authors write that “Seventy percent of countries follow the World Health Organization International Code of Marketing Breast Milk Substitutes that prohibits infant formula companies (IFC) from providing free products to health care facilities, providing gifts to health care staff, or sponsoring meetings. The United States rejects this code, which may impact breastfeeding rates in certain areas.”

The Lancet series authors provide recommendations to restrict the marketing of CMF to protect the health and wellness of mothers and babies, and ultimately society and the planet.

  • Curtail the power and political activities of the CMF industry
  • End state practices that do not uphold, or that violate, the rights of women and children
  • Recognise, resource, and redistribute women’s care work burdens in support of breastfeeding
  •  Address structural deficiencies and commercial conflicts of interest in health systems
  •  Increase public finance and correct the misalignment between private and public interests
  • Mobilise and resource advocacy coalitions to generate political commitment for breastfeeding

In Mexico, UNICEF and Instituto Nacional de Salud Pública have designed infographics for policymakers as well as parents and caregivers to educate on the impact of digital marketing.

The partners are also working on proposed modifications to current Mexican regulations that involve commercial formula milk and ultra processed food marketing to infants and young children. Further, development is underway for a mobile app tool for monitoring the Code in Mexico.

Legislation in El Salvador was recently passed–“Love Converted into Food Law, for the Promotion, Protection, and Support of Breastfeeding.”

PAHO is monitoring the implementation of the Baby-friendly Hospital Initiative in the Americas BFHI requires full compliance with the Code and subsequent WHA resolutions.

In other efforts to protect parents and babies, Breastfeeding Advocacy Australia released a video on how the organization monitors predatory marketing. Find it here. You can find their Facebook group here.

Also read:

Follow IBFAN’s coverage of the 43rd Codex Nutrition Session of the Committee on Nutrition and Foods for Special Dietary Uses here.

Happy National Midwifery Week!

October 2 to 8 marks National Midwifery Week. National Midwifery Week was created by the American College of Nurse-Midwives (ACNM) to celebrate and recognize midwives and midwife-led care.

Two of my three births were attended by midwives. My first birth in a hospital attended by an obstetrician might best be described using words like chaos, fear, coercion, and out of my control. Juxtapose that next to my subsequent home births with professional midwives which conjure words like calm, empowerment, grounded, respect and safety.

Midwives aren’t only attending births though, providing personalized, ethical care, but as this year’s Midwifery Week theme embodies– Midwives for Justice– midwives strive for justice on many fronts. You can find out about the North American Registry of Midwives (NARM) national advocacy efforts here.

Midwives also play an integral role in establishing healthy infant feeding practices. Read the Global Breastfeeding Collective’s advocacy brief The Role of Midwives and Nurses in Protecting, Promoting and Supporting Breastfeeding here.

I am proud of and inspired by the work that my midwife Erin does beyond helping catch babies. You can read about her efforts as an ally here.

ACNM has created a beautiful toolkit to help us celebrate the midwives around us and the midwifery model of care this week and beyond. You can access that PDF here. It includes sample social media posts and ways to engage online, suggestions for community gatherings, and ways to celebrate accomplishments like parties, team building events and award ceremonies.  

Check out past celebrations of the midwife for still relevant resources like WHO’s declaration of 2020 as the Year of the Nurse and the Midwife and the International Day of the Midwives.

For further reading on midwifery care, especially indigenous midwifery care, check out Knowledge Keepers: Why We Need Indigenous Midwives and Giving Birth Where the Family IsCommonSense Childbirth and Changing Woman Initiative’s  Power of One Indigenous Midwifery Fellowship program at http://www.changingwomaninitiative.com/power-of-one-indigenous-midwifery-fellowship.html.

Past Our Milky Way coverage on midwives

Honoring midwives during Women’s History Month

Alabama birth worker facilitates holistic, sustainable care for families

Taking ‘if’ out of the equation

Skin-to-skin in the operating room after cesarean birth

High schoolers explore human placenta, learn about physiological birth

Happy Birth Day, a new project by Dr. Kajsa Brimdyr

An opportunity for normal birth

Renaissance Woman

Dr. Soo Downe: International Breastfeeding Conference presenter Sneak Peak

#MidwiferyWeek2022 #MidwivesforJustice

Lactation Counselor Training Course (LCTC) offered completely online for first time ever

In this uncertain time, it can be helpful to remember that we have control over the way we respond to the things we don’t have control over. Healthy Children Project joins individuals, businesses and organizations that have had to adapt to this strange, challenging Covid-19 situation. 

“When you face challenges, we have two choices: Let it stop you or find a way to grow and make a difference, even during challenging times. Now, more than ever, lactation counselors are needed to promote, protect and support breastfeeding families, even though we temporarily find ourselves in a place where face-to-face courses can’t happen,” says Karin Cadwell, Healthy Children Project’s executive director. 

Since social distancing and safer-at-home policies have been implemented, Healthy Children Project (HCP) was propelled to use this as an opportunity to offer the Lactation Counselor Training Course (LCTC) completely online for the first time ever. 

“While we still strongly believe that the experience of being together for the LCTC course has provided wonderful opportunities for meeting new friends and colleagues and networking, the changing times have propelled us to revisit the course delivery options,” Cadwell says. 

ALPP will offer an online, remotely-proctored CLC exam starting this week

The LCTC course combines up-to-date high level evidence, counseling training, policy and practice.

“I have learned so much already that medical school, 20 years of practicing and nursing four babies never taught me. (I am only in the second section!)” one participant shares. 

Another participant shares: “I was extremely happy with this course, as it was taught in a way that was inclusive, free of bias, and with much knowledge. In addition, the evidence that was provided was exceptional. Though I was not able to do this course in person, the instructors created a course that was not only highly educational, but also enjoyable. Thank you again to all that made this course happen.”

Photo by Charles Deluvio on Unsplash

The online LCTC is a self-paced online course presented in an engaging and energetic format through videos, self-check questions and competency verification and twice-weekly office hours with faculty to answer additional questions for online participants. 

“I am truly enjoying the format of this course and it definitely helps that you are all so entertaining and fun! I feel like I am sitting in your living room and you are telling me everything you know and it is quite lovely!” on participant exclaims.

The course should take 52 hours to complete (just like the in-person version).

“I’m so impressed with our participants. They are working on the course when they get back from a long day working in the hospital or in between their kids online school zoom meetings. They are finding ways to grow and learn, even with this new ‘normal’ we are all experiencing,” according to Healthy Children Project faculty Kajsa Brimdyr.

Offering the LCTC online has produced some unexpected benefits like accessibility. 

“I love that we are able to offer this to those who need the flexibility of online learning, those who may not be able to get five days off in a row can take this course on their own time, in a way that works for busy lives and schedules,” says Brimdyr.

“I enjoyed the teaching methods utilized and enjoyed the ability to work on training while having the ability to pause and do other duties for my employment as well,” another participant attests.

What’s more, faculty has gotten creative about how to best replicate the face-to-face experience. 

“The office hours are a popular aspect of the new online class,” says Healthy Children Project’s Anna Blair. “Karin and I have had a great time getting to know the participants and help them think about how to integrate the new information into their practice. It’s really fun. My dog, Sandy, occasionally joins us and I love seeing all the faces (and participants’ babies and dogs) on the screen during the office hours.” 

Blair continues, “It is so nice to connect with the participants who are going through this journey.” 

Participants have also shared that one of their favorite parts of the course is  the virtual office hours with faculty. 

“It is really helpful hearing some of the questions and answers people are asking/getting,” one explains. 

Participants can email questions in advance or ask questions during the office hours in the chat feature of the program. In the absence of in-person learning, this feature replicates the value of hearing others’ questions. Each office hour section is logged and labeled by topic so that students can revisit and review the questions at their convenience. 

Photo by Richard Jaimes on Unsplash

“We kept thinking about the phrase ‘Laurus crescit in arduis’ –Laurel grows in steep and difficult places,” Cadwell begins. “Not only have we seen amazing stories of resilience in the news and with our friends, our team at Healthy Children has been focused on making a difference in the world. We all have, and need, the opportunity to bloom. Learning together, we can share our experiences and knowledge. We have loved hearing from our participants during the course – their ideas, experiences and future plans. We all can work together to make a difference for breastfeeding families.”


To register for the Online Lactation Counselor Training, please click here.