Centrul ProMama’s Magia Maternity facilitates skin-to-skin in Romanian hospitals

Romania suffers from one of the highest infant mortality rates in Europe.

The simple and inexpensive practice of “skin-to-skin contact immediately after birth is recognised as an evidence-based best practice and an acknowledged contributor to improved short- and long-term health outcomes including decreased infant mortality,” as articulated by the authors of Skin-to-skin contact after birth: Developing a research and practice guideline.

Photo courtesy of Centrul ProMama
https://www.facebook.com/promama.ro/posts/pfbid02N5nf5CJk47SbEkDFFoQnSB29SuxvHQuTLRCJCBiZ8HDSMBks9ucDgErH4JqeQDHAl

One Romanian organization, Centrul ProMama led by Sorana Muresan and Andreea Manea and their colleagues are working to implement immediate, continuous, uninterrupted skin-to-skin contact as the standard of care for all mothers and all babies across the country through their Magia Maternity Program.

The program provides medical staff  with about five hours of theoretical training, consulting on the practical implementation of The Magical Hour in the delivery or operating room, and a four-hour breastfeeding course. The program also includes six months of follow-up consultation.

Officially established in 2019, much of their work began in 2012, when Muresan and Manea facilitated a partnership with Healthy Children Project. As a result, the team helped implement The Magical Hour in two public and two private hospitals.

“We still remember the impact that we had during this time together!” the duo exclaims. “We learned and observed extraordinary things about skin-to-skin between the baby and the mother in the first hour after birth!”

The team goes on to report: “It took us six years to launch our programme. That was after hard work, offering antenatal classes where we constantly talked about the importance of skin-to-skin contact, organizing conferences and other events on the subject and lobbying to the Minister of Health. We even launched campaigns on social-media and television.”

Photo courtesy of Centrul ProMama
https://www.facebook.com/photo?fbid=665390452405066&set=pcb.665390772405034

During this time and sometimes today still, medical staff show(ed) less enthusiasm than Muresan and Manea.

“Many doors closed before our eyes, some brutally, others with a smile,” they remember the reluctance.

Over the years, facilitating skin-to-skin after birth has gained traction in their country though.

In the autumn of 2023, the ProMama team shared a Facebook post reporting an empty newborn nursery. Instead, all of the babies were with their mothers, a testament to the growth and effectiveness of the Magia Maternity Program.

“Some [staff] practice this routinely, but others in the public hospitals still have rigid bureaucratic procedures, which stands in their way of practicing the Magical Hour,” the ProMama team explains.

Romania is up against some of the highest c-section rates in Europe, around 40 percent.

“We believe that it is because we are not properly or only superficially informed about pregnancy, even though we have information about childbirth everywhere. In addition, mothers are anxious, some of them are over 35 years old and also have some medical problems,” the team suggests.

Learn about this little guy and his mom here: https://www.facebook.com/promama.ro/posts/pfbid034h1hChHFS6aQm8Pi189FtzTUGov5NXdtAaXNzoM1rvQ4dikoVCZHNPMKPM21BuoEl

Though high c-section rates are cause for concern, difficulty implementing skin-to-skin after a surgical birth is only a perception. Check out the following pieces to learn about how maternal child health advocates are changing the culture of mother baby separation after c-section here, here, here and here.

Muresan and Manea explain: “The Magical Hour and the immediate initiation of breastfeeding can compensate a lot in case of c- section and it is one of our goals as prenatal educators to promote the physiology of birth and the postpartum period.”

As humans have adopted more and more technological advances, the Magic Hour is often described as a “new” concept, when the practice is actually ancient. Muresan and Manea reflect on the phenomenon of how our modern lives often interfere with the natural, physiological processes of our reproductive experiences.

“We …feel that this is a kind of paradox,” they begin. “Something so natural, so physiological and instinctive shouldn’t need so many scientific arguments. Despite this, doctors still have doubts in practicing the procedure…It’s a great step that science has come so far and that medicine can now save more lives! The problem is that it interferes very much with nature and we can no longer or no longer want to trust our instincts.”

Closing out 2023, the Magia Maternity Program had reached its seventh maternity hospital.

The team is happy to report that with the support of Dr. Vaso Edvin “…amazing things are happening.”

In an effort to continue to spread knowledge about the importance of skin-to-skin contact, the team gathered a group of influential individuals from different sectors including Karin Cadwell and Kajsa Brimdyr of Healthy Children Project at the CONFERINȚA MAGIA MATERNITĂȚII – Ora Magică în România.

“We wanted to approach the topic from different angles – medical, maternal and social,” the team shares. “It was also important for everyone to listen to the specialists from Healthy Children Project to learn what meaningful studies they have so they can understand how a single hour right after birth can improve a child’s health and development in all areas.”

The team emphasizes the life-long impact skin-to-skin offers.

As such, Muresan and Manea say that the Magia Maternity Program is their most important project.

“Our wish is for the MAgic of MAternity program to become a national program because we strongly believe that this is the natural path to healthier children, generations and society…To achieve this, we need to enable mother and child to be together and fall in love with each other after birth. This way, mothers feel comfortable, are encouraged to breastfeed and have a beautiful relationship with their children in the future. Of course, the medical staff should be there to observe, protect and preserve mother and child…The emotions we experience at every birth when we see the face of the new mother with the newborn at her breast cannot be put into words! It is moving to tears!”

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!

******

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

 

Self-care strategies for lactation care providers

Tomorrow is World Mental Health Day. Read on about self-care strategies for lactation care providers.

Image credit: WHO

When a gas-powered vehicle is low on fuel, it’ll often show signs of fuel starvation like a sputtering engine and intermittent power surges. Eventually, when the engine dies completely, the hydraulic power to the brakes and steering lose power too. Steering and stopping is still possible at this point, but it requires greater effort.

Perinatal professional Sara BhaduriHauck, CLC of Mandala Motherhood analogizes the vehicle and the human body and how self-care and nurturing mental health is crucial to providing sustainable care.

“It feels good to give,” she begins, speaking from the perspective of lactation care provider. “But you can only give so much.”

Learning to sense the feelings and sensations that warn us of burnout, is like filling up the gas tank when it hits a quarter tank.

“Keep an eye on your gas tank,” BhaduriHauck advises.

This wisdom of self-discipline, knowing when to stop giving to others so that one can give to themselves, allows for a healthy care provider/client relationship.

Liba Chaya Golman, CLC with lev lactation shared her struggle after a particular session: “I just met with a dyad dealing with weight loss and low supply and while we have a short term plan and pediatrician involvement, I am feeling so emotionally spent after the consultation. I’m empathetic by nature and became a CLC after my own difficult breastfeeding experience. I feel capable of managing the situation and have people to refer to and rely on, but came home and cried after the visit.” Soliciting tips for lactation provider self-care, BhaduriHauck offered up some suggestions.

“I find therapy to be an amazing self-care tool, especially when client situations trigger my own traumas,” she shared. “The situations that hit us the hardest shed light on the areas inside of ourselves that need some tender attention.”

BhaduriHauck endured traumatic birth experiences herself, like so many maternal child health care providers who are drawn to this work because of personal challenges that they endured.

After slogging through our mental health system,  BhaduriHauck eventually connected with a trauma-informed therapist specializing in EMDR and a perinatal mental health specialist. Later, BhaduriHauck pursued training as a postpartum doula.

“Doing that work and learning how to help other people also helped me help myself,” she explains. “You have to have healed enough of your own emotional stuff to put it down and to pick up someone else’s, but in learning to help others, I was also learning how to support myself.”

She continues that journaling allows care providers to give their feelings space and “attention to be seen and articulated.”

“Sometimes I just need the space to express them before I can let them go,” she shares.

Affirmations are another avenue of self-care for care providers to explore.

BhaduriHauck uses this one most often: This work isn’t about its outcomes. It’s about making a difference.

“Over-giving/over-investing is something I fall into naturally, and I have to work at creating distance between a client’s situation and my responsibility to it,” she explains. “Reminding myself that me just doing my job, makes a world of difference to the client [and]  helps me release some of the big feelings I’m holding onto about the client’s situation.”

BhaduriHauck acknowledges two types of processing: active and passive.

Going to therapy, having someone who is trained in validating and providing empathy, is an example of active processing. When our feelings are “infused with empathy,” as BhaduriHauck puts it, “we can put them away inside ourselves softer.” The opposite of this can happen if we have not chosen the listener appropriately, she warns.

Passive processing sometimes comes in the form of slowing our pace and down regulating our nervous systems. For BhaduriHauck, she finds a calmer state of being by going for a walk, snuggling her dog, or taking a hot bath. In these scenarios, she might not be actively processing trauma or emotions, but she’s giving her body space.

Intentionality in practice can help preserve mental health, and allow a care provider to be a more effective support person too. BhaduriHauck suggests checking in with oneself, “Am I doing this in service of the client, or in service to myself?” If it’s the latter, there are better avenues to pursue the boost of “feeling good by doing good” and/or getting the assurance that “my knowledge is valuable”.

BhaduriHauck shares some final thoughts on mental health as a lactation care provider. “The emotional learning I’ve done in becoming a care provider and overcoming my own struggles, they’ve gone hand in hand.  My experiences help other people and others’ experiences have helped me in learning emotional management techniques. When I talk to parents… I can listen without it triggering past traumas.”

Photo by Madison Inouye

She goes on, effective care requires the provider to have trained themselves to embrace the emotional component of the work in ways that are in service to their clients.

In 2021, the CDC issued a call to action to protect health care workers’ mental health. You can find that  information here.

The National Alliance on Mental Illness (NAMI) offers resources for Health Care Professionals including peer and professional support options. Find those resources listed here.

Praeclarus Press offers Burnout, Secondary Traumatic Stress, and Moral Injury in Maternity Care Providers, an opportunity to learn about the stresses of maternity care and how to care for yourself on the job. Learn about the course here.

VA Maternity Care Coordinator (MCC) program facilitates specialized care for military Veteran parents

For new families, healthy, evidence-based infant feeding education and support can be hard to come by, but among this often barren landscape of support, the VA Maternity Care Coordinator (MCC) program provides an oasis for military Veteran mothers.  

Retired USAF Lt Col Tammy Tenace BSN, MS, APRN-BC, now Women Veteran Education, Outreach and Research Coordinator  for James A. Haley Veterans Hospital in Tampa, Fla. says that the VA understands that pregnancy and parenthood often requires specialized care.

About a decade ago, as care providers started to notice that lactation and breastfeeding support was severely limited in civilian communities, they established the MCC role. MCCs maintain contact with Veteran families throughout the perinatal period, facilitating care that meets their specific needs. 

Because the VA does not provide obstetric care, the MCC acts as a liaison between the VA and the community obstetrical provider. MCCs follow Veterans through pregnancy and postpartum at one and six weeks postpartum. [https://link.springer.com/article/10.1007/s11606-019-04974-z]  The VA supplies Veterans with lactation supplies like breast pumps, nursing bras, nursing pads, storage bags, etc.

The MCC role has been established at every VA medical center, and Tenace has served as MCC at her hospital since 2016.  

Photo by George Pak : https://www.pexels.com/photo/family-sitting-on-sofa-beside-house-plant-near-the-windows-7983863/

Throughout the COVID-19 pandemic, what little perinatal support existed in civilian spaces, dwindled to almost nothing, Tenace points out. 

Hospital breastfeeding support groups, while only meeting a couple of times a week, stopped meeting altogether. Women weren’t allowed support people or their partners at appointments, and they began to feel isolated. 

“I realized I needed to do something; I couldn’t depend on the community,” Tenace says.  

Working through the Office on Women’s Health as a subject matter expert, VA National Consultant for Lactation Ashley M. Lauria, MA, RD, LDN, IBCLC helps establish standards of care in lactation programs at VA facilities nationwide. 

Tenace and Lauria both comment that among the hundreds of parents they have cared for, it is truly a rarity for an individual to express disinterest in lactation. Their experience reflects national numbers, where most dyads start out breastfeeding. 

Women Veterans are the fastest growing group among the Veteran population. In fact,  “by 2040, VA estimates they will comprise 18% of the Veteran population, versus just 4% in 2000,” according to a VA Pittsburgh press release.

In order to keep up with this demand, Tenace and her colleagues are in the process of curating a Certified Lactation Counselor (CLC) program. Made possible through funding from the Women’s Health Innovations and Staffing Enhancements (WHISE), ten of their staff members are completing the Lactation Counselor Training Course (LCTC), including Tenace, physicians, a health coach, advanced practice nurses, among others. 

“The most up-to-date information is really important,” Tenace begins. “[We are all] unlearning the things we thought we knew. The course has been instrumental to helping us feel like we are actually helping women, instead of relying on the knowledge that we thought we had. The course is detailed and professional, yet practical. The practicalness is what’s to our advantage. It’s how we actually help women breastfeed.”

Photo by Timothy Meinberg on Unsplash

Tenace and Lauria go on to explain that their efforts are Veteran-led. That is, their facilities host quarterly focus groups where they can learn about Veterans’ requests. 

“We want to know from women: what do they want?” Tenace comments. 

Because Veteran women often prefer support groups comprised of other Veterans, Lauria offers virtual lactation support groups that also act as social circles and a place for comradery. 

As James A. Haley Veterans’ Hospital designs new facilities, Tenace has been invited to offer input on the creation of lactation space for both employees and patients. Tenace applauds their leadership for focusing on improvement for the patient and employee experience. She also highlights that the newly designed main entrance will host a lactation pod. 

“I can’t think of a better way to show commitment,” she adds.  

Tenace and Lauria have embodied a passion for birth and lactation since their youth. Their work with the VA allows them to continue their mission to celebrate parents and their families and position themselves as life-long learners, evolving with the needs of Veteran mothers. 

 

Photo by Brianna Lisa Photography: https://www.pexels.com/photo/mother-breastfeeding-her-child-in-park-11620457/

For more on VA maternity care services visit https://www.womenshealth.va.gov/docs/WomensHealthReproductiveHealthBrochure508.pdf

More on Veteran Health https://www.commonwealthfund.org/blog/2021/birth-equity-Veterans-and-servicemembers  

Regulations and resources for all military branches https://www.mom2momglobal.org/bficb 

Coverage for pregnancy and lactation care in the military health system https://www.military.com/daily-news/2021/11/01/tricare-cover-doulas-lactation-consultants-some-starting-jan-1.html