Tag: WHO

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Changing the culture of mother baby separation in one Northeastern hospital

“I got to touch him once and they took him right away from me,” Northern Light Eastern Maine Medical Center labor and delivery nurse Jennifer Wickett says, remembering the birth of her first child 19 years ago.

Wickett desired non-medicated births, but her three children ended up being born via cesarean sections for various reasons. Wickett’s personal birth experiences coincided with her early professional life, working at a hospital in Massachusetts as a labor and delivery nurse.

At the time, she explains, the process was this: the baby was born,  taken to the warmer, vitals and weight were recorded. The baby was wrapped in a blanket and held next to mom’s face for five to ten minutes and then taken to the newborn nursery.

Skin-to-skin in the OR, Healthy Children Project

“I hated that for my patients and I hated that for me,” Wickett says.

So Wickett singularly started changing that culture of mother baby separation.
Now, at Northern Light Eastern Maine Medical Center, Wickett attends about 95 percent of the c-sections, and she says she was able to “take control.”

“[Initially] I wasn’t tucking baby in skin-to-skin, but I was putting baby on top of mom with the support person helping hold the baby,” Wickett explains.
She deemed it the Wickett hold: baby placed chest down on mom with knees tucked under the left breast and baby’s head on the right breast.

Attending a Kangaroo Mother Care Conference in Cleveland galvanized her efforts: the evidence clearly supported skin-to-skin contact immediately after birth and beyond.  Fellow nurses, anesthesiologists and other team members were resistant, but Wickett and a few other fellow nurses who created the Kangaroo Care Committee kept at it, always leading with kindness and communication. Rather than approaching the process with an “I have to do this” agenda, Wickett involves and acknowledges all of the participants in the room.

For instance, to the mother, she asks permission while also explaining the importance of skin-to-skin contact.

“They’re in hook line and sinker when I explain that their body regulates their baby’s temperature,” Wickett explains. “They don’t want to give that baby up; they are not letting that baby go.”

To the anesthesiologist, she facilitates open communication. Wickett lets them know that she assumes responsibility for the baby. “Are you good?” she often checks in with the anesthesiologist, while minding their space to work safely and efficiently.

Wickett  makes certain to involve the partner in their baby’s care, asking them to keep a watchful eye over mom and baby.

Photo by Jonathan Borba

Just about half of the babies she sees begin breastfeeding in the OR, she reports. From the OR, babies are kept on their mothers’ chests as they’re transferred to the recovery room, continuing the opportunity to breastfeed. All in all, Wickett says that babies born by c-section at her hospital spend more time skin-to-skin than those who are born vaginally.

After a vaginal birth, eager nurses often disturb skin-to-skin contact to complete their screenings and documentation. Excited partners wanting to hold their baby tend to do the same.

In the OR though, Wickett says there are at least 30 minutes without these disruptions.  Once mother and baby are transferred to the PACU, mothers report decreased pain when skin-to-skin is practiced.

What’s more, Wickett reports hearing often “This baby is such a good breastfeeder!” because the babies have an opportunity to initiate breastfeeding within the first two hours of life.

The World Health Organization (WHO) recommends that immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth. The recent Skin-to-skin contact after birth: Developing a research and practice guideline synthesizes the evidence. [Read more here.]

Skin-to-skin, Healthy Children Project

Wickett and seven other colleagues had the opportunity to complete the Lactation Counselor Training Course (LCTC) last year.
While she says she would have loved to have been able to take the course in-person, Wickett still found the material and resources “fabulous.”

For the past four years, there’s been a vacancy in the perinatal coordinator position at her hospital, so Wickett hopes that her new credentials will allow her to fill the need.  In the meantime, Northern Light Eastern Maine Medical Center offers outpatient lactation visits. The center’s breastfeeding support groups halted during the height of COVID and have yet to resume; Wickett reports that they are trying to bring those back virtually.

Additionally, Maine residents have access to the CradleME Program which
offers home-based services to anyone pregnant up to one year postpartum.
In partnership with the Mothers’ Milk Bank Northeast , Northern Light Eastern Maine Medical Center became the first milk depot in the Bangor area.

You can read more Our Milky Way coverage on skin-to-skin after cesarean birth in  Skin-to-skin in the operating room after cesarean birth , The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth , and Skin to skin in the OR.

Also check out Skin to Skin in the First Hour After Birth; Practical Advice for Staff after Vaginal and Cesarean Birth Skin to Skin.

Find some beautiful KMC imagery here.

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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

 

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Monumental ‘Skin-to-skin contact after birth: Developing a research and practice guideline’ calls for immediate, continuous, uninterrupted skin-to-skin contact for all mothers and all babies from 1000 grams, after all modes of birth

In Western culture, we tend to trust the process of pregnancy and the capability of a human body to grow and nourish a fetus, but there’s a moment between then and the approaching birth of the baby and beyond when that confidence is lost. Among other reasons, loss of trust in the female body forces mostly unnecessary and often harmful interventions on the process of labor and birth. Thereafter, though the safest place for most newborns immediately after birth is skin-to-skin with their birthing parent, common maternity practices often strip the dyad of this sacred, critical transition diminishing the capability of the mother and the infant.

As the authors of The nine stages of skin‐to‐skin: practical guidelines and insights from four countries put it, alarmingly, “despite the research and compelling directives from world authorities, the implementation of immediate, continuous and uninterrupted SSC for all healthy mothers and newborns, regardless of feeding choice, has not become standard practice.”

Last month, Kajsa Brimdyr, et al published the monumental Skin-to-skin contact after birth: Developing a research and practice guideline.

Authors not in order of appearance: Kajsa Brimdyr, Jeni Stevens, Kristin Svensson, Anna Blair, Cindy Turner-Maffei, Julie Grady, Louise Bastarache, Abla al Alfy, Jeannette T. Crenshaw, Elsa Regina Justo Giugliani, Uwe Ewald, Rukhsana Haider, Wibke Jonas, Mike Kagawa, Siri Lilliesköld, Ragnhild Maastrup, Ravae Sinclair, Emma Swift, Yuki Takahashi, Karin Cadwell

It’s an “excellent overview of the huge quantity of evidence supporting skin-to-skin contact after birth and give evidence-based guidelines, endorsing the recommendations of the World Health Organisation, that ‘immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth,’” Andrew Whitelaw writes in this editorial.

Source: United States Breastfeeding Committee (USBC)

In the review, the expert panel– representing all continents but Antarctica– sifted through roughly 8,000 articles and ultimately pared down to only include those with a clear definition of immediate, continuous, uninterrupted skin-to-skin contact.

The panel concluded that “delaying non-essential routine care in favour of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviours.”

The guideline includes the Pragmatic Implementation Guide for Skin-to-Skin Contact after Birth which serves as a how-to for staff, preparing them to facilitate skin-to-skin contact before and during the birth. The document is downloadable here: Appendix S1.

Brimdyr points out that none of the information presented is new; instead it’s consolidated in a way that hasn’t been done before.

“It takes the expertise of so many people and puts it in one place,” she explains.

Brimdyr says she believes it will give practitioners the confidence to make this practice work for moms and their infants.

“All of these babies, all of our mothers really deserve this opportunity,” Brimdyr advocates. “They deserve to have the best start.  This research is so well established… the fact that we’re not doing it everywhere is absolutely upsetting.”

Also last month, Brimdyr released a new film, The 9 Stages of Premature Infants, which documents  the nine stages as demonstrated by premature infants. The film brings to life the implementation of facilitating skin-to-skin for this population of infants and their parents.

“There is something absolutely magical seeing how capable babies are that really transforms any words on a page into reality,” Brimdyr says. “The research has been there to say premature babies can do this, but it’s so much more powerful to see premature infants do this.”

You can find a collection of skin-to-skin research here.

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Centers for Disease Control and Prevention (CDC) changes their breastfeeding policy for HIV-infected mothers

Without major announcement, in February 2023,  the Centers for Disease Control and Prevention (CDC) changed their breastfeeding policy for HIV-infected mothers and no longer recommend advising against breastfeeding.

Photo by Paul Hanaoka

The new recommendation gets closer to the updated 2010 World Health Organization (WHO) guideline on HIV and infant feeding. Before 2010, “WHO guidance on HIV and infant feeding (UNICEF et al., 2003; WHO et al., 2006) recommended an individualized approach in which women living with HIV would be counselled on feeding options according to their household circumstances.”

The new CDC guideline acknowledges that, “For mothers on antiretroviral therapy (ART) with a sustained undetectable HIV viral load during pregnancy, the risk of transmission through breastfeeding is less than 1%, but not zero,” as determined in the PROMISE Study.

The guideline goes on to recommend “patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.” Read the full document here.

Organizations like the National Institute of Health Office of AIDS Research, the Infectious Disease Society of America and National Association of County and City Health Officials announced the new guidance, but it has gone largely unacknowledged in the field of lactation.

“This change in HIV policy serves as a reminder to always check sources. New research findings and policy reconsiderations make it imperative that the most up-to-date information is available to the families we serve,” Healthy Children Project’s Karin Cadwell PhD, RN, FAAN, IBCLC, ANLC comments.

Photo by Wren Meinberg

In the U.S., HIV diagnoses among women have declined in recent years; still, nearly 7,000 women received an HIV diagnosis in 2019. (The CDC has commented on the effect of the COVID-19 pandemic: “Data for 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state and local jurisdictions. While 2020 data on HIV diagnoses and prevention and care outcomes are available, we are not updating this web content with data from these reports.”)

How does the U.S. compare in their recommendations to other high-income countries?

The British HIV Assocation’s 2018 guidelines for the management of HIV in pregnancy and postpartum states that “Women who are virologically suppressed on cART with good adherence and who choose to breastfeed should be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation and the requirement for extra maternal and infant clinical monitoring” among other recommendations for helping manage lactation in HIV-positive mothers.

Photo by Laura Garcia

A National Health Service (NHS) Greater Glasgow and Clyde document Management of infants born to HIV positive mothers reads: “There is now evidence from developing countries that breast feeding while mum’s viral load is fully suppressed is safe, and BHIVA/CHIVA no longer regard a decision to breast feed as grounds for referral to child protection services. For HIV positive women who choose to breast feed, maternal HAART should be carefully monitored and continued until one week after all breastfeeding has ceased. The mother’s viral load should be tested monthly to ensure that HIV virus remains undetectable; this testing will be undertaken by the obstetric/ID team. It is recommended that breastfeeding be exclusive, and completed by the end of 6 months.”

You can learn more about Canada’s approach here and Switzerland’s here.

For more, check out  Lacted’s Clinical Question and the CDC’s Preventing Perinatal HIV Transmission.

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From Africa to Appalachia, improved relationships and communication through nutrition research

 From Africa to Appalachia, Stephanie L. Martin’s, PhD, CLC research on nutrition during pregnancy, lactation, and childhood, has gone beyond nutrition alone.

In a world where infant feeding is commonly reduced to input and output, “perfect” latches and weighted feeds, Martin’s work illuminates the added benefit of improved relationships and communication. 

In Zambia for instance, Martin and her colleagues have looked at how to engage family members to support nutrition in women living with HIV and their children. 

Twenty years ago, when antiretroviral therapy (ART) was less accessible, the risk of transmitting HIV through breastfeeding was high. Today though, with an increase in availability and access to ART, the World Health Organization (WHO) recommends the use of antiretroviral drugs as a safe way to prevent postnatal transmission of HIV through breastfeeding. 

Still, Martin has found that mothers talk about their fears of transmitting HIV to their infants the same way they did two decades ago. Mothers often use unfounded strategies like breastfeeding for shorter durations, breastfeeding less often or offering other liquids in an effort to limit the risk of transmission. So, Martin and her team have counseled mothers not to cut feedings short. Martin shares that her most recent Lactation Counselor Training has offered new insight.

“I’m going to change things in our counseling materials based on what we learned in the CLC training [in regard to] how we phrase things about breastfeeding for longer periods of time; if there is efficient milk transfer, we don’t need to focus on this longer length of time,” she explains.   

Additionally, in an effort to reduce caregivers offering infants under six months food or drink other than breastmilk, alternative soothing recommendations were offered. Martin remembers one mother who tried the suggestions to calm her crying baby. The mother reported that propping her infant onto a specific shoulder alleviated the baby’s discontent. “I don’t know what it was about that shoulder, but she stopped crying,” Martin quotes the mother, noting the importance of empowering mothers and caregivers through counseling. 

In Tanzania, Martin and partners at Kilimanjaro Christian Medical University College sought to identify  facilitators and barriers to exclusive breastfeeding among women working in the informal sector. And in Kenya, Martin and colleagues have worked to improve adolescent nutrition in informal settlements.

Martin pictured with colleagues from Kilimanjaro Christian Medical University College and Better Health for the African Mother and Child organization

Throughout all of her work in East and Southern Africa, Martin says they are reliant on community health workers to roll out their programs. 

“It’s so important to understand their experiences,” Martin says of hearing out the helpers. 

Through her research , Martin has explored the experiences of peer educators, community health workers, WIC breastfeeding peer counselors, health care providers, and program implementers.

Surveying global health professionals provides an opportunity to learn from their experiences and fill gaps in the peer-reviewed literature to strengthen intervention design and implementation as concluded in Martin, et al’s Experiences Engaging Family Members in Maternal, Child, and Adolescent Nutrition: A Survey of Global Health Professionals. 

Through Facilitators and Barriers to Providing Breastfeeding and Lactation Support to Families in Appalachia: A Mixed-Methods Study With Lactation Professionals and Supporters, Martin draws parallels in the challenges lactation care providers in Africa and Appalachia face, including compensation and availability of services. 

Specifically in Appalachia, the authors heard lactation care providers expressing the desire for additional training for providing support around mental health, chest feeding, drug use, etc. 

Martin says that she found the Lactation Counselor Training Course (LCTC) covered many of these topics. 

“[The course] seemed very intentional in all of the right ways,” she says. 

The Appalachian Breastfeeding Network (ABN) also offers an Advanced Current Concepts in Lactation Course which covers these desired topics with scholarship opportunities. 

When asked if she’s optimistic about the future of maternal child health, Martin answers with a slightly tense laugh: “I feel like I have to say yes.” Martin goes on to explain the inspiring work of ABN and all of the lactation care providers she’s interacted with.

“If they were in charge of the world, it would be such a better place,” she begins. 

“When I think about them, I feel optimistic. I’d like to see different laws that are supportive of women’s health and families. We have all the right people to make positive changes.”

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