Abby Block, CD(DONA), CBC

Doula & Breastfeeding Support ~ Serving Brooklyn & NYC

evidence-based care

Evidence On Doulas

Abby BlockComment
DoulaHeader1.png

The following text and photo is excerpted from "Evidence on: Doulas" a recent article August 14, 2017 by Rebecca Dekker, on her incredibly informative website, Evidence Based Birth. You can read the full text of her article here: https://evidencebasedbirth.com/the-evidence-for-doulas/


Why are doulas so effective? 

There are several reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, laboring people are frequently submitted to institutional routines, high intervention rates, staff who are strangers, lack of privacy, bright lighting, and needles.

Most of us would have a hard time dealing with these conditions when we’re feeling our best. But people in labor have to deal with these harsh conditions when they are in a very vulnerable state. These harsh conditions may slow down a person’s labor and their self-confidence. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).

A second reason that doulas are effective is because doulas are a form of pain relief in themselves (Hofmeyr, 1991). With continuous support, laboring people are less likely to request epidurals or pain medication. It is thought that there is fewer use of medications because birthing people feel less pain when a doula is present. An additional benefit to the avoidance of epidural anesthesia is that women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).

This finding—that people with doulas are less likely to have an epidural—is not due to the fact that clients with doulas in these studies were more likely to want these things up front and were more motivated to achieve them. In fact, randomized trials account for these differences—this is why they are called randomized, controlled trials. The people assigned to have a doula, and those assigned to not have a doula, are randomly assigned, meaning that the same percentage in each group would have a desire for an unmedicated birth.

A third reason why doulas are effective has to do with the attachment between the birthing person and doula which can lead to an increase in oxytocin, the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010a study about effective labor support. In personal correspondence with Dr. Gilliland, she wrote, “I believe the Doula Effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother’s attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula… theoretically, oxytocin is the hormone of attachment, and it is released during soothing touch and extended eye contact, which are habitual behaviors of birth doulas.” (Personal communication, Dr. Amy Gilliland, July 2015).

Swedish oxytocin researcher Kristin Uvnas Moberg writes that the doula enhances oxytocin release which decreases stress reactions, fear, and anxiety, and increases contraction strength and effectiveness. In addition, the calming effect of the doula’s presence increases the mother’s own natural pain coping hormones (beta-endorphins), making labor feel less painful (Uvnas Moberg, 2014).

Based on the evidence, I have come up with a conceptual model of how doula support influences outcomes.

A conceptual model  is what researchers use to try and understand how a phenomenon works. Here is my conceptual model on the phenomenon of doula support.

 

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World Breastfeeding Awareness Month

Abby BlockComment

It's world breastfeeding awareness month! In honor of this, my next several posts will be focusing on breastfeeding information, resources, research, best practices, stories, and photos. I of course understand and respect that not all families I work with are breastfeeding, whether by choice or not, and there is of course some that fall in between. As a birth doula, I am always happy to support my doula clients any way they choose, however I find that most often, my clients are worried about and are asking me about breastfeeding -- usually right after birth and the postpartum visit. I had the great pleasure this year of becoming a Certified Breastfeeding Counselor, and am loving that I am able to provide a greater depth of support to my clients around breastfeeding.

To kick off the week, I want to share an awesome blog post from Lamaze's Science and Sensibility blog, which has excellent resources for breastfeeding or soon-to-be breastfeeding families.

Read the blog post here.

The Cesarean Rate Epidemic

Abby BlockComment

This article looks at the current rates, state, and climate of Cesarean Births in the U.S. It provides statistics and rates, reasons for Cesareans, as well as the associated risks. 

Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems to high.
— contemporaryobgyn.modernmedicine.com

An excerpt discussing the rising rates and unusual number of Cesarean rates below:

"One possible reason for the rise in the cesarean delivery rate may be that there has simply been a rise in the need for cesarean. The most common indication for a primary cesarean is cephalo-pelvic disproportion, or arrest of progress in labor. It is unlikely that maternal pelvis size has changed over the past 3 decades, but it is possible that birth weight has increased. In fact, evidence suggests that rates of macrosomia have increased over the past 2 decades.8 Other issues that contribute to increasing rates of cesarean delivery, possibly through the mechanism of birth weight, are maternal obesity and gestational weight gain.9,10 Without question, the proportion of obese women has increased over the past decade and higher weight classes are associated with even higher rates of cesarean.11,12 In addition, increased gestational weight gain has been associated with cesarean delivery and is commonly above standard guidelines.13

Another reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). Because there was no ICD-9 code for CDMR, it is unclear what proportion of cesareans are due to it. One recent study, however, estimated the proportion as high as 4% in the United States.14 Interestingly, CDMR is more common in other countries, such as Brazil, Taiwan, and Chile. A study in Chile comparing women receiving private care (cesarean rate >40%) to women receiving public care (cesarean rate <20%) found that 8% of those receiving private care and 11% of those receiving public care stated a preference for cesarean delivery, with the vast majority preferring to deliver vaginally.15 Thus, even in this setting, it is unclear that maternal preferences are driving the increase in cesarean delivery rate."

Full article can be read here: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/cesarean-epidemic-are-we-too-quick-cut?cfcache=true

 

Why delay cord clamping?

Abby BlockComment

Science and Sensibility, the research blog from Lamaze, has an excellently evidence based article on the practice of delayed cord clamping. The article is structured by listing objections, which is a great way to go about learning the benefits, as well as to be prepared to answer to someone's concerns about this practice. Delayed cord clamping is becoming so much better understood and common place. Many Ob and midwife practices in Brooklyn and NYC do this as a matter of protocol. 

Read the full article here

 

 

VBACs are more likely successful if you call the midwife

Abby BlockComment

A new study shows that VBACs (Vaginal Birth After Cesarean) are more likely to be successful if a midwife provides the care instead of an obstetrician. 

You can read a portion of the abstract of the study here, and an excerpt is below:

Background

Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England.

 

Conclusions

Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.

What to expect with your baby's weight after birth

Abby BlockComment

This is an excellent article, with very wise advice on baby's weight loss within a the first couple of weeks of life. If you have concerns or questions about your newborn's weight loss and milk intake, you are of course advised to seek support from a Lactation Consultant (IBCLC), a Certified Breastfeeding Counselor (CBC), or a Certified Lactation Counselor (CLC). Any of these lactation professionals should be able to support you or point you in the right direction.

An excerpt is below and the full article can be read here.

"This weight loss has nothing whatsoever to do with breastfeeding and milk intake.  In fact, the authors suggest that if clinicians want to use weight loss as a gauge of milk intake, they calculate baby’s weight loss not from birth weight, but from their weight at 24 hours.  According to their findings, this could neutralize the effect of the mother’s IV fluids on newborn weight loss.

This is one more reason weight loss alone should not be used to determine when newborns need formula supplements.   The Academy of Breastfeeding Medicine put this well in one of its protocols: “Weight loss in the range of 8-10% may be within normal limits….If all else is going well and the physical exam is normal, it is an indication for careful assessment and possible breastfeeding assistance.”

Postpartum & Breastfeeding Nutrition For the New Mother

Abby BlockComment

Postpartum nutrition! Many women aren't aware that for breastfeeding a newborn (or older baby), that often women need to eat more than they did when when they were pregnant! Of course, quality is important as well, as it's not just about getting enough calories.  The amount a breastfeeding mother should eat also depends on level of exercise, overall caloric needs, and other variables, or course. The best rule of thumb is to eat to your hunger, being mindful of making healthy choices whenever possible. Through recent research, we know that a mother's varied diet will encourage her child to enjoy a wide palette of flavors - all the more encouraging to eat well while breastfeeding! Check out the links below for more info on postpartum eating and nourishing the new mother:

Recovery From Childbirth: Postpartum Foods

Do Breastfeeding Mothers Need Extra Food or Fluids?

Nourishing the New Mom

Maternal Nutrition During Breastfeeding

New Evidence: Give Women More Time in Labor.

Abby BlockComment

This one is so simple, so straight forward. Give women a bit more time to labor and we can reduce the cesarean rate. This is of course assuming that everything points to the mother and the baby being in good health. As long as everyone is doing find, and the mother is game, let's create the space and be encouraging and supporting to women who want to labor just a bit longer and potentially avoid a c-section. This recent study showed that giving mothers just one more hour of time can cut the Cesarean rate in half. That's big. Here's the article you can read to learn more:

http://www.huffingtonpost.com/entry/new-evidence-that-we-just-need-to-give-women-more-time-to-labor_us_56ec4f66e4b084c672203418

US C-Sections Rate: Too High

Abby BlockComment

If you've been or are pregnant in NYC,  probably one of the first things you did was to figure out who your doctor would be and where you would give birth. You may have spent hours googling something like "NYC OB low cesarean rate," or "NYC hospital low c-section rate." And you may or may not have found the answers you were looking for. Consumer Reports just released an article reviewing the current state of cesarean births and rates by hospitals around the country. Many of the hospitals in NYC that my clients have given birth in do not release their statistics. Considering that your biggest Cesarean risk might be the hospital that you give birth in, withholding c-section rates by hospital (and even by practice or doctor) just doesn't seem ethical.

You can read the full article here: http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

Seeding the Microbiome

Abby BlockComment

This is a relatively new phenomena that has come up in the birth world as more and more research on the significance of gut health and our microbiomes has emerged. In birth, this applies in particular to a vaginal vs. Cesarean birth. During a vaginal birth, the baby is colonized, or "seeded" with bacteria from the mother's vagina, which leads to long term health benefits; in a Cesarean birth, the baby does not have the same bacterial colonization opportunity. It is because of this that some women are looking to simulate this process at the time of a Cesarean.

We are just now beginning to understand that many modern day health conditions, such as colon cancer, Autism, and mental health (just to name a few) are likely affected by the balance, or lack of balance, in good and bad bacteria in our bodies. Think of the recent surge in the understanding and promotion of probiotics, our understanding of antibiotics, and the fermented food movement. 

The recent documentary "Microbirth" focuses on bacterial health in birth, as well as some recent articles below. You can also check them out to understand how some women are choosing to take vaginal seeding into their own hands in the event of a Cesarean.

https://www.scienceandsensibility.org/p/bl/et/blogid=2&blogaid=825

http://www.positivebirthmovement.org/pbm-blog/category/gauze-seeding

http://www.mostlymicrobes.com/vaginal-seeding/

 

Advanced Maternal Age

Abby BlockComment

What does this mean? In the U.S., women who are 35 years and over who are giving birth are considered "Advanced Maternal Age" (AMA). According to the research, only about 15% of women who are giving birth are 35 years are older, however it's hard not to believe that rings true in NYC. I would estimate that about 1/3 of my clients could be categorized as AMA. The important thing to know about this, if you are 35 or over, is that your care provider may apply different policies to you than if you were under 35. Please read this very important article from Evidence Based Birth by Rebekkah Dekker, Mimi Niles, and Alicia Breaky for some well-rearched info on what AMA means in pregnancy:

The Evidence on Advanced Maternal Age

Placenta: Essential Resuscitation Equipment

Abby BlockComment

When people hear "placenta" these days, they may tend towards thinking about placenta encapsulation. What about the placenta's role and potential as the baby is born? This is fascinating article on the placenta, delayed cord clamping, and newborn resuscitation. It's a little bit birth-nerdy, but if you are interested in cord clamping and your newborn's transition to breathing on her/his own, please have a read!

Read the full article here from Midwife Thinking.

 

Partners & Doulas: What you need to know

Abby BlockComment

You've chosen your doctor or your midwife; you've decided on the hospital, the birthing center, or giving birth at home; you've decided on a natural birth or that you'll use pain medication or maybe something in between; you have a list of baby names; you have the baby gear list... so what's missing? Your doula, of course! For some couples, whether or not to hire a doula is not an easy choice. One of the main concerns I hear from couples - especially those who are planning to have a natural birth with full support of their partner - is that they wonder if a doula is really necessary. Completely valid question. Below is an article that gives you some perspective on the Doula and the Dad - although  prefer to use the term " birth partner" as there's not always a dad in every birthing couple!

Excerpt:

"But doulas aren't there only for moms-to-be. They also play a key role in helping their partners, offering them invaluable emotional and practical support during the overwhelming experience of childbirth. "I see myself as having many roles, fitting in where I am needed, lifting up and supporting the partner in order for them to support the laboring mom," says Zoe Etkin, a birth and postpartum doula and women's sexual health coach in Los Angeles. "Looking back on the birth, I hope they will both remember how connected they were, and I will just fade into the background. Although I believe my role is important, it's ultimately about the birthing couple."

Even so, it's common for dads-to-be to worry that having a doula during delivery might push them out of the main labor support role. Doulas insist that couldn't be further from the truth. "I'm there to accentuate their involvement, not to take their place," explains Gena Kirby, a doula of 10 years, childbirth educator, and host of Progressive Parenting radio. "Partners have taught me so much over the years about different ways to approach different personalities and births."

Full article here.

The Truth About Your Due Date

Abby BlockComment

Get some perspectives on your due date, or "EDD" (estimated due date), as well like to call it. Read what a midwife, a doula, an OB, a labor nurse, an acupuncturist, and a pediatrician have to say about. it And in case you didn't know already, only about 5% of women give birth on their due date. The rest of us tend to naturally go somewhere from week 37 (full term) to week 42. There are exceptions to this, of course - as always, with birth. My best advice on the "due date" situation is to consider it your due month, and when people ask you when you are due, you give them the month, not the date :)

Read the article on due dates from Well Rounded NY here.

The Forgotten Art of Untucking The Tail

Abby BlockComment

Very interesting as it relates to birthing a human...

“Modern birthing science has placed a large burden on secreted hormones (like relaxin) to prepare the body for needed mobility.” Katy Bowman says. Yes, hormonal relaxin is useful in letting the body open up for the birth, but it’s not enough, unless we have strong muscles that can fully contract, but also fully release. But then, strong isolated muscles are not enough either. In order to have smooth births we need to have a whole-body endurance. A great way to develop endurance is to walk as much as you can. “The woman who wants to go about a birthing process naturally can follow the lead other “natural” processes women have been doing for millennia — walking 5–6 total miles per day, and squatting to bathroom multiple times daily” — she adds.

Read the full article here.

 

Using a Mother’s Microbes to Protect Cesarean Babies

Abby BlockComment

"The first germs to colonize a newborn delivered vaginally come almost exclusively from its mother. But the first to reach an infant born by cesarean section come mostly from the environment — particularly bacteria from inaccessible or less-scrubbed areas like lamps and walls, and skin cells from everyone else in the delivery room.

That difference, some experts believe, could influence a child’s lifelong health. Now, in the first study of its kind, researchers on Monday confirmed that a mother’s beneficial microbes can be transferred, at least partially, from her vagina to her baby after a C-section."

Read the full article from the NYT Well Blog here.

The Big Baby Card

Abby BlockComment

Below is an excerpt from When A Big Baby Isn't So Big

"The new study, called Listening to Mothers III, was based on Childbirth Connection’s nationally representative survey of some 1,960 new mothers. It found that four out of five of the mothers who were warned they might have large babies gave birth to infants who were not large, and weighed less than 8 pounds 13 ounces.

Yet these mothers were almost twice as likely to have medical interventions such as having doctors medically induce their labor or attempting to self-induce labor, presumably out of concern the baby would continue growing otherwise. They were also nearly twice as likely as other mothers to have a planned cesarean, though the increase fell just short of being statistically meaningful."