The Power of Childbirth The Power of Childbirth Education as a Gateway to Education as a Gateway to

Making Changes in Maternal Making Changes in Maternal and Child Healthand Child Health

Tamara Wrenn, MA, CCETamara Wrenn, MA, CCEJust Us Women Productions, Just Us Women Productions,

LLCLLCP.O. Box 744P.O. Box 744

Harriman, NY 10926-0744Harriman, NY 10926-0744917-945-0765917-945-0765

www.JustUsWomen.org

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My Philosophy of Childbirth Education

Pregnancy is not an illness but a normal part of a woman’s lifecycle. Unless her pregnancy, labor or birth deviates from a natural & predictable physiological course she should be encouraged, supported and empowered to use her inner strength and instincts to give birth with a conservative use, if any, of medical and technological interventions.

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Setting the framework

Approach childbirth education as a scientific discipline whose major

concerns are helping expectant parents prepare for an optimal birthing experience and learning skills that will enhance wellness throughout life (Nichols, 2000).

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National Healthy Start Association The National Healthy Start Association believes that the Healthy

Start program offers the best models for the reduction of infant mortality, low birth weight and racial disparities in perinatal outcomes. This model emphasizes both the importance of community-based approaches to solving these problems, and the need to develop comprehensive, holistic interventions that include health, social and economic services.

Each Healthy Start project is mandated to develop a local consortium composed of neighborhood residents, medical providers, social service agencies, faith-based representatives and the business community. This consortium guides and oversees the design and implementation of the local Healthy Start project.

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ASK YOURSELF 3 KEY QUESTIONSIs your Healthy Start project where you

want it to be?Is your Healthy Start project where it

needs to be?Who is on your Healthy Start team?

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Take Home Message-Food for ThoughtCertified Childbirth Educators (CCE): trained healthcare specialists skilled in developing

evidence based curriculums that support the needs of mothers.

in collaboration with Healthy Start have the capacity to identify and address the specific perinatal health needs of a target population for the purpose of improving behavioral, policy and systems changes; and improving client self-efficacy and decision making skills.

through the use of a conceptual framework the interdisciplinary maternal child health team, inclusive of a CCE, can expand the use of evidence based practices in childbirth education.

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Healthy People 2010

16-7. (Developmental) Increase the proportion of pregnant women who attend a series of prepared childbirth classes.Potential data sources: National Pregnancy and Health Survey, NIH, NICHD; National Survey of Family Growth (NSFG) or National Health Interview Survey (NHIS), CDC, NCHS.As part of comprehensive prenatal care, a formal series of prepared childbirth classes conducted by a certified childbirth educator is recommended for all women by the Expert Panel on the Content of Prenatal Care.[49] These classes can help reduce women’s pain[50] and anxiety[51] as they approach childbirth, making delivery a more pleasant experience and preparing women for what they will face as they give birth. A full series of sessions is recommended for women who have never attended. A refresher series of one or two classes is recommended for women who attended during a previous pregnancy. At a minimum, the childbirth classes should include information regarding the physiology of labor and birth, exercises and self-help techniques for labor, the role of support persons, family roles and adjustments, and preferences for care during labor and birth. The classes also should include an opportunity for the mother and her partner to have questions answered about providers, prenatal care, and other relevant issues, as well as to receive information regarding birth settings and cesarean childbirth. Attendance is recommended during the third trimester of pregnancy so that information learned will be used relatively soon after presentation. Classes should begin at the 31st or 32nd week and be completed no later than 38 weeks. The refresher class should be completed at any time between 36 and 38 weeks.

Source: http://www.healthypeople.gov/Document/HTML/Volume2/16MICH.htm#_Toc494699663

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Healthy People 2010 Mid-Year Review Objectives that could not be assessed. At the time of the

midcourse review, data to assess progress were unavailable for childbirth classes (16-7).

As stated in Healthy People 2010, "Most developmental objectives have a potential data source with a reasonable expectation of data points by the year 2004 to facilitate setting 2010 targets in the mid-decade review.  Developmental objectives with no baseline [or data source] at the midcourse will be dropped."  Although some developmental objectives with no baseline data or data source were deleted as part of the Midcourse Review, the U.S. Department of Health and Human Services and the agencies that serve as the leads for the Healthy People 2010 initiative will consider ways to ensure these emerging public health issues retain prominence despite their current lack of data. Source: http://www.healthypeople.gov/data/midcourse/html/focusareas/FA16ProgressHP.htm

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Mothers surveyed who took childbirth education classes (CBE)

“70% said the classes helped them to better communicate with their caregivers”

Source: Listening to Mothers Survey II

Report of the Second National US Survey of

Women’s Childbearing Experiences

Childbirth Connection

# Surveyed Participated in CBE

Total 1,573 25%

519 first time mothers

56%

1,054 experienced mothers

9%

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Definition of a Certified Childbirth Educator

A certified childbirth educator (CCE) is a health specialist trained to be a resource and guide for women on issues of pregnancy, labor and birth. They are responsible for providing balanced information to clients that is accurate and evidence-based, including identifying social systems and policies based on the risks and benefits they pose to maternal, infant and child health and wellness. CCEs work with clients so that they can become informed decision makers in their own health care practices and choices.

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Advocates

The childbirth education movement was impacted early on by social, political and feminist influences.

International Childbirth Education Association (ICEA) was founded in 1960. It began as a federation of local consumer groups convened by the Maternity Center Association (now Childbirth Connections). Its motto was “Parents and professionals working together to provide parents with the knowledge of alternatives to make informed choices.” The catalyst for national chapters of CEA.

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LeadersASPO/Lamaze Summit on Childbirth and Perinatal

Education in Chicago 1994. Top three conclusions-1) increase the confidence women have in themselves and their ability to give birth without unnecessary interventions: 2) to increase the control women have over their healthcare and education; and 3) to improve the physical and psychological outcomes or pregnancy (Nichols, 2000).

Inclusion of childbirth education in HP 2010 goals organized by Lamaze international. Encouraged childbirth educators to begin a letter writing campaign to project committee members. It was included in the draft and subsequently adopted (Nichols, 2000).

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Teachers Example of 2007-2008 curriculum offered by Childbirth Education Association of

Metropolitan NY, Teacher Certification Program

HISTORY OF CHILDBIRTH; INDUSTRIALIZATION TO THE PRESENTANATOMY & PHYSIOLOGY OF PREGNANCY, LABOR & BIRTHTEACHING BREASTFEEDINGNUTRITION & FETAL DEVELOPMENTMEDICATIONS IN PREGNANCY, LABOR & BIRTHOBSTETRICAL TESTING AND PROCEDURESCESAREAN BIRTH & PREVENTIONTEACHING LABOR SUPPORTUSE OF ALTERNATIVE THERAPIES IN LABOR AND BIRTH; ACUPUNCTURE, HERBS, MASSAGE AND BREATH WORKTEACHING NEWBORN CAREPAIN COPING STRATEGIES FOR LABOR & BIRTH MATERNAL POSTPARTUM ISSUESPERINATAL LOSS PUBLIC SPEAKING TEACHING TECHNIQUES

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Change AgentChildbirth Connections (formerly Maternity Center

Association) Used its nurse-midwifery service in1948 to

provide “natural childbirth” classes emphasizing exercise, breathing and relaxation for the prenatal period and labor and birth (Ettinger, 2006).

Conducted first natural childbirth demonstration projects in Connecticut and New York. Nurse-Midwives taught a series of six-prenatal classes; one lecture and two exercise classes during the early stages of pregnancy and another lecture and two exercises during the last month on labor and birth (Ettinger, 2006).

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Little Known Fact

During a low risk pregnancyA traditional certified childbirth educator

spends 15-18 hours with a client over a 5-6 week period in her third trimester alone.

Prenatal care providers spend about 2-3 hours with a client over the course of her pregnancy during the routine 10 to 15 minute office visit (averages 13 visits).

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Financial Costs-The potential for impactTotal 2002 Medicaid Births 1,661,320Source: Kaiser Family Foundation, www.statehealthfacts.org/comparemaptable

Average Health Educator CostAnnual Median $41,330Source: US Department of Labor

Certified Childbirth EducatorsAnnual Median $49,008Source: www.swz.salary.com/salarywizrd

Cost for CertificationRange $505 to $1,450-does not include reading

materials and incidentals related to certification

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Financial Case for Health Insurance Coverage of Childbirth Classes

Enhance the image of insurance companies and managed care plans that provide coverage as a benefit (Nichols, 2000).

Prevention of high risk situations through childbirth education which is part of the wellness model (Nichols, 2000).

Childbirth classes open the door to the discussion of on-going women’s health issues.

Childbirth classes create a circle of trust where myths can be dispelled and healthy habits supported.

Decreases the risk of a surgical birth ($11,000) versus a vaginal birth ($8,800) (March of Dimes, 2007).

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Options for staffing Certified Childbirth Educators

1) Hire health educators who are certified childbirth educators.

2) Hire childbirth educators with a background in health education.

3) Train existing health education staff using nationally accepted childbirth education programs/standards (Broussard & Weber-Breaux, 1994 and Dietrich, 1997)

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PROBLEMS

IMMEDIATE CAUSES

ROOT CAUSES

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Problems

Only 1 in 9 (11% out of 1,573 women surveyed ) view childbirth education as part of routine prenatal care

Lack of integration of childbirth educators as part of interdisciplinary maternal infant health team

childbirth education has been institutionalized and lost within the medical model of pregnancy (sickness model)

Healthy People 2010 mid-course review-data to assess progress is unavailable

Limited community based/grassroots involvement in the delivery of childbirth education

Research on childbirth education has primarily focused on attitudes of birthing experience with limited focus on its promotion of health behaviors; and influences on self-care.

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Immediate Cause

Exclusion of childbirth education as a component of

comprehensive-holistic prenatal care.

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Root Causes

No particular order Insurance reimbursement policiesHealthcare economics Internalized racismHospital policiesCapitalismMedical institution monopoly on all things birth relatedMedical model of pregnancy elitismLack of knowledge of the historical development of

childbirth education, its relationship to the natural childbirth movement, and the related decrease of maternal mortality

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Long-range Plan of Action

Participatory research-ASK the women Childbirth education curriculums specific to cultural, economic, social and political

needs of communities Conduct studies on childbirth education that include health focused outcomes; health

promotion; nutrition; exercise; self-health advocacy (Koehn, 2002) Universally health coverage for childbirth education classes as comprehensive-

holistic prenatal care Decrease in use of the medical model of pregnancy care Decrease in medical institution monopoly on normal births Expand the use of grassroots/community control of birth Birth interests of women defined by individual communities Identify and implement research activities that support increasing the number of low-

income and women of color who participate in childbirth classes Develop a media/social marketing campaign for the target population that identifies,

supports, and extols the benefits of low-income women and women of color participating in childbirth education classes.

Federal financial support for the inclusion of certified childbirth educators on the Healthy Start teams

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Short-range Plan of Action

Standardize the use of certified childbirth educators on the Healthy Start teams

Integrate certified childbirth educators into research activities

Develop policy briefs addressing accountability for developing strategies to assess the HP 2010 progress.

Research and analyze the literature about childbirth education, its efficacy and cost-effectiveness

Evaluate childbirth education from a wellness model versus the traditional health education sickness model

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Take Home Message-Certified Childbirth Educatorstrained healthcare specialists skilled in

developing evidence based curriculums that support the needs of mothers

in collaboration with Healthy Start have the capacity to identify and address the specific perinatal health needs of a target population for the purpose of improving behavioral, policy and systems changes; and improving client self-efficacy and decision making skills

through the use of a conceptional framework the interdisciplinary maternal child health team inclusive of a certified childbirth educator can expand the use of evidence based practices in childbirth education

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References

Boyd, A. (2006). A Childbirth Educator Speaks Out for Increased Advocacy for Normal Birth. Journal of Perinatal Education, 15 (1), 8-10.

Broussard. A. & Weber-Breaux, J (1994). Applications of childbirth self-efficacy model in childbirth education classes. Journal of Perinatal Education, 3 (1) 7-14

Dietrich, L. (1997). Assessment and development of childbirth belief-efficacy model in childbirth education classes. Journal of Perinatal Education, 3 (1), 7-14

Ettinger, L. E. (2006). Nurse-Midwifery. The Birth of a New American Profession. Columbus: The Ohio State University Press

Humenick, S. & Nichols, F. (2000). Childbirth Education: Practice, Research and Theory. (2nd edition) Philadelphia, PA: W.B. Saunders Company

Koehn, M. L. (2002). Childbirth Education Outcomes: An Integrative Review of the Literature. Journal of Perinatal Education, 11(3), 10-19.

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References

Childbirth Connection by Harris Interactive in partnership with Lamaze International (2006). Listening to Mothers Survey II. Report of the Second National US Survey of Women’s Childbearing Experiences.

Document 11: Anne A. Stevens, “The Work of the Maternity Center Association, reprinted from the Transactions,” 10th Annual Meeting, American Child Hygiene Association, November 11-13, 1919. Asheville, N.C., WCCNY Papers, Archives and Special Collections, Hunter College, New York, N.Y. (WCCNY microfilm, reel 20, frame 209-31).

Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington (DC): National Academy Press; 2001.

March of Dimes Study Reveals New Data on the Cost of Having a Baby. Washington, DC (2007)