The Power of Childbirth Education as a Gateway to Making Changes in Maternal and Child Health

1
The Power of Childbirth Education as a
Gateway to Making Changes in Maternal and Child
Health

• Tamara Wrenn, MA, CCE
• Just Us Women Productions, LLC
• P.O. Box 744
• Harriman, NY 10926-0744
• 917-945-0765
• www.JustUsWomen.org

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My Philosophy of Childbirth Education

• Pregnancy is not an illness but a normal part of
  a womans 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 QUESTIONS

• Is 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 Thought

• Certified 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 womens pain50 and anxiety51 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/midcour
  se/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
• Womens 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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Leaders

• ASPO/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 Agent

• Childbirth 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 pregnancy
• A 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 impact

• Total 2002 Medicaid Births 1,661,320
• Source Kaiser Family Foundation,
  www.statehealthfacts.org/comparemaptable
• Average Health Educator Cost
• Annual Median 41,330
• Source US Department of Labor
• Certified Childbirth Educators
• Annual Median 49,008
• Source www.swz.salary.com/salarywizrd
• Cost for Certification
• Range 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 womens 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

• Hire health educators who are certified
  childbirth educators.
• Hire childbirth educators with a background in
  health education.
• 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.

22
Root Causes

• No particular order
• Insurance reimbursement policies
• Healthcare economics
• Internalized racism
• Hospital policies
• Capitalism
• Medical institution monopoly on all things birth
  related
• Medical model of pregnancy elitism
• Lack 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 Educators

• 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 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

26
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 Womens 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)