Access in Healthcare

I have several posts written that haven’t been posted.  This is partly due to me trying to find my space in this new space, and partly because as we learn about and settle into a new practice in a new community, there is not much time for editing.  This article is from March of 2018 and examines our model of care through the lens of one of our programs, group prenatal care.  This program and many of the classes that spin off of requests made in the group, are open to all families, even if they are not in our care.  If you are in Memphis and want to join us for a program or come into care, please contact me.

As a community-based midwife I have been drawn to, pulled, and stewed in the places where midwifery and public health come together like a heated 32-beat tango.  Connected, dependent, free-spirited in nature yet grounded in science, this form of perinatal healthcare is my deepest heart’s work.  In Seattle our clinic, situated in the heart of a medically underserved neighborhood, was founded with the basic premise that we could reimagine healthcare.  The families, colleagues, health systems, and communities that participate in the care are committed to this mindset or to providing space within a more rigid system where we can explore the outer bounds of our ideas.  That organization continues to evolve and stretch into places and ways of being present for families and communities that astound me.  There are other midwifery-led clinics innovating and serving their communities around the US. Midwives are busy people, working through the wee hours trying to make a dent in maternal and infant health outcomes. In Memphis I am again working in an environment where that element of possibility leads us forward and exposes innovations as they naturally arise from our efforts to meet the needs of the families we serve.

Over and over again, wherever I am, I am taught a singular lesson about imagination and healthcare.  I am taught to follow my commitment to seek the strength and health of families I serve, even when it is not arranged as we are told it should be. When I first learned about labor I understood it to come in phases and stages which one neatly progresses through.  My doula certification required rote memorization of these steps, the signs of each one, and how to provide physical and emotional comfort and support for the pregnant person through labor and birth.  Yet I did not attend my first birth as a trained doula.  I sat in a small hospital birthing center with my brother and sister-in-law while they labored and birthed my nephew.  It was not my response to the phases and stages that provided her comfort.  It was my presence and attunement with her and my brother, my faith in her abilities, my interest in seeing my brother become a father from a place of strength, and my keen sense of wanting her to have a meaningful and timeless experience that mattered.  This experience was the first of many that taught me to look at pregnancy, birth, and early parenting as equally whole, layered, complex, and varied as the mothers and fathers I served. As equally needful of a response that understood both the expected norms and the reality and potential of the person in front of me.  I have witnessed alchemy a thousand and thousand times.  A shifting, morphing, and transforming moment.  Sometimes it is in prenatal care when a connection is made, sometimes during labor when the power of contractions takes a mother away from us and she retreats to a private universe, sometimes when she breathes her first breath as a mother to her baby now here, warm in her arms.

The science of pregnancy and birth is remarkable.  It allows us to support, aid, and even rescue mothers and babies every day.  As providers what do we have to learn from but the tools we are given?  Our books, our lectures, our machines that keep us moving in linear phases and stages through expected norms.  Those great teachers of mine gave and continue to give me command of the skills I need to care for families safely during their perinatal year.  But those other great teachers—the mothers, the fathers, the babies—they have informed me too.  From them I learned that the work I feel pulled to—this creation of micro-systems where families don’t just survive but really thrive and come into their fullness does not exist or occur in a linear progression.  It lives in the expansive reaches of our imagination.

It lives in discarding programs and services that always meet the needs of a linear and ordered system but rarely the true needs of the people in it. 

For many years I have run models of group pregnancy and postpartum care.  I have tested and tried curricula written by organizations committed to improving maternal and infant outcomes.  They have demonstrated success in these important areas.  The organizations that designed them have a lot of rules—so many people need to be present, they all need to be pregnant within about the same gestational age, they are assigned topics and facilitated, there is required attendance at a specified number of groups, they replace the individual visits with the midwife or doctor.  This makes perfect sense if we are trying to facilitate a group that teaches to the phases and stages of pregnancy and birth.  It makes perfect sense if we read any of the text books.  They all highlight “expected changes at this time” by trimester.  Naturally, we group pregnant people together who are the same gestational age experiencing the same changes.  We can conveniently teach to these issues and this does provide a kind of comfort—knowing that you are not alone in your changes and learning to adapt to them.  However, I have never been able to exactly stick to the prescription or the curriculum.  Usually because someone wants to participate but for work or life or financial reasons they can only get to a group that is running at a certain time.

Not the group they are slotted to, but to the group that is accessible when they can access it.

People arrive to group care full of ideas, needs, and questions that are totally unrelated to any prescribed content.  So what if the curriculum is the content of their lives in that moment? Ours is.

Now buckle up, I’ve said this before but let’s discover what it means:

When it comes to maternal and infant health,

there are only no answers if all of the answers are “no”.

If you are running a community-based clinic which fundamentally believes in access to care and services, you say yes a lot.  You say yes when the curriculum says no. You say yes when it means someone is going to skip a phase or jump over half of the progression.  You say yes when someone can come tonight but not again for six months.  You say yes when someone has never shown up but wants to sit in group now.  You say yes when a grandmother-to-be shows up with her pregnant child to explore this new model of care.  You say yes when a patient calls and tells you their car won’t start and they are out of money and they need a ride—even when it means the group will wait an extra five minutes to start. You say yes when a new mom shows up because she was lonely and knew that there was a prenatal group today.  You say yes because connection is the remedy for isolation and prevents depression, and her mental health matters.  You say yes because her presence there teaches the expecting mothers about what it looks like to care for a baby over the course of two hours in ways you could never script.  You say yes because someone else, maybe even someone else’s grandmother will hold and rock and walk that baby and tell her what a good job she’s doing.  You say yes because there are not limits on your imagination and you don’t see the people who come into care as limited, as broken, as needy, as powerless.  Your system does not rely on anything that resembles a normal healthcare delivery experience.  Why should it?  You are unbound so you are allowed to follow the dictates of the moment, the needs of the individual, the kindness that needs to manifest from your own heart.  And you are unbound so you can think with curiosity about the clinical presentation of disease, disorder, and dysfunction.  You are unbound so you can think about prevention and isolating a remedy that leads to health and not merely symptom management.

You can accomplish all of this in deep partnership with patients, clients, and their family members. 

And here’s what I’ve learned from saying yes.  As a provider, it is no toll on me to do so.  I don’t mean to be romantic about it–this is hard work.  It is also a remedy, a boon, and a manifestation of my humanity.  The people I work with feel the same way.  They are fanned out all over the city right now as you’re reading this bringing food, giving rides, sitting and listening, available, and present.  And in this example, of group prenatal care that evolves into group perinatal, parenting, god-parenting, and grand-parenting care, each person present feels their experience reflected in the shifting, morphing, and transforming moments of others.

We are learners and teachers, we are wise and vested and new and afraid.  We see where we are going, we feel where we have come from, we sit where we are.

We recognize the suffering and joy in others and freely bestow and receive compassion in that space.  This is a platform for health.  This is our platform for healthcare.  And this is one reason why I believe families in our care emerge with health outcomes that do not reflect the societal norms even though they have extraordinary life stressors. They are at risk for all of the risks, yet they very rarely manifest any of them.  This form of midwifery exists at the intersection of love and justice and healthcare.  It is not about leveraging the cost of healthcare, though it costs less. It is not about the birth. It is about good and even robust physical, emotional, and mental health where the right kind of birth in the right place for each family is the natural outcome of a platform where every idea has the potential to become a solution and every person is worthy of our best yes.

GBS Prevention

Read the long article

See the Infographics up-close

This post examines the role of preventative health care in the inhibition of Group B Streptococcus (GBS) infection.  It uses the term “mother” for simplicity’s sake although babies have all kinds of parents who identify in all kinds of ways and all are welcome here.

Let’s break down the long article:

Infections resulting from GBS  can be life-threatening to a newborn.  All pregnant moms are offered a test which detects this bacteria around 36 weeks of pregnancy.  If found, it can be treated through the use of IV antibiotics during labor, which significantly reduces the rate of infection and resulting meningitis and/or sepsis in newborns. While this article does not focus on the treatment of women who test positive, it does promote prevention, which improves the overall health of both mom and baby through the use of probiotics taken orally throughout the pregnancy.  These come in tiny capsules or a liquid packed with powerful lactobaccili (among other gut-friendly bacterium) that usually cost between five and twenty dollars per bottle or package).  It’s a small price to pay for so many amazing benefits.  As a midwife, I often pay for them for clients because of the massive health benefits of these supplements to every mom and baby, including avoiding a host of obstetric complications that would increase risks to mom and baby and often require transfers out of my care.  Great midwifery promotes the intrinsic health of mother and baby through programs like this which lend greatly to positive birth outcomes.

Let’s explore just some of the many benefits:

The Mother

Take a look at what the microbiota is if you aren’t already familiar with it.  The use of probiotics promotes this system that does a bit of everything good in the body including prevent the over-colonization of “bad” bacteria like GBS.  It also happens to prevent diabetes and keep your mood even.  It exists in the mouth, gut, and vagina of the mom and the placenta (and some studies found evidence in the fetal gut as well).

Over the course of pregnancy, the levels of good bacteria in the microbiota change.  By the time you give birth, you have an over-growth of lactobacilli which ensures that your baby will get exposure to this important “good” bacteria during vaginal birth.  When the system is supported right it will also prevent yeast infections, and keep the bacteria that cause UTIs and GBS in check.

The Baby

Impaired levels of probiotics have been correlated to preterm birth.   They are correlated because “bad” bacteria like GBS and candida (yeast) cause cellular damage to the cervix.  It loses its integrity and is not able to hold in the pregnancy as long as it should.  There are dramatic consequences for being born too early—the March of Dimes was founded because of babies born too early or too small.

When mothers take probiotics, they are found in the placenta and fetal gut and stay with the baby after birth to help regulate the baby’s microbiota.  That’s profound!!  You can help your baby synthesize vitamins and amino acids, regulate immune function, have smoother transitions between emotional states, and get a balanced healthy start just by taking probiotics during pregnancy.  After pregnancy, breast milk takes over the important function of populating the baby’s microbiota with everything it needs.

What Matters

  • Take probiotics throughout pregnancy to help keep your body hostile to “bad” bacteria and to strengthen the integrity of your tissue (muscles and skin included), especially uterine tissue like the cervix (and to boost your immune system, keep your mood even, etc., etc., and etc.!)
  • If you are planning a VBAC this winds up mattering a lot. Infections like candida and GBS can wear down the tissue that you are relying on to keep the scarred area strong and healthy.  Take a full dose of 4 probiotic capsules per day for your entire pregnancy.  I have supported an extremely high percentage of VBACing moms in my practice and this statement is NOT a judgment about your scar.  It is part of a recipe that will contribute to your overall success.  Check out this article for more ideas from the VBAC playbook or contact me to discuss further.
  • Have a vaginal, antibiotic free birth for maximum exposure to lactobacilli
  • Ask your provider ahead of time about swabbing your vaginal tract during labor prior to any antibiotics if you need them for any reason (including a planned or unplanned cesarean birth)
  • Regardless of how you deliver your baby, spend time skin to skin with her or him. Allow them to touch your breasts and arm pits with their hands.  You have lactobacilli on your skin that they will benefit from
  • Breastmilk feeds babies and promotes the growth of healthy bacteria in baby’s own microbiota, boosting their immune system and setting them up for good health
  • Babies born to a mom who had to take antibiotics or who were born by cesarean or who drink formula exclusively or as a supplement can all be given oral probiotics. They are available with a dropper or can be mixed into breast milk or formula and given through a bottle or made into a paste (just break open a capsule and add one drop of water at a time, mixing with your finger) and applied to mom’s nipples which is both soothing and healthy for the breast

Some disclaimers and information of note

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can eliminate or greatly reduce the high colonization. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Capture

You can see the source for these infographics and get an up-close view by clicking here

Share your thoughts on preventative health care during pregnancy and your comments and questions below!

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/

5 P’s from the VBAC Playbook: Lessons for Every Pregnancy

These 5 P’s have come to us by way of families who have been down incredibly difficult roads and have emerged wizened. You can use their wisdom to jump into your own best health and birth outcomes.

Parents who have birthed by cesarean often talk about what they didn’t know for their first birth.  By the time we meet, there is normally some recognition that they didn’t know because they didn’t access the information they could have. This is said without judgement of self or other.  We all do the best we can in the moments we have to navigate decisions.  But the list of “I didn’t know…” is a common thread in our prenatal conversations and VBAC support groups.  Every expecting family can use the lessons these families have grown to embrace.

“Preventing the Primary C-Section” is a phrase used in research that demonstrates the fallout from a first birth that falls into the 20-60 percent of all American births (depending on where you live) that end in an operative delivery.  Some cesareans are necessary, this is not an article slamming those of us who’ve had surgical births.  Regardless of origin, the data clearly shows that we tend to struggle with a host of problems as a result of that surgery. These extend well beyond the first baby and can have severe impact on the health of future pregnancies. (As a midwife who has cared for many, many VBACing moms, the data collected does not reflect the emotional and mental health implications, which is a whole other book we want to write book we need to write, or maybe just a blog post–check back frequently).

The American College of Obstetricians and Gynecologists put out a consensus statement called, “Safe Prevention of the Primary Cesarean Delivery” in which they state:

A large population-based study from Canada found that the risk of severe maternal morbidities––defined as hemorrhage that requires hysterectomy or transfusion, uterine rupture, anesthetic complications, shock, cardiac arrest, acute renal failure, assisted ventilation, venous thromboembolism, major infection, or in-hospital wound disruption or hematoma––was increased threefold for cesarean delivery as compared with vaginal delivery (2.7% versus 0.9%, respectively).  (source) There also are concerns regarding the long-term risks associated with cesarean delivery, particularly those associated with subsequent pregnancies. The incidence of placental abnormalities, such as placenta previa, in future pregnancies increases with each subsequent cesarean delivery, from 1% with one prior cesarean delivery to almost 3% with three or more prior cesarean deliveries. In addition, an increasing number of prior cesareans is associated with the morbidity of placental previa: after three cesarean deliveries, the risk that a placenta previa will be complicated by placenta accreta is nearly 40%.  (source)

The most important moment of your pregnancy might be right now.  Did you just skim that last paragraph–assuming that these things won’t happen to you?  Take a deep breath, exhale, and know that with some preparation and education the one single thing during your pregnancy or birth that you can be assured of is that nothing in your birth experience happened because you made the choice not to face it, grapple with it, ask questions about it, become educated and engaged with your provider about it.  Take a step into becoming a highly informed consumer.  It is your right.  Pregnancy and birth are the first links in a long and multi-string chain of decisions and consequences that you will make for yourself as a parent and for your baby.  Approach with curiosity, flexibility, and a mindset that you can learn all you need to know.  Sink into the idea and the belief that you can rely on that knowledge along with your inner wisdom to forge your way into parenthood. Don’t relinquish your power by standing by, looking the other way, or ignoring the questions and ideas in your mind.

So let’s get to it.   The explanation with these is intended as a starting point for you to begin your exploration of the options–if you have questions ask them!! Ask people you know and trust, read books that are evidence based or thoughtful and inclusive.  There is no one answer that is right for everyone and your answers might change as your pregnancy progresses.  That’s normal, act on your education and knowledge!  Don’t be afraid to ask in the comments and we can identify some resources together.

The 5 P’s that can help Prevent that Primary Cesarean birth:

Place
I know, this is not the first item you might expect to find on this list.  But for planning your birth, you need to work backwards.  The place you want to birth determines what kind of provider and even specifically which provider you can choose.  Hospital, Birth Center, Home birth?  Where do you imagine yourself when you meet your baby?  Who is around you?  What does it sound like?  If you are unfamiliar with out of hospital birth options, take a gander at this great book for a stress-free introduction to it all.  If it is a hospital, take a look at their cesarean section rate.  A huge percentage of your birth will be impacted by where you are and the system at work there.  In a hospital the protocols and procedures generally determine the way that a provider acts.  If the hospital has high rates of intervention you should expect that to effect your experience.  Some would argue that certain hospitals have high rates because they see high risk patients.  Guess what?  We believe what we will see long before we actually see it.  If the experience is that women fall apart and need saving during labor, one might ask how much of the beliefs and behaviors affect outcomes for all women who birth there. It is not born of neglect or bad intention, but we know what we know what we know what we know.  And we do, what we know.
Model of Care
Your provider has been trained in a specific way–and they have adapted their training and developed their own style.  There’s no way to know what you’re getting until you ask.  Typically speaking you can get all of the same tests and screens from and OB or a midwife (nurse or licensed).  The focus of care differs with each provider–the time, approach to education, resource-sharing, and commitment to shared-decision making will all vary.  What do you want?  Go and meet with a few different providers who offer births at the location of your choosing.  The right fit will be clear after three interviews for most families.
Participate
Not to ring a bell too many times in one blog post.  You can go back and read why it is so important to take active, intentional steps to become a highly informed consumer.  If you don’t hesitate to ask what comes on the turkey sandwich and tell them what you like and don’t like at a restaurant, you certainly need not hesitate to ask what to expect from your care, state your needs as they arise, and switch providers if something is not working well, or you get an impending sense of discomfort.  Read, gather, discuss, bring your ideas to your visits, ask all the questions, tell all the ideas you have–it all matters so so much.  Taking the step into your strength as an informed consumer will change your life.  It will also show you if you have a provider who will engage with you on mutual terms.  This is not about fighting or being obstinate, it is about learning and engaging in the learning process with a person who should be a great teacher for you.
Prevent
Your pregnancy is a time to set up the environment of your body for optimal health.  A lot of people approach chronic conditions during pregnancy with the mindset that if we can just “get through this time” we can work on it after the baby.  But you are laying the brickwork for how you feel everyday.  You don’t have to suffer.  You don’t have to greet your baby in anything less than vigorous good health–find a provider who will approach you as a whole person and a mother, not just a vessel that needs to stay together just enough to support the life of your baby.  You are your baby’s health–the chances are that if you don’t feel well, the placenta isn’t going to get the life support it needs to do what it is designed to do for all the days your baby needs it.  You are the soil, sun, and water of your baby’s growing physical and mental health.  Rich in nutrients, full of energy, and supported with just enough of all of the building blocks–not too much or too little, you can grow a healthy, full term baby.
Predict
A provider who pays attention to you and the messages your body is giving will better offer care that answers the prediction of what might happen next.  This can be long-term:  something in your health you want to work on that you feel is at a tipping point.  Labs that come back that can be corrected before they get out of control.  Or it can be short term.  A provider who knows you will believe you and act immediately if you have a sign or symptom that is a red flag.  A provider who knows you knows your family health history and will work closely with you to see into the future and offer solutions and resources to support you in writing the health story you want for your and your baby’s life.
The more healthcare consumers approach their healthcare as consumers with consumer rights the more providers feel like this applies to them. 
These 5 P’s have come to us by way of families who have been down incredibly difficult roads and have emerged wizened.  Families can use their wisdom to jump into your own best health and birth outcomes.
What have your best moments been as a healthcare consumer?  What advice would you give other families as they prepare for pregnancy and birth?

What do you imagine?

“…It is a design which rises up the mother as a qualified expert on her body and her baby. That is not to say that she knows everything. All experts get help, advice, and learn from others. So can she, but without relinquishing her role as primary in the relationship with her health…”

Today I attended a breastfeeding research update at a local (I’m now living in Memphis, y’all!) hospital.  The two-hour long program was aimed at providing understanding and context around the recent uproar regarding Sudden Unexpected Postpartum Collapse and best practices for breastfeeding.  Long story short:  keep practicing safe feeding and sleep practices and keep feeding your baby and keep looking for hospitals with the baby-friendly designation.  It matters.

I was struck there (and said so at the end of the program so this is not news to anyone who was there) by the quantity of information, data, charts, opinions, expectations, to-do lists, not to-do lists, etc…that providers are expected to impart on brand new moms.  The best of brains at the best of times has about 5 minutes of capacity and will recall just about three things if you carefully point out that you want them to remember the three things, explain them and review them in short to the point terms.  A postpartum brain will not under any circumstance recall pages of information, diagrams, or lectures albeit usually lovingly given, prior to discharge.  It’s not a mystery why parents and babies suffer from the very things we providers are “teaching”.  The only mystery is that we all keep moving our mouths when all the science tells us that’s probably not the way a pregnant or newly postpartum mother will learn.

Let’s shift the paradigm.  Let’s ask questions, listen, and contextualize the information that matters to each family.  Let’s sit down on the bed or in the rocking chair (rocking is notoriously good for you–among other benefits it releases endorphins– so this is a win-win, you’ll come away from the conversation feeling calmer and more energized) and talk with moms ask moms questions and listen to their responses.  How do you imagine feeding your baby when you get home?  Where will you sit?  Where will you rest?  Where is your baby while you’re resting?  Who is around you?  What kind of items are near you?  What kind of questions do you have?

As you can see–the conversation that will unfold out of her idea about what being a mother means to her will give lots of opportunity to get into all of the items on your checklist but most likely she will actually bring them up herself!  Does it cost more?  More than what?  Healthcare costs drop when patient-provider conversation increases.  Does it take longer? Longer than if we teach her to pay attention to her own sense of wonder, knowledge, and ability to ask questions and find a willing and engaged healthcare provider?

Take a moment, take a breath, people feel good when they feel heard.

Nurses often talk about the pressure related to the patient ratings they receive–this is very real and very terrifying in terms of job security.  If you want those high marks you can get them by listening and responding to the woman or family in front of you with kindness and more listening.  That is human nature, it is biology and physics at play in the world and you can rely on it to bring you higher job satisfaction and moms and dads and babies a healthier postpartum experience where they can really engage in the process of learning about each other, from each other, with you as their support system.  That is participatory medicine at it’s best. That is the true meaning of patient-centered care.  It is a design which rises up the mother as a qualified expert on her body and her baby.  That is not to say that she knows everything.  All experts get help, advice, and learn from others.  That’s most likely exactly how they got to be experts. So can she, but without relinquishing her role as primary in the relationship with her health.

Can you imagine the outcomes in a world where we ask new mothers what they imagine and provide healthcare education that is timely, relevant, and meaningful to them?   Do you remember what you imagined about yourself as a mother or father?  Did you get support to grow you in that work?  Do you want to learn more about how to be this kind of provider?  Share your story!