Even Super Heroes Need Help! How Policy Makers, Home Visitors

Even Super Heroes Need Help! How Policy Makers, Home Visitors and Doulas Can Team Up to Support Healthy Moms and Babies 2018 Maryland MIECHV Conference Stacey Tuck, MS Kaitlin Law, MS RN Baltimore City Maternal and Infant Care Nurse Family Partnership Program

Today’s Session Objectives Discuss Maternal Mortality and Power dynamics when dealing with health care system Shine hope through discussion policy and ground level interventions Compare and contrast home visiting and doula work Highlight the B’more for Healthy Babies home visiting and doula collaboration Share other resources related to doula work

Maternal Mortality The rate of maternal mortality is now worse in the US than it was 25 years ago. – US: 20.7 – Maryland: 23.5 Of the 4,000,000 American women who give birth each year, about 700 suffer fatal complications during pregnancy, while giving birth, or during the postpartum period, and an additional 50,000 are severely injured. For Black women, the risk of death from pregnancy-related causes is three to four times higher than for white women, and Black women are twice as likely to suffer from life-threatening pregnancy complications.

Stress, Racism, and Implicit Bias High rates of maternal mortality among Black women span income and education levels, as well as socioeconomic status; moreover, risk factors such as a lack of access to prenatal care and physical health conditions do not fully explain the racial disparity in maternal mortality. Stress from racism and racial discrimination factors into hypertension and pre-eclampsia, which are especially high in African American women. Pervasive racial bias and unequal treatment against Black women happen within the health care system resulting in inadequate treatment for pain and dismissal of cultural norms. – Myths: Black patients have less-sensitive nerve endings and thicker skin than their White counterparts.

What we can do about it From a Policy Perspective Federal Level: Maternal Care Access and Reducing Emergencies (CARE) Act https://www.harris.senate.gov/imo/media/doc/ERN18510.pdf Creates two new grant programs focused on reducing racial health disparities in maternal health: Implicit Bias Training Grants: Addresses implicit bias—bias in judgment or behavior resulting from implicit attitudes and stereotypes—by establishing competitive grants directed to medical schools, nursing schools, and other health professionals training programs to support implicit bias training. Priority is given for training in obstetrics and gynecology. Pregnancy Medical Home Demonstration Project: Establishes a demonstration project to assist 10 states with implementing and sustaining pregnancy medical home (PMH) programs to incentivize maternal health care providers to deliver integrated health care services to pregnant women and new mothers and reduce adverse maternal health outcomes, maternal deaths, and racial health disparities in maternal mortality and morbidity. Directs the National Academy of Medicine to study and make recommendations for incorporating bias recognition in clinical skills testing for U.S. medical schools. State Level: House Bill 1518: Proposes changes to the State’s Maternal Mortality Review Board to make it more inclusive of community service providers, family members of women who have died during the antenatal period, greater emphasis on discrimination, racism and other psychosocial risk factors that contribute to maternal mortality. http://mgaleg.maryland.gov/2018RS/bills/hb/hb1518f.pdf

The Case for Home Visiting Reduces incidences of child abuse and neglect Decreases pre-term and low-birthweight births Improves school readiness for children and increases high school graduation rates for mothers participating in the program. Cost-benefit analyses shows that high quality home visiting programs offer returns on investment ranging from 1.75 to 5.70 for every dollar spent because of reduced costs of child protection, K-12 special education and grade retention, and criminal justice expenses.

The Case for Doulas Women who had doulas attending their births were four times less likely to have a low birth weight (LBW) baby, two times less likely to have birth complications, and initiated breastfeeding at a higher rate Strong association between doula care and healthy birth outcomes among women who are low income, socially disadvantaged, or who experience cultural barriers to getting care American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine, endorsed doula work in 2014 as effective, cost containing intervention https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647727/ http://onlinelibrary.wiley.com/doi/10.1111/birt.12213/full

The Role of a Doula-”woman who helps” Doula: a trained professional who provides continuous physical, emotional and informational support to a mother before, during and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible” – Physical Support – Emotional Support – Partner Support – Evidence Based Information and Advocacy https://www.dona.org/what-is-a-doula/

Comparing Home Visiting and Doula Care Home Visitor Pregnancy Birth Doula Relationship initiated 1-2 prenatal visits Monitor health / wellbeing of mother help develop a birth plan Postpartum Doula Optional 1-prenatal visit to connect / get to know mom’s goals / priorities / preferences Provide health education / anticipatory guidance for labor/birth/parenting Screen for perinatal mood disorders Labor and Delivery Provide anticipatory guidance Possibly review birth plan prior to labor Provide emotional support postpartum to process birth experience Breastfeeding Support woman to reach her long-term breastfeeding goal by: -Providing prenatal education / guidance -Link/refer to lactation services /WIC services -Provide hands on support postpartum and beyond - provide trouble shooting guidance throughout postpartum Length of 2.5-5 years depending on program relationship Provide Resources YES and Referrals Continuous emotional presence No involvement Practical physical support Assist the support person Protect the labor “space” Advocate for client to receive or avoid interventions. Stay with the mother after delivery of baby Assist with initial skin to skin / “Golden Hour” / Breast crawl Provide hands on support with establishing milk supply and initial latch Provide trouble shooting guidance in immediate postpartum Late pregnancy to immediate postpartum May have additional lactation training (either formal such as CLC or IBCLC or informal such as peer – counselor) “4th Trimester” – 3 months YES YES

Comparing Home Visiting and Doula Care Home Visitor Birth Doula Example of Service Home visits biweekly 1 to 2 prenatal appointments o Get to know each other o initiated in mid-pregnancy (before 28 weeks) review basic labor / child birth through child’s 2nd birthday education o review client’s birth plan and implementing evidence based curriculum priorities Continuous presence for duration of hospital labor/delivery Availability / On Call Day time / work week only Postpartum Continue home visits throughout entire postpartum period -screen for perinatal/postpartum mood disorder -education / assist with understanding baby cues -breastfeeding assistance -monitor postpartum “danger signs” in mother 1 follow up visit in hospital or in home w/in 10 days of delivery (emotional support, process labor/delivery/birth experience, immediate breastfeeding support) 1 to 3 scheduled daytime prenatal and postpartum visits. “On Call” 2 weeks /- due date Present for entire duration of in hospital labor/delivery 1 postpartum visit to provide closure of relationship and allow for client to process birth experience Postpartum Doula 1 prenatal appointment to connect / get to know each other Choose between daytime support vs night time support. Daytime support example: - six 3-hour visits to be scheduled anytime in the first three months postpartum Nighttime support example: - three nights of overnight support over the first 1-2 weeks postpartum See above for night / daytime example schedules. -Basic newborn care / assistance -Light Housekeeping assistance -Assist with newborn care while client showers, naps, etc - meal prep - assist with childcare of older children - breastfeeding assistance - assist with understanding baby cues - screen for postpartum mood disorder *bold are also role of HV

Birth Doulas During Labor and Delivery Offer continuous emotional presence Show compassion and support as a neutral party. Assist significant others and relatives in providing physical / emotional support (giving suggestions, helping them feel confident as support people). Give words of encouragement Practical physical support Suggest ideas around non-pharmacological pain management- (massage, position change, deep breathing, meditation, aromatherapy, music, offer ice chips/water, wipe forehead, double hip squeeze, help up to the bathroom etc.) Protect the labor “space” and promote productive labor Dim the lights Minimize interruptions / strangers (students) in and out of the room. Advocate for client to receive or avoid interventions. Examples include: “Did you want to ask the doctor ” “Can you give us a few minutes to discuss?” Help the client to “meet her birth plan” when possible Assist with initial bonding and stay with the mother after delivery of baby

How Doula Work has progressed in B’more for Healthy Babies

Community Doula Program Vision To empower community peers with a passion for antenatal care to serve as doulas for pregnant and postpartum women in Baltimore City as part of the array of BHB services.

BHB Doula Mission to ensure that selected Baltimore City residents who were selected to be trained as doulas have the support they need to become fully certified by April 2018.

BHB Continuum and Levels of Care Home Visiting (NFP, HFA, Healthy Start, Early Head Start) Outreach and Group-Based Programs (Baby Basics Moms Clubs, B’more Fit) BHB Overall (provider outreach, social marketing, centralized intake)

Results of BHB Baltimore Community Doula Project 10 women of color have received doula training 62 clients have been engaged between November and the present time 45 postpartum visits have been completed among 15 clients Trainees have received instruction in “doula 101” and some have received advanced training Family League is pursuing continuation funding

Doula Resources Doula Services Baltimore City/ County: Birth Companions Assist during births and with a postpartum visit for women delivering in any hospital [email protected] (410) 614-6458 DC/ Prince Georges County: Mamatoto’s Village Offers birth and postpartum doula services, doula trainings, and trainings for other maternal and child health workers www.Mamatotovillage.org 202-248-3434

Other Resources Books: The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions by Penny Simkin (2013, or later) Pregnancy, Childbirth and the Newborn: the Complete Guide by Penny Simkin, April Bolding, Ann Keppler, and Janelle Durham (2010, or later) The Doula Book: How a Trained Labor Companion Can Help you Have a Shorter, Easier and Healthier Birth by Marshall and Phyllis Klaus (2012, or later) DONA International’s Position Paper: The Birth Doula’s Contribution to Modern Maternity Care by DONA International (2012, or later) DONA International’s Position Paper: The Postpartum Doula’s Role in Modern Maternity Care by DONA International (2008, or later) Article: https://www.theounce.org/wp-content/uploads/2017/03/FirstDaysofLife.pdf

Want to learn more about maternal mortality, doulas, etc?

Thank you! Kaitlin Law, MS RN Community Health Nurse II/ Doula Baltimore City Health Department (410) 396- 9404 [email protected] Stacey Tuck, MS Director of Maternal and Infant Care System Operations Baltimore City Health Department (410) 396-9404 [email protected] *Ms. Law’s doula work is not affiliated with the Baltimore City Health Department or our home visiting program.