CAPPA Position Papers

Position Papers

CAPPA has strong positions on the subjects for which we provide certification. Please click the links below to download our position papers on each field in PDF format.


Labor Doula Position Paper


CAPPA Position Paper - Evidence-Based Labor Doula Care
Introduction

Childbirth is not simply a medical event. Having a baby is an experience that is remembered forever by the woman and her family. It is an experience that changes the dynamics of a family as well as the entire life of each family member. It is more than just another day, and the way a birth unfolds will affect a woman's confidence as a person and mother, her self-esteem, and her relationships with others. This is true for her husband/partner as well.

CAPPA believes that women in labor require the safety of skilled healthcare by a qualified physician or midwife. However, they also require emotional support, information, reassurance, encouragement, respect, and love. Each woman will have different needs, both medically and emotionally due to her individual situations and desires. A labor doula can meet many of these non-medical needs and assist the woman's caregivers in their goal of a good outcome for mother and baby and a good birth experience for the mother. Doulas provide guidance and encouragement to minimize the pregnant woman's fears and anxiety. The continuity of care provided by doulas contrasts with the experience of many women who have little contact with the person assisting with their birth. (Koumouitzes, 2006)

Labor Doulas as Part of the Birth Team

Women have complex needs during pregnancy, labor, birth, and immediate postpartum. Doula care represents a return to the tradition of woman-to-woman support during pregnancy, labor, birth, and the immediate postpartum period. (Meyer, 2001) Throughout history women have been surrounded by other women. There was usually a midwife present and then one or more other women to help the mother to remain as comfortable as possible, and to comfort, reassure, and protect her space as she labored. Today, labor doulas continue this tradition of providing support, information, and non-medical comfort measures to assist the laboring mother. Continuous support during labor should be the norm, rather than the exception. Labor doulas are professionals; trained, and experienced in childbirth. The doula has a long term commitment to the woman and through her intimate knowledge of the woman's needs and expectations; she provides individualized care that includes physical, emotional, and informational support to the mother and those who are attending her. One of the most important roles of the labor doula is to attend to the mother's emotional needs during labor, birth, and immediate postpartum as positive emotional care can strengthen bonding with her infant. The labor doula will assist the father or other birth partners by giving suggestions of what will be helpful to the mother, giving them a break, and making sure that they eat, drink, and rest to maintain their strength. In addition, the labor doula will assist the family in gathering information and asking the questions necessary to make informed decisions when the need arises, although the doula should never make decisions for them. She will assist the mother and her partner to find the best methods to relax and encourage labor, including helping with maternal position change, breathing, relaxation, imagery, massage, acupressure, and other comfort measures. For middle-class women laboring with the support of their male partner, the presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. (McGrath, 2008) The labor doula does not leave the laboring woman, maintaining continuity of care throughout the labor and birth. Labor doulas provide and specialize in only non-clinical aspects of care of the laboring woman. A labor doula will not perform any medical tasks, such as fetal or maternal monitoring, vaginal exams, blood pressure, or other vital signs. Medical providers (midwives, doctors, and nurses) must focus on the medical needs of both mother and baby and those needs take precedence over non-medical and psychosocial needs of the woman and her fetus. Thus the labor doula is a perfect addition to the maternity care team as the role of the doula specializes in meeting the non-medical needs of the woman. Adding the role of the labor doula makes for a more well-rounded maternity care team. A labor doula does not diagnose medical conditions, will not give medical advice or second opinions, and will not project her own agenda and values onto the laboring woman. Doulas encourage and support self-advocacy for the couple. Labor doulas work to help the woman have a safe and satisfying birth experience, according to the mother's goals she has set for herself. When a doula is present, many women find there is less need for pain medication, while other women may choose to utilize pain medication to assist them as they labor. A labor doula is also very beneficial to a woman who has chosen pain medication as she continues to labor. Doulas can help minimize the undesirable side effects of pain medications by providing emotional care, maternal positioning, reassurance, comfort measures, and information.

Labor doulas do not replace the mother's partner - her husband, the baby's father, or other friends or loved ones. They work together with family and friends of the mother's choosing and many times this support allows those present to be more actively involved. The partner provides love and support that the labor doula can never provide, as he/she knows the mother intimately and possesses a love that can come from no one else. The labor doula can offer unique help to the partner and friends by providing suggestions for him/her, and allow the partner, loved ones, and friends to participate at their comfort level. The labor doula and the partner, in conjunction with the medical caregivers, form the perfect support system for the laboring mother. The roles of the obstetrical nurse and the professional doula differ markedly, yet they also overlap somewhat and should complement each other. (Gilliland, 2002) Nurses and doulas can establish a working relationship and work effectively together. (Ballen & Fulcher, 2005) The labor doula's mandate is to work in tandem with health care staff to support a woman in having a safe and satisfying childbirth experience. Having a labor doula present improves medical outcomes. Doulas work in three primary models: private practice, hospital-based programs using volunteers or paid doulas, and community-based programs. Each model of care has advantages and disadvantages. Through utilization of culturally sensitive, community-based doulas pregnant and parenting teens are provided with a comprehensive relationship-based nurturing. (Breedlove, 2005) Young mothers can have quite positive outcomes and the support a doula gives can be a positive behavior change for teens. (Logsdon, 2006) It seems that a key contributor to postpartum depression may be the gap that exists between lack of social support and caring for the woman during the several weeks before and following birth. The doula may be the link to bridging the gap that may exist between medicalized birth, lack of social support, and postpartum depression. (Goldbort, 2002) Research by Hodnett indicates that women who are supported by a doula are more likely to be satisfied with their childbirth experience. (Hodnett, 2003) As doulas and childbirth educators feel and remain centered, they may effectively continue the journey to educate, support, and nurture pregnant women and their partners in times of stress, trauma and grieving. (Pascali-Bonaro, 2003) In order to provide the best care possible, it is essential that the doula and other medical professionals accept and respect each other's unique roles. Labor doulas can help the medical team meet the laboring woman's physical and emotional needs. Together doulas and medical professionals can work together for positive birth outcomes and the betterment of all birthing families.

In 2003, a national survey of doulas working as paraprofessionals the following results were found:


Doula Services

There are four types of doula programs: independent doula services, community-based doula services, agencies who offer doula services, and hospital-based doula services. Independent doula practices are employed directly by the expectant parents. The labor doula schedules several meetings to assess the expectations of the couple and establish a working relationship. When the woman is in labor she contacts the labor doula to arrive; the doula stays throughout the labor, birth, and immediate postpartum time. Doula agencies are often communitybased and the doulas may be volunteers or paid employees. Some agencies serve specific populations (i.e. incarcerated women, teens, women in poverty, etc). Some doula programs have an extremely diverse population such as the Cambridge Doula Program. Pregnant women in this program are served by per diem labor doulas who speak a dozen languages. (Brill, 2005) Some programs (i.e. Doulas Care program) offer a model in which doulas provide services without charge. (Low, 2006) In some agencies, the doulas may meet with the couple in pregnancy and in other programs the doula only meets the pregnant woman when she is in labor. Agencies often train and employ their own doula staff. Doulas of hospital-based programs may be volunteers or paid employees. Some hospitals contract with agencies to staff their doula service. Other hospital-based programs are set up as an on-call service. The labor doula may meet the pregnant woman prenatally or may not meet her until labor has begun and establishes a relationship then. In some hospital-based programs, the pregnant woman meets and chooses her doula during pregnancy and that doula is on-call for the birth. In other programs, the labor doula is assigned to the pregnant woman during labor. (Perez, 2010)

Research on Labor Doulas

In 2011, the Cochrane Library reported on 21 clinical studies, from 15 countries, involving more than 15,000 women in a wide range of settings and circumstances. The continuous support was provided either by hospital staff (such as nurses or midwives), women who were not hospital employees and had no personal relationship to the laboring woman (such as doulas or women who were provided with a modest amount of guidance, or companions of the woman's choice from her social network such as her husband, partner, mother or friend). Women who received continuous labor support were more likely to give birth 'spontaneously', i.e. give birth with neither cesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labors. Their babies were less likely to have low 5-minute Apgar scores. We conclude that all women should have continuous support during labor. Continuous support from a person who is present solely to provide support, is not a member of the woman's social network, is experienced in providing labor support, and has at least a modest amount of training, appears to be most beneficial. Doula support should not exclude other social support. Support from a chosen family member or friend appears to increase women's satisfaction with their childbearing experience. (Hodnett, 2011) In Chicago, the Chicago Doula Project was started to assist pregnant teens. The Chicago Doula Project was a collaborative effort of three agencies: Chicago Health Connection; the Ounce of Prevention Fund; and the Illinois Department of Human Services. The teen moms who worked with a labor doula had 43% fewer cesarean sections, 74% fewer epidurals, and 70% higher initial breastfeeding rates. This is a tremendous achievement for a group of already at-risk teen moms.

Having a labor doula has also been studied in regards to breastfeeding initiation and success. In a study done in Mexico and reported in the British Journal of Obstetrics and Gynecology, it was found that significantly more mothers were exclusively breastfeeding at one month past birth. More of the mothers who had labor doulas also felt they had a high degree of control over the birth experience than those mothers not attended by a labor doula. (Langer, Campero, Garcia, Reynoso, 1998) A hospital-based doula support program is strongly related to improved breastfeeding in an urban, multi-cultural setting. (Mott-Santiago, 2008)

A meta-analysis of 11 clinical trials showed that having a labor doula present continuously throughout labor significantly shortened labor, and decreased the need for analgesia, Pitocin, cesarean sections, and forceps. (Scott, Berkowitz, Klaus, 2000) Another meta-analysis again showed shortened labors and decreased use of cesarean births, forceps, and vacuum extraction, Pitocin administration, and analgesia. Mothers who used labor doulas for their births also rated childbirth as less difficult and painful than those mothers not supported by a labor doula. (Scott, Klaus, Klaus (1999) - Langer, Campero, Garcia, Reynoso (1998) and Zhang, Bernasko, Leybovich (1996)

In 2007, a clinical trial was reported that examined the association between doula support and maternal perceptions of the infant, self, and support from others at six to eight weeks. In this study there is a minimally trained close female relative or friend. Overall, when doula-supported mothers were compared with mothers who received standard care they were more likely to report positive prenatal expectations about childbirth and positive perceptions of their infants, support from others, and self-worth. (Campbell, 2007) A study by Van Zandt, Edwards, and Jordan showed that interventions of baccalaureate nursing students, trained as doulas, were examined for their association with epidural anesthetic use. Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Analysis showed an association of lower epidural use with increased complementary doula interventions and an association of higher epidural use with longer labors. These findings support previous research of decreased analgesia use by doula-supported women and suggest benefits of the interventions by student nurse doulas. Students trained in providing low-tech supportive care may change the environment for intra-partum nursing practice. Institutional changes may be required to allow greater opportunity for intra-partum nurses to provide support to laboring women. (Van Zandt, 2005)

CAPPA Labor Doula Training and Certification

CAPPA believes that all women who want a labor doula should have one and to ensure this, CAPPA encourages labor doulas to become trained and certified. CAPPA provides the highest quality trainings and focuses on teaching non-medical comfort measures such as massage, positioning, breathing, relaxation, how to assist the laboring mother and her partner emotionally, how to provide unbiased and evidence-based information, and how to start and run a labor doula practice. CAPPA offers onsite labor doula seminars as well as distance learning. The onsite seminars and the distance training option use a standardized curriculum, with the distance option providing a way for doulas in remote areas around the world to train using video (DVD or online) to bring the training seminar to the doula. To attain certification as a CAPPA labor doula, the doula must attend an approved childbirth class series, an approved breastfeeding class, read books from the approved reading list, complete additional online learning modules, pass a written exam, and provide positive evaluations from three mothers they have worked with, their physicians or midwives, and their nurses.

Conclusion

Pregnancy, labor, and birth are all part of the pregnant woman's life continuum. How the woman is supported during that time is vitally important to not only her, but her baby and others in her family unit. Based on the evidence and research available, labor doulas should be an integral part of the woman's support system during the childbearing year. Labor doulas improve the outcome, both medically and emotionally, for the mother and her partner as well as the baby. One of the most critical roles of the labor doula is providing continuous reassurance, comfort, and emotional support during labor and birth. Doulas make every effort to ensure that the pregnant woman is empowered and respected during the labor and birth process. CAPPA supports the availability of labor doulas to all women who want one.


References
Ballen, Lois E. and Fulcher, Ann J. (2005) Nurses and Doulas: Complementary Roles to Provide Optimal Maternity Care. J Obstet Gynecol Neonatal Nurs, Mar-Apr, 35(2):304-11.

Breedlove, Ginger. (2205) Perceptions of Social Support from Pregnant and parenting Teens Using Community-Based Doulas. J Perinata Educa, Summer, 14(3):15-22.

Campbell, D., Scott, KD, Klaus, MH, Falk, M. (2007) Female relatives or friends trained as labor doulas: outcomes at 6 to 8 weeks, Birth, Sep, 34(3): 220-7.

Gilliland, Amy. (2002) Beyond Holding Hands: The Modern Role of the Professional Doula, JOGNN, Nov/Dec, 31(6):762-769.

Goldbort, Joanne. ( Dec. 1, 2002 ) Postpartum Depression: Bridging the Gap Between Medicalized Birth and Social Support, IJCE, Vol 17, No. 4, 11-17.

Hemminnki, E.; Virta, A.L.; Kopinen, P.; Malin, M.; Kojo-Austin, H.; Tuijmala, R. "A Trial on Continuous Human Support during Labor: Feasibility, Interventions and Mothers' Satisfaction.: Journal of Psychosomatic Obstetrics and Gynecology (1990): 237-250.

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Hodnett, E.D., and Osborn, R. "Effect of Continuous Intrapartum Professional Support on Childbirth Outcomes." Research in Nursing & Health 12 (1989): 289-297.

Hodnett, E.D., Gates S, Hofmeyer, J.G. & Sakala, C. (2003) Continuous support for women during childbirth, Cochrane Database of Systematic Reviews, Issue 3, Art .No.: CD003766.

Hodnett, E.D, Gates, S, Hofmeyer, J.G., Sakala, C, Weston, J. (2011) Continuous support for women during childbirth, Cochrane Database of Systematic Reviews 2001, Issue 7.

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Kennell, J.H.; Klaus, M.H., McGrath, S.K.; Robertson, S.S.; Hinkley, C.W. "Continuous Emotional Support during Labor in a U.S. Hospital." Journal of the American Medical Association 265 (1991): 2197- 2201.

Klaus, M.H.; Kennell, J.H.; Berkowitz, G.; Klaus, P. "Maternal Assistance and Support in Labor: Father, Nurse, Midwife or Doula?" Clinical Consultations in Obstetrics and Gynecology 4 (December 1992).

Koumouitzes, Douvia, J & Carr, C. A. (2006) Women's perceptions of their doula support. Journal of Perinatal Education, 15 (4), 34-40.

Lantz, PM, Low, LK, Varkey, S & Watson, RL. (2005) Doulas as Childbirth paraprofessionals: Results from a National Survey, Women's Health Issues, May-Jun, 15(3): 109-116.

Low, LK, Moffat, A & Brennan, P. (2006) Doulas as Community Health Workers: Lessons Learned from a Volunteer Program, J Perinata Educa, Vol 15, No 3.

McGrath, SK, Kennell, JH. A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth, Vol 35 (2):9297.

Meyer, BA, Arnold, JA, & Pascali-Bonaro. (2001) Social Support by Doulas During Labor and the Early Postpartum Period, Hospital Physician, Sept 2001, 57-65.

Logsdon, MC, Gagne, P, Hughes, T, Patterson,J & Rakestraw, V. (2004) Social support during adolescent pregnancy: Piecing a quilt, JOGNN, 34, 5, 606-614.

Mottl-Santiago, J, Walker, C, Vragovic, O, Stubblefield, P. (2008) A hospitals-based doula program and childbirth outcomes in a urban, multicultural setting, Matern Child Health J, May, 12(3):372-7.

Pascali-Bonaro, D. (2003) Childbirth Education and Doula Care During Times of Stress, Trauma and Grieving, Journal Perinatal Education, Fall, 12(4): 1-7.

Perez, P., and Snedeker, C. Special Women: The Role of the Professional Labor Assistant. Seattle: Pennypress, Inc., 1990.

Perez, Paulina with Thelen, Deaun. (2010) Doula Programs: How to Start and Run a Private or Hospital-Based Program with Success!, Cutting Edge Press, Johnson, Vermont.

Brill, Julie. (2005) The Cambridge Doula Program: Helping Women Access Their Deepest Courage, Midwifery Today, Fall. Simkin, P. The Birth Partner. Boston: Harvard Common Press, 1989.

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Scott K.D., Klaus P.H., Klaus, M.H. (1999) "The Obstetrical and postpartum benefits of continuous support during childbirth". Journal of Women's Health and Gender Based Medicine. 8(10): 1257-64.

Scott, K.D., Berkowitz, G., Klaus, M. (2000) "A comparison of intermittent and continuous support during labor: a meta-analysis". American Journal of Obstetrics and Gynecology. 8(17): 16, 19.

Langer, A., Campero, L., Garcia, C., Reynoso, S. (1998) "Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospita: a randomized clinical trial". British Copyright 2002 CAPPA Journal of Obstetrics and Gynecology. 105(10): 1056-63.

Gordon, N.P., Walton, D., McAdam, E., et al. (1999) "Effects of providing hospital-based doulas in health maintenance organization hospitals". Obstetrics and Gynecology. 93(3): 422-6.

Campero, L., Garcia, C., Diaz, C., Ortiz, O., et al. (1998) "Alone, I wouldn't have known what to do: A qualitative study on social support during labor and delivery and Mexico". Social Science and Medicine. 47(3): 395-403.

Van Zandt, SE, Edwards, L, & Jordan, ET. (2005) Lower epidural anesthesia use associated with labor support by student nurse doulas: implications for intrapartal nursing practice. Complement Therapeutic Clinical Practice, Aug, 11(3):153-60.

Zhang, J., Bernasko, J., Leybovich, E., et al. (1996) "Continuous labor support from labor attendant for primiparous women: a meta-analysis". Obstetrics and Gynecology. 88(4) part 2: 739-744.

Paulina (Polly) Perez, RN, BSN, FACCE, LCCE, CD is a CAPPA senior advisor and author of the 2011 updated CAPPA Labor Doula position paper. She is also the author of numerous articles and books which include Special Women: The Role of the Professional Labor Assistant, The Nurturing Touch at Birth: A Labor Support Handbook, Doula Programs: How to Start and Run a Private or Hospital-Based Program with Success!, Special Women: The Role of the Professional Labor Assistant- the video/DVD, Birth Balls: The Use of Physical Therapy Balls in Maternity Care, and Brain Attack: Danger, Chaos, Opportunity and Empowerment.

Postpartum Doula Position Paper


CAPPA Position Paper Evidence-based Postpartum Doula Care

Introduction

Many birth professionals feel the postpartum adjustment period lasts well into the first year, making the fourth trimester the longest. In her book Mothering the New Mother, Sally Placksin states "It seems more accurate and more realistic to offer women a broad timetable of postpartum cushioning that covers the first twelve months of new motherhood. Some women will feel that they have settled in a shorter period of time; others will find it might take longer, depending in what kind of support they have to help them."

When considering birth in industrialized societies, birth is relegated to three trimesters. Rarely is the final and most life altering time period, the postpartum period or fourth trimester considered. By medical definition, the postpartum period is the six weeks following the birth of a baby or completion of pregnancy. This is the period where the woman's body returns to its pre-pregnant state. Many birthing professionals recognize that this adjustment period is not only physical but also emotional, intellectual and relational.

The impact of rituals on the physical, emotional, intellectual and relational aspects of the postpartum period is undeniable. Research indicates that the lack of effective rituals of reintegration may be a cause of postpartum disorders. The transitional adjustment period between birth and parenthood should include rituals such as baby care basics, the role of the new family, emotional support, breastfeeding or bottlefeeding support, and maternal mentoring. These rituals, when present in sufficient quantity, empowers society by empowering the family unit by increasing the confidence level and increasing the incidence of positive parenting experiences.

In many cultures, women and their families are cared for and nurtured by the community around them for weeks, and sometimes months after the birth of a new family member. Women living in kinbased communities adhere to customary postpartum rituals and typically do not experience postpartum disorders. They also tend to breastfeed their babies for a longer period of time and feel closer to their infants than women who have had no support. Strong social support is vital.

In today's mobile society, extended families do not live close and may be unable to provide care for the new family. New parents may expect medical professionals to provide not only informational support but also educational and physical/emotional support outside of the hospital setting. When this support from family or professionals is lacking, mentoring is then lost. This is where the postpartum doula can be an invaluable resource, by bridging the gap and providing the missing mentoring opportunity.

From Marshall H. Klaus, John H. Kennell and Phyllis H. Klaus in Mothering the Mother, "Most studies show that a person's previous history or a family history of psychiatric problems increases the chances of postpartum depression. In most cases, however, psychosocial factors are important. The woman may be experiencing bereavement, the effects of unemployment or inadequate income, unsatisfactory housing, or unsupportive relationships. The experience of childbirth may have aroused memories of a past stillbirth or miscarriage, abortion or death of her mother. When a woman has had a poor relationship to her own mother or was separated from one or both parents before the age of eleven, she is more likely to be depressed and anxious. Another factor may be the woman's inability to confide in her partner or a friend. Women are often embarrassed to tell another how badly she feels. Loneliness, isolation and lack of support are serious contributors to postpartum depression. Some mothers may find it difficult to reconcile the realities of mothering with their prenatal fantasies."


The Role of the Doula

Although some families have all the support they need from their extended families and community, this type of care can be rare. When family members are not able to provide the support during the postpartum period, the Postpartum doula is a viable option. Postpartum doulas are knowledgeable professionals who assist families during the critical period immediately after the birth of their baby. They "mother the mother" and offer physical, emotional and informational support to the family as well as practical help. The doula's expertise in mother and baby care enables her to CAPPA Position Paper Evidence-based Postpartum Doula Careassist with postpartum comfort measures, breastfeeding support, non-judgmental guidance in infant care techniques, information on normal postpartum restoration, and family emotional assistance through this major transition.

Postpartum doulas are trained to know when things are not progressing normally and how to utilize available resources plus suggest referrals for help when appropriate. Doulas have a deep respect for the family structure and know how to balance information and help in a way which empowers the new parents to care for their own baby while at the same time offering guidance and support.. In turn, this gives the parents a sense of accomplishment and success in their parenting skills. While fulfilling this role, the doula may also perform light household chores, provide meal preparation, sibling care and parent education, all while nurturing the family in a nonjudgmental, objective way.

The postpartum doula does not provide medical care for the mother or baby, however she may provide extensive information regarding maternal/child health during the normal postpartum period. The postpartum doula should be well acquainted with the professionals in her community who can help the postpartum family, such as physicians and midwives, lactation consultants and educators, pediatricians, counselors and support groups. Her vast knowledge of the birth and postpartum process makes the postpartum doula a valued member of the birth team.


CAPPA Training and Certification Process

Critical to a comprehensive training and certification program is the quality of the evidence-based standard of care and scope of practice. Persons interested in pursuing a career in postpartum care should investigate certifying organizations for philosophy, inclusiveness, perspectives, researchbased curriculum, efficacy of trainers, and follow-up during the certification process and postcertification. Training for postpartum doula care should include but not be limited to newborn care and feeding methods, comprehensive care of the postpartum woman, infant development, postpartum depression, support of the postpartum family, coping skills, developing resources, working within the birthing community, and business development skills.


Conclusion

With changes taking place in the family structure over many years, and new families not having the resources available to them as in the past, the postpartum doula is making a significant impact on the process that takes place in the postpartum period. All the research seems to indicate this to be a very positive impact. The fourth trimester can be a very turbulent time for some families in that they have limited resources for support. The postpartum doula fills a void left by families not being close enough or able to offer help, and reassurance while parents adjust to their new role and responsibilities. New families deserve the support and encouragement a postpartum doula can give.


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Wolman WL, Chalmers B, Hofmeyr GJ, Nikodem VC. Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study. Am J Obstet Gynecol 1993; 168: 1388-93.

This Position Paper was written by CAPPA Director of Postpartum Doula Programs, Crystal Sada and approved by the CAPPA Board of Directors. Copyright remains with CAPPA, PO Box. 491448, Lawrenceville, GA 30043. 1- 888-548-3672, www.cappa.net.

Copyright CAPPA 2002. CAPPA hereby grants permission for reprint with complete attribution.

Antepartum Doula Position Paper

Childbirth Educator Position Paper


CAPPA Position Paper Evidence-Based Practice In Childbirth Education
Introduction

The experience of childbirth is beyond the physiological aspects. It has been said that it is more than just a usual day in a woman's life. This experience influences a woman's self-confidence, self-esteem, view of life, view of her relationships and view of her children. It can be one of the most influential experiences for a woman.

Utilizing the research that has been made available to maternal child-health professionals can enhance the learning experience for the expectant mother and her supportive companions. Understanding the historical significance of education in the childbearing year and honoring the learning process, can bring heightened professionalism and evidence-based practice to childbirth education.

Factors Influencing The Meaning of Childbirth

The Historical Perspective

Historically, childbirth was an experience of women and with women. The birthing triad, one of the most common birthing postures seen in ancient art, demonstrates this concept. Wise women instructed expectant women in the traditional practices of birthing of the time. Additional wise women were needed for support during the antepartum, partum and postpartum periods. Birth was seen as a normal developmental task of a healthy woman ... a rite of passage from being a woman to becoming a mother.

During the 17th century, physicians (primarily male) became involved in the birthing process. One of the earliest involvements of men is that of the Chamberlen brothers who developed several types of obstetrical forceps to assist in difficult labors/births. Conversely, Oliver Wendell Holmes, in his 1850 essay on puerperal fever, linked this deadly disease to the fact that physicians went from birth to birth without washing their hands - thus transmitting the disease. Additionally, Fannie Longfellow's request for chloroform for her birth in 1847 ushered in consumerism and the paradigm began to shift again.

While Velvovsky and Nikolayev were studying the birthing woman's response to labor contractions, Grantley Dick-Read of England rejected the chloroform concept and proposed that the pain in childbirth was the result of cultural conditioning. Like his Russian counterparts, Read hypothesized that fear was the determinant of pain in childbirth. A French physician, Lamaze, visited Nikolayev in Leningrad in the early 1950's. He observed the concept of psychoprophylaxis: a combination of deep breathing to stimulate relaxation, touch to employ the Gate Control Theory to reduce the perception of pain, and education to resolve fear due to ignorance of the process. Marjorie Karmel, one of Lamaze's patients, along with Elisabeth Bing began the American Society for Psychoprophylaxis in Obstetrics or ASPO, now called Lamaze International, in 1960. ICEA, the International Childbirth Education Association, was also formed in 1960 as an association of consumers.

In 1998, CAPPA, the Childbirth and Postpartum Professional Association, was formed as an umbrella organization to encompass not only labor support professionals but also childbirth educators.


CAPPA Philosophy of Childbirth Education

In most situations and for most people, natural childbirth is the safest way to have a baby. Women should be encouraged to trust their bodies in the birth process and myths about natural childbirth should be dispelled. They should be given the tools to achieve a natural birth, if that is what they desire and should be equipped with knowledge to make informed decisions about their birth. This knowledge should include a full understanding of the risks of interventions and medications, as well as their benefits in certain situations. Education should not involve guilt but should empower women to choose the kinds of birth that is best for them, be it medicated or unmedicated, intervention-free or with traditional interventions. CAPPA believes that, given the facts, more women would choose a natural birth for themselves and their babies.

Expectant parents should be taught that, although labor is painful, there are ways to deal with this pain both pharmacologically and nonpharmacologically. CAPPA generally encourages deep, abdominal breathing during labor. Some hypothesize that patterned breathing techniques may not be effective. They often lead to hyperventilation, performance anxiety, and confusion. In some situations, however, women use them effectively and CAPPA feels that patterned breathing should be among the topics presented. If a woman wants a natural birth, it is the responsibility of the CAPPA Childbirth Educator to give her many techniques and assist her with practice so that when the time comes, she has a variety of techniques at her disposal. Relaxation is a vital achievement if an expectant woman is to achieve a natural birth. Partners should be taught to recognize relaxation vs. tension and the tools and techniques of how to bring the expectant mother into a relaxed state with an emphasis on calm breathing. Vocalization is another technique that should be included in a CAPPA childbirth education class as it has been proven beneficial cross-culturally. Additionally, there are pain-relieving benefits of changing positions, frequent urination, walking, and hydrotherapy.

The learning process varies according to culture, age and socioeconomic status. Mothering practices, family integration and authority structure should all be taken into consideration. Therefore, standardization in presentation of educational programs should be adjusted to meet the learning needs of the adults present. Adult learners (1) are independent and self-directed in learning; (2) utilize previous experiences that are rich resources for learning; (3) portray a readiness to learn based on current social roles and tasks; (4) desire to learn things that have immediate applications; and (5) prefer a problem-oriented learning approach as opposed to a subject-oriented learning approach. It is also important that the childbirth educator be aware that the amount of learning is directly influenced by the amount of involvement of the adult learner. Adult learners tend to remember 10% of what is read, 20% of what is heard, 30% of what is seen, 50% of what is seen and heard, 70% of what is said by the adult learner and 90% of what is both said and done by the adult learner. Therefore incorporating a variety of teaching/learning styles within the context of a childbirth education class or series will enhance the learning experience for the adult learners.


Conclusion

Abraham Maslow once said "If you see every problem as a nail, the only tool you need is a hammer." Evidence-based childbirth education changes as research provides new information enabling the educator to provide expectant parents with the highest quality of education possible.


References

Bradley, R.A. (1965) Husband-coached childbirth. New York: Harper & Row.

Chabon, I. (1966) Awake and aware. New York: Delacorte Press.

Davis-Floyd, R. (1992) Birth as an American rite of passage. Berkeley: University of California Press.

Dick-Read, G. (1979) Childbirth without fear. New York: Harper & Row.

Gaskin, I. (1977) Spiritual midwifery. Summertown, TN: The Farm.

Harper, B. (1994) Gentle birth choices. Rochester: Healing Arts Press.

Korte, D. and Scaer, R. (1992) A good birth, a safe birth. Boston: Harvard Common Press.

Lamaze, F. (1972) Painless childbirth: psycho-prophilactic method. New York: Pocket Books.

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

Phillips, Celeste R. (1991) Family-Centered Maternity/Newborn Care. St. Louis: Mosby.

Reeder, S., Martin, Leonide, Koniak-Griffin, D. (1997) Maternity Nursing: Family, Newborn, and Women's Health Care. Philadelphia: Lippincott.

Rothman, Barbara Katz (Editor) (1993) The Encyclopedia of Childbearing. New York: Henry Holt and Company.

The Coalition for Improving Maternity Services (1996) The mother-friendly childbirth initiative. The First Consensus Initiative of the Coalition for Improving Maternity Services (CIMS).

This Position Paper was written by CAPPA Directors of Childbirth Education, Connie Livingston BS, RN, LCCE, FACCE, CD(DONA), CLD, CCCE and Sandy Dennedy ICCE, CD(DONA), CLD, CCCE and approved by the CAPPA Board of Directors. Copyright remains with CAPPA, PO Box 2406, Buford, GA 30515. 770.932.7281, www.cappa.net. Copyright CAPPA 2002. CAPPA hereby grants permission for reprint with complete attribution.



Lactation Educator Position Paper

CAPPA Position Paper: The Lactation Educator's Role in Providing Breastfeeding Information and Support

Copyright 2011, 2009, 2002 CAPPA, All Rights Reserved
Edited 2011 by Laurel Wilson, IBCLC, CLE, CCCE, CLD and Mandy Nicolosi
Edited 2009 by Kimberly Hill, BS, IBCLC, CLE, CCCE

Introduction

Extensive research has proven the numerous benefits of breastfeeding for infants, mothers, and society. The contribution of breastfeeding to infant and maternal health is so significant that policies have been set by the American Academy of Pediatrics 1, the World Health Organization 2, the American College of Obstetricians and Gynecologists 3, and the American Public Health Association 4, among others, to actively promote and protect breastfeeding. Cooperatives between governmental agencies and professional and voluntary organizations have been formed to help implement these policies. However, in practice, breastfeeding is often neither protected nor promoted in our society. As a result, breastfeeding rates fall short of the goals cited in these policies. The steps, which have been designated as critical to changing this scenario, largely focus on two necessary components: education and support.


The Importance of Breastfeeding

In 2007, the Agency for Healthcare Research and Quality (AHRQ) published an evidence report on the effect of breastfeeding on maternal and infant health outcomes in developed countries. This report included 86 primary studies and 29 meta-analyses and found that a history of breastfeeding was associated with a reduction in the infant's risk of otitis media, asthma, type 1 and type 2 diabetes, obesity, childhood leukemia, and sudden infant death syndrome. In addition to these benefits, a history of lactation was associated with lower maternal risk of type 2 diabetes, breast cancer and ovarian cancer. Early weaning or not breastfeeding was also associated with a higher risk of postpartum depression 5. Economically, studies have shown that breastfeeding shows significant savings over formula feeding both due to direct costs (such as formula and health care expenses) and indirect costs (such as time and lost wages of a parent caring for a sick child) 6 Clearly, increasing breastfeeding initiation and duration rates would lead to significant improvements in public health.

In March 2011, the Surgeon General released The Surgeon General's Call to Action to Support Breastfeeding. This document recognizes that while most others desire to breastfeed, within three months, two thirds of all breastfeeding mothers are using artificial milk to feed their baby. The Call to Action includes the following:

Some obstacles that are recognized in the document include:

Furthermore, this Call to Action asks the healthcare community, which includes the CLE to do the following:

This builds on the work of previous U.S. Surgeon General, David Satcher, with the help of the Office on Women's Health, developed by the HHS Blueprint for Action on Breastfeeding 9 in 2000. This document, along with the World Health Organization's Evidence for the Ten Steps to Successful Breastfeeding 10 and the UNICEF Baby-Friendly Hospital Initiative, have all emphasized 2 factors in increasing breastfeeding rates: education (of medical staff, the public and the childbearing family) and providing supportive conditions (emotional support, guidance and avoidance of practices which hinder breastfeeding).


Working to Improve Breastfeeding Rates

Healthy People 2000 set a goal of a breastfeeding initiation rate of 75% and a breastfeeding rate of 50% at 6 months postpartum. Unfortunately, these goals were not met. Healthy People 2010 continued these goals and added the objective that 25% of mothers will breastfeed their babies at one year 7. According to the National Health and Nutrition Examination Survey, 77% of infants born in 2005-2006 were breastfed in the immediate postpartum period, a significant increase over the 1993-1994 data. Unfortunately, there was no significant increase in the breastfeeding rate at 6 months. Furthermore, while the African-American population saw a drastic jump in breastfeeding initiation during this time period (from 36% to 65%), there is still a large disparity between the breastfeeding rate for Mexican-American and Caucasian infants and that for African-American infants. There is a similar disparity between infants of older and younger mothers and infants from higher income and lower income families 8 . Efforts must be made to promote breastfeeding in general and to target the needs of those groups that still show lagging breastfeeding rates. Specifically, there must be a stronger emphasis on the promotion of breastfeeding without supplements for 6 months and continuing to breastfeed for at least one year. At the end of 2010, the U.S. met only one of its Healthy People 2010 goals, that of 75% initiation rates. The new goals for 2020 include the following:

Lactation Educators can assist in reaching all these goals which include: strengthening the support of breastfeeding (including within the health care system), improving professional education in breastfeeding, initiating a national promotional effort to support working women who want to breastfeed, and developing public education, promotional efforts and a range of community support services.


The Role of the Lactation Educator

Lactation Educators fill an important function in educating and supporting families interested in learning about breastfeeding. This education may take place in the public, hospital, clinical or private setting. Since many CAPPA-Certified Lactation Educators are willing to come to the family's home, this helps assure that families without easy access to lactation consultant offices or La Leche League meetings will not fall through the cracks. They may have common breastfeeding questions and concerns addressed in the comfort and privacy of their home, and referrals will be made, if needed. As our society becomes more "breastfeeding-friendly" the number of Lactation Educators, lactation consultants and La Leche League groups should grow, making all of these valuable resources available to the childbearing community.

Breastfeeding education is not restricted to new families, but applies to medical staff as well. The American Academy of Pediatrics Policy Statement on "Breastfeeding and the Use of Human Milk" refers to research that indicates that "obstacles to the initiation and continuation of breastfeeding include physician apathy and misinformation." 1 Due to the limited breastfeeding information provided in standard medical training, and the misinformation about breastfeeding that is so prevalent in our society, the Certified Lactation Educator serves as a resource for accurate, evidencebased information to the public and health care providers, as well as to childbearing families.

CAPPA does not issue Certified Lactation Consultant status, nor does the Lactation Educator Program qualify a member to provide medical advice, diagnose or prescribe medication. However, Lactation Educators provide a wealth of information about how and why to breastfeed; establishing a breastfeeding-friendly environment; basic breastfeeding anatomy and physiology; the normal process of lactation; deviations from normal; physical, emotional and sociological barriers to breastfeeding; overcoming challenges; and resources available (including medical referrals) for the breastfeeding family. They can also be a source of vital support, guidance and encouragement throughout the duration of breastfeeding 11. Lactation Educators play a vital part in increasing breastfeeding rates and helping families who choose to breastfeed.


CAPPA Philosophy of Lactation Education

Breastfeeding is undeniably the best nutrition and care for babies and should be strongly encouraged. All families should have the opportunity to become educated as to why breastfeeding is best for both mother and baby. They should also be encouraged to attend a breastfeeding class and support group while they are still pregnant so that they may make an informed decision about infant feeding. Many women, when they become educated, will want to breastfeed, but it is important to recognize that there are many reasons why some cannot or choose not to do so. It is not the place of the Lactation Educator to create guilt surrounding infant feeding, but rather to educate parents so that they may make truly informed decisions. Health care providers who work with childbearing families have great influence over whether or not a parent chooses to breastfeed or continue breastfeeding. It is critical that all medical staff working with these families have access to updated, evidence-based information on the mechanics and benefits of breastfeeding and how to provide an environment that supports this choice. CAPPA supplies the highest quality of training, to ensure that Certified Lactation Educators meet the diverse informational needs of the public.


Conclusion

The promotion and protection of breastfeeding is clearly a priority in improving public health. A general lack of education and support for breastfeeding remain in our culture as barriers to breastfeeding. Lactation Educators play a critical role in removing these barriers. Studies show that encouragement, counseling, peer support and guidance are important factors that increase initiation and duration of breastfeeding. Lactation Educators can assist parents with their needs and ensure that families, health care providers and the public receive the accurate, evidence-based information necessary to promote a breastfeeding-friendly culture.


References
1. American Academy of Pediatrics Policy. Statement on Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115(2), 496-506. Available from: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496 [Accessed 5/13/09].

2. World Health Organization. Global Strategy for Infant and Young Child Feeding. 2003. Available from: http://whqlibdoc.who.int/publications/2003/9241562218.pdf [Accessed 5/13/09].

3. American College of Obstetricians and Gynecologists. Breastfeeding Position Statement. 2003. Available from: http://www.acog.org/departments/underserved/breastfeedingStatement.pdf [Accessed 5/13/09].

4. American Public Health Association. A Call to Action on Breastfeeding: A Fundamental Public Health Issue. Policy number 200714. 2007. Available from: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360 [Accessed 5/13/09].

5. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No. 290- 02-0022). AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality. April 2007.

6. Weimer J. The economic benefits of breastfeeding: A review and analysis. ERS Food Assistance and Nutrition Research Report No. 13. USDA Economic Research Service, Washington, D.C. 2001.

7. U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services. 2000. Available from: http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm#_Toc494 699668 [Accessed 5/13/09].

8. McDowell MA, Wang C-Y, Kennedy-Stephenson J. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys 1999-2006. NCHS data briefs, no. 5, Hyattsville, MD: National Center for Health Statistics. 2008. Available from: http://www.cdc.gov/nchs/data/databriefs/db05.htm [Accessed 5/13/09].

9. U.S. Department of Health and Human Services. HHS blueprint for action on breastfeeding. Washington, DC: U.S. DHHS, Office of Women's Health. 2000. Available from: http://www.cdc.gov/breastfeeding/pdf/bluprntbk2.pdf [Accessed 5/13/09].

10. World Health Organization. Evidence for the Ten Steps to Successful Breastfeeding. 1998. Available from: http://www.who.int/nutrition/publications/evidence_ten_step_eng.pdf [Accessed 5/13/09].

11. Childbirth and Postpartum Professional Association. CLE Scope of Practice. 2008. Available from: http://www.cappa.net/get-certified.php?cle-scope [Accessed 5/13/09].

12. U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General.