West Michigan VBAC Access Update

Source: 2015 Geocoded Michigan Birth Certificate Registry.
Division for Vital Records & Health Statistics, Michigan Department of Health & Human Services

A year ago, I wrote a blog about how hospital bans against vaginal birth after cesarean (VBAC) limit options for Muskegon families. I used birth data from the Michigan Department of Health and Human Services to compare percentages of people with low-risk pregnancies who have a cesarean after a prior cesarean in Muskegon and surrounding counties. Not surprisingly, VBACs are more common where hospitals support them.

The data available that I used was from 2008 to 2014. Since then, 2015 data has been released. I wanted to update this information to see if there were any changes, explore what might be impacting this change and predict how this situation might change in coming years based on current developments in healthcare policy and services.

Statewide, there has been improvement. In 2015, a total of 2,006 people had VBACs, compared to 1,882 in 2014, an increase of 124. When we look at West Michigan counties, however, only Muskegon County and District Health Department #10, which includes Oceana, Newaygo and eight other counties, saw an increase. Kent county births included 40 fewer VBACs and Ottawa county had 3 fewer than the year before.

There are a few issues with this data and that make it difficult to draw conclusions from. First, the two-to-three-year lag time from when the year ends until the data becomes available makes it less useful. We can reflect on what may have happened two years ago to impact these changes, but it is less relevant than being able to access real-time data. Secondly, the online database only provides this particular piece of information by county. In a large county, like Kent, it would be interesting to see how being in an urban, suburban or rural area or proximity to a specific hospital may impact access.

When applying this information to our doula practice, we see clients make a lot of different choices when it comes to choosing a provider and location for their planned VBAC. While some Muskegon area families are happy to travel to Spectrum Health Butterworth in Grand Rapids to deliver, others prefer the intimacy of the small practice at Gerber Memorial Women’s Health, also under Spectrum, in Fremont. Still others have decided to stay in Muskegon and show up in labor at Mercy Health Hackley, while home birth after cesarean (HBAC) is a clear choice for others.

Things may change in 2018. Dr. Tami Michele, who has practiced at Spectrum Health Gerber Memorial for many years, is switching over to Spectrum Health Medical Group Ob/Gyn, with locations on 68th St. and on Mid Towne in Grand Rapids. Some say the move is to help increase the access to VBACs at Butterworth, which serves more patients. Dr. Michele is former doula, whose advocacy for those who wish to plan a VBAC has earned her a national reputation. What is less known at this time is how her moving from a small, rural hospital to a large metropolitan one will impact access to VBACs for those outside of Grand Rapids. Some will surely follow her, while others may feel that they lost a resource.

Another recent change on the national landscape was the publication of the American Congress of Obstetricians and Gynecologists updated guidelines on VBAC, which appeared in the November issue of Obstetrics and Gynecology. According to Mark Turrentine, MD, chair of ACOG’s Committee on Practice Bulletins-Obstetrics, the guidelines are meant to ensure delivery at the safest facility, “However, this absolutely should not result in women having limited access to VBAC.”

According to Jen Kamel, founder of VBACFacts.com, the guidelines are an improvement over those released in 2010. She quotes the new guidelines, “Available data confirm that TOLAC [trial of labor after cesarean] may be safely attempted in both university and community hospitals and in facilities with or without residency programs.” She interprets this to mean that if a hospital can handle deliveries, they should offer VBAC, because an emergency cesarean may be required in any birth, even a low-risk one.

How local staff changes and changes in the ACOG guidelines will impact local access remains to be seen. Will more people be able to access VBACs at Butterworth, or will support at Gerber decline? Will the 2017 ACOG guidelines result in a reversal of bans at Mercy Health Hackley, North Ottawa Community Hospital and Spectrum Health Gerber Memorial, or will the liability concerns prevail? Time will tell, but we won’t be able to see the data until 2020!

In the meantime, we will continue to support families in all their choices, whether they choose a repeat cesarean, a VBAC at a hospital or birth center of their choice, or at home.

Dimming the Lights: An Aid for Helping Labor Progress

Getting out of the bathtub at Spectrum Health Butterworth, after laboring under the light of LED flameless candles.

— By Beth Singleton, Birth Quest birth doula and photographer

I still remember my last labor like it was yesterday. Waking in the wee hours to discover I was in labor, only to have it stall during the daylight hours and then ramp back up after the sun set. When pushing, the room was dimly lit and to make things even darker, I had my face buried into the couch.

What is it about darkness that seems to ease and promote the progress of labor? A very common desire among laboring women, I thought it’d be a great idea to look into this.

The need for darkness is observed in nature.

If you’ve ever had the experience of witnessing a cat during labor, you probably noticed her need for a safe, dark place. When my cat had her kittens a few years back, that’s exactly what she did. In a box under my bed, our proud momma cat gave birth to her babies. This need stems from the mammalian brain, a commonality that affects cats, dogs, mice…and humans! I mean, we’re mammals, too, so regardless of the countless ways in which we’re nothing like our pets, the biological event of birth reaches deep to reveal that our needs are ultimately very similar.

Bright lights can make a laboring woman feel exposed.

Birth is a very private event for a woman. During such an intimate moment in her life, bright lights shining down can cause her to feel like she’s being observed or like she has no privacy. In nature, laboring animal mother’s will stop mid-labor if they think they are being watched in order to find safety. In a hospital setting, though, a woman can’t follow in the footsteps of her fellow mammal mothers and relocate if she feels like she isn’t safe.

Bright lights stimulate the neocortex of a laboring woman’s brain.

This increases brain activity during a time when labor progress relies on a woman’s primitive brain instincts. This stimulation can interfere with a woman’s ability to produce the hormones necessary for labor to progress and to help with pain. Some sources of bright light include:

• overhead lighting
• windows
• computers
• cell phones
• tablets
• televisions
• monitors

In particular, electronic devices affect the body’s ability to rest. Blue light, the light produced from items like cell phones and tablets, interferes with the production of sleep-promoting hormones. So even in a room where the lights are off, it’s important to consider the effect of having the television on or staring at a phone if relaxation is the goal.

How does darkness aid in relaxation?

When the lights go down and the room darkens, this signals to the brain that it’s time for rest. One of the hormones produced is melatonin. Also known as the “hormone of darkness”, melatonin promotes relaxation and sleep. When a laboring woman is better able to relax, she will probably rest better and more deeply between contractions. Her contractions might also be less painful if she isn’t holding so much tension in her body.

There are numerous ways to labor with the lights down low.

Whether laboring at home or in a hospital, there are several ways to create a dimly lit setting.
For a home birth, consider some of these ideas:

• night lights
• LED candles
• string lights
• votive and/or pillar candles
• dimmable lamp
• blackout curtains
indoor light projector

For a hospital birth, most of the above options aren’t as feasible. For example, a hospital probably isn’t going to permit burning candles; they will, however, allow LED candles. And items like string lights or lamps are bulky and may not be allowed, either. Night lights and indoor light projectors, on the other hand, are small and the room will likely have at least one outlet you can use to plug them in.

Sometimes, though, darkness isn’t the best option.

While it makes sense that many women desire to labor in darkness or a space that is dimly lit, there are
circumstances when the issue shouldn’t be pressed. Examples include:

• women who are afraid of the dark
• women who might become anxious if they feel the darkness would interfere with their care
• women with a history of trauma who feel safer with the lights on
• women who simply object to having the lights off

In the end, it all comes down to a woman’s preference.

Whether she chooses to labor with the lights on or off, the point is that she gets what helps her the
most. Ultimately, it’s the support she receives from those around her that will have the biggest impact
on her birth experience.

If you’ve already given birth, did you dim the lights? Why or why not?

We’d love to hear your feedback on this!

Hakomi & Healing: An Interview with Hakomi Practitioner Rachael Koeson

Hakomi Blog Photo

Hakomi can provide healing through mindfulness.

— by Beth Singleton, Birth Quest doula and photographer

In May of 2016, I attended a postpartum mood disorder class in Grand Rapids. As someone who supports moms – and as someone who struggles with bouts of anxiety and depression – I was eager to learn as much as I could.

Navigating my way through the parking lot, looking for the entrance, I noticed a woman who I figured was probably doing the same thing I was. But there was something about her that stood out to me, and I gravitated towards her without any real thought. Her energy was warm and kind. We met in the parking lot and found our way in together.

There had to be at least a hundred people there for the class, probably more as they couldn’t all fit in the main room. We (Rachael and I) sat together and got acquainted. I was one among a handful of doulas in the room. Rachael, however, was one of a kind.

In the short time we spent there that day, I did my best to take in and understand what Hakomi was. We’ve even kept in touch since then; but to this day, I’ve wanted to know more. Thankfully, Rachael, who practices through her business, Making Space Hakomi, was kind enough to oblige my request for an interview.

I hope you’ll all enjoy what she has to share. As she is just getting started on this path, I also hope you’ll all welcome her and encourage her on in her calling to serve women and their families.

Beth: First of all, what is Hakomi? I know when I met you, it wasn’t something I’d ever heard of and I haven’t really met anyone else who has.

Rachael: Hakomi is a mindfulness-based, body-centered form of assisted self-discovery. It is also experiential. What this means is that we work to stay mindful and in the present moment to explore our underlying unconscious beliefs about ourselves and the world. Often we learn a lot when we pay close and respectful attention to the wisdom of our bodies. It is an extremely gentle, respectful and sensitive method that understands the client to be the expert of themselves; the job of the Practitioner is to assist the client to maintain mindfulness and help guide them toward a more complete awareness of themselves.

Beth: What was it about Hakomi that appealed to you?

Rachael: I knew from my experience as a client that it really works and it felt so much more elegant and respectful than anything else I had tried. I love the founding principles of non-violence, organicity, unity, mindfulness and body-mind holism.

Beth: What inspired you to become a practitioner?

Rachael: My own experience as a client. It was a truly transformative experience for me through which I realized so many things about myself that I hadn’t consciously been aware of before and I felt like I gave (with the help of my Practitioner) those wounded places within myself the healing they needed; that resulted in really knowing I could choose to inhabit my life differently than I had been before. The result is that I generally feel more resourced, more connected to myself and able to connect with others, more aware of my unconscious beliefs and more able to make more life-affirming and nourishing choices in my daily life. Of course, I have hard days and I forget all these things sometimes, but generally feel much more whole, aware and vibrant than I did before going through my Hakomi process. I continue to learn and struggle but am so grateful for what I continue to learn through this lovely method.

Beth: What kind of training did you have to complete in order to become a practitioner?

Rachael: I completed an 18 month comprehensive training program through the Hakomi Institute. I then completed the certification process, which is based on competence rather than hours, about 16 months after I graduated from the program.

Beth: How would you say Hakomi is helpful for women before, during, or after pregnancy?

Rachael: The transition into motherhood or transitioning from mothering one to two or two to three children, etc. is significant in all women’s lives. So much happens to women as we go through that process. It is a time when we can be particularly vulnerable and particularly in need of extra support to find our footing in who we are and how we want to embody our life as a person who is also a mother. The way that process unfolds is different for everyone, but across the board it is a unique time of life that lends itself to mindful self-discovery as we come face to face with a lot of our own wounding, fears, desires and the impacts of our personal history. Hakomi is such a lovely way of learning to be with and learn from those parts of ourselves that can arise during times of transition.

Beth: What are some of the reasons women might seek out the assistance of a Hakomi practitioner?

Rachael: I often see clients who are having trouble transitioning into motherhood, feeling stuck in behavior patterns that don’t serve them or interacting with their children in ways that feel triggered but not grounded or based on their truest desire for how to be in relationship with their child(ren).

Beth: Is Hakomi something that can help new parents adjust to the changes they’ll face as well? If so, how?

Rachael: Absolutely. Hakomi is based on the idea that when we are mindful and we have a skilled assistant on our side we can uncover our unconscious beliefs that often drive our behaviors and ways we live in the world. Hakomi allows us to gently make space for the wounded parts of ourselves that can become particularly activated upon becoming a parent as so many of our developmental wounds
are revealed as our children grow. Hakomi also provides amazing and individualized resources and skills that people can take home with them and practice using in their daily lives.

Beth: I see you have a Mindful Mothering Support Group coming up in November. Is this a little different than other support groups for moms and if so, how?

Rachael: Yes. This is a unique support group because it is founded in mindfulness. Mindfulness is slowing down, being aware and also cultivating a sense of non-judgement or curiosity. So we will engage in some guided meditation time and be able to study what arises during those times of mindfulness. It will be a highly facilitated group where participants will be encouraged to speak from their present experience rather than retell the “story” of their struggles. In doing that we can more easily access the issues UNDER the story and hopefully offer some healing to those places that need it.

Beth: Do you offer any other classes or provide private consultations?

Rachael: Yes. I provide one-on-one sessions as well as an eco-grief mindful support group which is designed to support people who deeply feel the pain of the earth and the damage we have done to it in this moment in time. The goal is to provide a safe space to share grief and pain and also allow those feelings to flow and move and see what else can arise through that process. This is inspired by the work of Joanna Macy and her book, “Active Hope.”

Beth: Is there anything else you’d like to share?

Rachael: Thank you for the opportunity to share about Hakomi. I am grateful. I have myself worked at a college for midwives, trained as a birth and postpartum doula, volunteered as a postpartum doula and experienced postpartum mood disorders. So I have a deep well of empathy, compassion, and resonance with the struggles that come with the transition into mothering and learning how to be who you truly are in the new and overwhelming role of parent.

Beth: Thank you so much, Rachael, for your time and help with this. I can honestly see how this is something everyone could benefit from, and I hope that services like yours continue to grow and help people heal.

October is Pregnancy and Infant Loss Awareness Month

Muskegon area bereavement doula, Jen Cantrell, is a gift to our community.

With October being Pregnancy and Infant Loss Awareness Month, I wanted to share a blog on the topic. The one person I knew I could count on to help with this is Jen Cantrell of Angel Wings Bereavement Services. She is a certified bereavement doula and chaplain. Dedicated to her calling, her work with families is a priceless gift.

Initially, I wanted to sit down for a video interview with Jen…but, for two busy moms like us, that isn’t so easy. So, with a little effort from the both of us, we’ve got the interview for you – minus the video.

Beth: With October being Pregnancy and Infant Loss Awareness Month, I thought now would be the perfect time to highlight your services and the event that you have coming up in October on the 15th. To get started, I was wondering if you could describe for everyone what a bereavement doula is, as I know it’s not something most people have probably ever heard of.

Jen: A bereavement doula is someone who provides support before, during, and after labor and delivery. I assist providing education about memorial or funeral arrangements along with educating families and ensuring compassion by all in contact with the family. A bereavement doula is an anchor, a stable source to hold on to when the whole world seems to be spinning around you.

Beth: What lead you to become a bereavement doula?

Jen: I am the mother of 15 children who I hold in my heart and 4 I hold in my arms. When I was pregnant with my last rainbow baby (a rainbow is a baby born after a loss), I was assited by two incredible doulas. They inspired me to give the same compassion to others that I received from them.

Beth: About how many families have you served?

Jen: I serve families in a variety of capacities; some only prior to birth, many during, some only after and some who aren’t local. In 4 years I’ve served about 340 families.

Beth: Every year you have an event to remember the babies gone too soon. How long have you been doing that and how much has this event grown over the years? I’m curious as to how many babies are being remembered this year so far (if you know).

Jen: I’ve been hosting events for Pregnancy and Infant Loss Awareness Month since 2008 – so 9 years now. It started with me remembering about 75 babies and as of today, I’m remembering over 2000 babies this year.

Beth: How does what you do work? Do most people know ahead of time that they will need you?

Jen: Our local hospitals and OBGYN’s are aware of me and what I do. Sometimes I’m contacted by the hospital. Others find me via a variety of loss groups and websites. Sometimes it’s just word of mouth. 95% of the time, I’m meeting families in their hospital room.

Beth: What about your family? How do they feel about what you do?

Jen: My family is very supportive of what I do. My older children help create keepsakes. My husband is always open and available to meet and talk with other dads.

Beth: StillBirthday is the organization that certifies bereavement doulas. Can you tell everyone a little bit about this?

Jen: StillBirthday was created by Heidi Faith 5 years ago after her son Christian was born not alive. StillBirthday currently has certified doulas all over the world, as well as chaplains like myself. The website itself is full of information for anyone experiencing any type of loss of a child.

Beth: What advice would you give to anyone who might be interested in becoming a bereavement doula? Like, what are some really important things you think they should know?

Jen: This is not an easy job by any means. You are on call 24/7/365. You will be the rock in a variety of uncomfortable situations. But you will also fall in love, each and every time. I’m always open to talk to anyone who’s interested in becoming a bereavement doula.

Beth: Since your position as a bereavement doula requires that your services are voluntary, what can people do to help you? Other than donating money, are there other ways they can contribute?

Jen: Donations of any sort are always needed and appreciated. Monetary allows me to obtain immediate needs. But I’m always in need of blankets, hats, candles, tissue packs, stuffed animals…I could go on for hours. To find out more, there is a list on my website.

Beth: Any words of advice for those trying to offer support to a mom who’s experienced a loss? I know it’s hard for most of us to know what to do or what to say.

Jen: Say the baby’s name! That would be my #1 word of advice. Acknowledge the baby’s life, no matter how brief. Sometimes the most comforting thing is allowing mom to cry, and yell…allow them to hurt.

To wrap this up, I want to thank Jen for her time in helping me with this interview, but even more so for the work she does. This is such a sensitive topic, and I can’t think of anyone better to be there for women and their families during loss than her.

(Article written by Birth Quest doula and birth photographer, Beth Singleton)

Preterm Labor: Understanding Treatment Protocols

Birth Quest doula attends lecture with Obstetric residents about preterm labor.

On August 22nd, 2017, Sandy Parker from On the Path Yoga and I drove to the New Holland Brewery in Grand Rapids to hear Dr. June Murphy, DO, Maternal Fetal Medicine Fellowship Director at St. Joseph Mercy Oakland Hospital, talk about “Advances in Management of Preterm Labor: Achieving Optimal Practice.” The lecture was at an event that combined the journal clubs of obstetric residents at Mercy Health Hackley in Muskegon and Metro Health (University of Michigan) in Grand Rapids. The event was sponsored by Hologic, the makers of the fetal fibronectin test.

Understanding the ever-changing standard of care involving preterm labor is important for maternal and infant health advocates, like doulas and childbirth educators. People who experience preterm labor are often confused about why treatment varies so much between patients. Not understanding the standard of care can lead to anger when it appears that patients have not been treated equally. While unequal care can occur, protocols can prevent bias and reassure patients that everything possible is being done to protect them and their infant.

While preterm labor is the leading cause of infant mortality in the US, it is very common and often harmless. In fact, I learned that as many as 1 in 4 women will experience four contractions per hour prior to 32 weeks! However, 30% of preterm labor resolves spontaneously, without treatment. Only 1 in 10 women who are diagnosed with preterm labor will give birth within 7 days. In other words, uterine contractions poorly predict whose baby will be born too soon!

To complicate matters, steroids given to mothers with preterm labor improve newborn outcomes when given as late as 34 – 36 weeks, but can be harmful when given unnecessarily.

So, what are providers supposed to do? Fortunately, the March of Dimes created the Preterm Labor Assessment Tool (PLAT), an algorithm, or decision tree, based on the Rose et al study (2010), to assist healthcare providers in deciding whether to admit someone in preterm labor. Dr. Murphy explained how the cut-offs for cervical length combined with the fetal fibronectin results best predicted who would deliver early. Unfortunately, the protocol does not prevent preterm birth, but does save money, time and stress from unnecessary hospitalizations.

In addition to the lecture, residents reviewed two articles, one comparing the efficacy of vaginal progesterone to an injection. Studies in the last decade have shown that progesterone treatment to prevent preterm birth is effective. Barriers to this treatment include problems with insurance reimbursement and compliance with office visits to receive injections. Vaginal progesterone has the advantage of being cheaper and easier to administer. Although the study was small, it showed promise for an alternative, but effective, treatment to prevent preterm delivery and save lives.

Dr. Murphy said that if a woman presents to a hospital in preterm labor and there was a thought bubble above her fetus, if would say, “Follow the protocol!” The causes of prematurity are complex and interrelated. Clinical providers have a limited role in addressing the underlying causes of prematurity and the infant mortality that results. Standardized care based on the latest research can reduce treatment influenced by bias and help achieve equity.