Monday, December 26, 2011

More Reproductive Anthropology Readings

So, the semester got away from my and I never did keep up with typing up my Anthropology of Reproduction readings and notes. But hey, half of the syllabus is pretty good. Here is a list of the rest of the readings, in case you're interested personally, academically, or educationally!

Past reading lists and notes are available here: Anthropology of Reproduction Part 1, Anthropology of Reproduction Part 2, and Childbirth/Breastfeeding Day in Anthropology

Chi, B. K., T. Gammeltoft, et al. (2010). "Induced abortion among HIV-positive women in Quang Ninh and Hai Phong, Vietnam." Tropical Medicine & International Health 15(10): 1172-1178.

Grossman, D., K. Holt, et al. (2010). "Self-induction of abortion among women in the United States." Reproductive Health Matters 18(36): 136-146.

Joffe, C. and T. Weitz (2003) Normalizing the exceptional: incorporating the “abortion pill” into mainstream medicine. Social Science and Medicine 56:2353-2366.

Roth, R. (2004) Do Prisoners Have Abortion Rights? Feminist Studies 30,2:353-381.

Schuster, S. (2010). "Women's experiences of the abortion law in Cameroon." Reproductive Health Matters 18 (35): 137-144.

Infertility/Assisted Reproduction
Bharadwaj, A. (2003) Why adoption is not an option in India: the visibility of infertility, the secrecy of donor insemination, and other cultural complexities. Social Science and Medicine 56:1867-1880.

Berend, Z. (2010). "Surrogate Losses." Medical Anthropology Quarterly 24(2): 240-262.

Birenbaum-Carmelia, D and M. Dirnfeldb (2008) In Vitro Fertilisation Policy in Israel and Women’s Perspectives: The More the Better? Reproductive Health Matters 16(31):182–191.

Friese, C. G. Becker, and R.D. Nachtigall (2008) Older motherhood and the changing life course in the era of reproductive technologies. Journal of Aging Studies 22 (2008) 65–73.

Hough, C. A. (2010). "Loss in childbearing among Gambia's kanyalengs: Using a stratified reproduction framework to expand the scope of sexual and reproductive health." Social Science & Medicine 71(10): 1757-1763

Sexually Transmitted Infections
Buelna, C., E. Ulloa, and  M. Ulibarri, (2009) Sexual Relationship Power as a Mediator Between Dating Violence and Sexually Transmitted Infections Among College Women
Journal of Interpersonal Violence. 24,8: 1338-1357

Daley, E. et al. (2010) “Influences on Human Papillomavirus Vaccination Status Among Female College Students” Journal of Women's Health.  19(10): 1885-1891.

Dyer, K. E. (2010) “From Cancer to Sexually Transmitted Infection: Explorations of Social Stigma among Cervical Cancer Survivors” Human Organization 69: 321-330.

Gautham, M., R. Singh, H. Weiss, R. Brugha et al. (2008) Socio-cultural, psychosexual and biomedical factors associated with genital symptoms experienced by men in rural India. Tropical Medicine and International Health, 13(3):384–395.

Philpott, A., W. Knerr, and V. Boydell. (2006) Pleasure and prevention: when good sex is safer sex. Reproductive Health Matters 14(28): 23-31.

Special Populations
Ballard, K.D., M.A. Elston, J. Gabe (2009). Private and Public Ageing in the UK. The Transition through the Menopause. Current Sociology 57(2): 269-290.

Lewin, E. (1995) On the Outside Looking In:  the Politics of Lesbian Motherhood. In Ginsburg and Rapp Conceiving the New World Order: The Global Politics of Reproduction. California University Press: 103-121.

Marhefka, S. L., C. R. Valentin, et al. (2011). "I feel like I'm carrying a weapon.”  Information and motivations related to sexual risk among girls with perinatally acquired HIV." AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV.

Smid, M., P. Bourgois, et al. (2010). "The Challenge of Pregnancy among Homeless Youth: Reclaiming a Lost Opportunity." Journal of Health Care for the Poor and Underserved 21(2 Suppl): 140.

Buhi, E. et al. (2010) Quality and Accuracy of Sexual Health Information Web Sites Visited by Young People. Journal of Adolescent Health 47:206-208.

Belisario, O. C. V. (2010). “Muslim Women and Circumcision: A Study of Intergenerational Practice and its Continuity in Southern Philippines." WMSU Research Journal 28(1).

Johansen, R. (2006) Care for infibulated women giving birth in Norway: an anthropological analysis of health workers’ management of a medically and culturally unfamiliar issue. Medical Anthropology Quarterly 20(4): 516-544.

Kurth, E., F. Jaeger, et al. (2010). "Reproductive health care for asylum-seeking women-a challenge for health professionals." BMC Public Health 10(1): 659.

Obure, A. F. X. O., E. O. Nyambedha, et al. (2011). "Interpersonal Influences in the Scale-up of Male Circumcision Services in a Traditionally Non-circumcising Community in Rural Western Kenya." Global Journal of Community Psychology Practice 1(3).

Shell-Duncan, B. (2001) The medicalization of female “circumcision”: harm reduction or promotion of a dangerous practice? Social Science and Medicine 52:1013-1028.

Also, if you are a scholar, MIT Open CourseWare lists tons of anthropology course syllabi and reading lists! 

Friday, December 23, 2011

Another Semester Down

Another semester down...

So I've found that I can hold down 2 part time jobs, doula work, a full grad course-load including 3 group semester-long projects, and not go totally insane. I still managed to get all A's and see my friends at least once a week for dinner. My wonderful SO was there to help me through the emotional breakdowns (I didn't say there weren't any!), and I managed to come out alive. I'm quite proud of myself! This semester was very hard and I'm so glad its over.

I had two fantastic doula clients give birth in the same week. Though it totally messed up my sleep and homework life that week, I thoroughly enjoyed helping both these wonderful families. Here is some of what I experienced and learned:

One was a primip who had switched to a birth center birth during her pregnancy. The birth center was big and beautiful and totally empty while we were there. I was with her and her husband for 24 hours at home and the birth center before the decision was made to transfer to a hospital so mom was able to get some pain relief and some sleep. She had been awake for nearly two days! First time moms never follow this advice which I always give, but you really have to sleep in early labor! She was such a trooper - she would have kept on going if she wasn't just so tired. Really such a sweet couple, great midwife and midwives' assistant at the birth center, and a seamless transfer to midwifery care at a nearby hospital. The transfer was very upsetting, and she did reverse some in dilation. I've heard of this happening before and I'm very sure this is what happened here. It was a beautiful labor that ended up being an asynclitic occiput posterior baby giving her so much trouble! (I learned at this birth that the baby can be OP and the mom might not have back labor). 

The second labor was the fastest dilation I've ever seen - another primip who I didn't end up laboring at home with because her husband was very nervous in early labor and insisted they go to the hospital. I met them there and the labor was great - very quiet, calm, peaceful. Very few nurses or doctors bothered us the whole time. Mom, dad and I slept on and off in between contractions. There was also some salsa dancing! I really think this may have been partly responsible for such a quick labor - She actually dilated 5 centimeters in about 2.5 hours. I was definitely jaw-drop shocked when I heard she was complete. I've never seen that before!

Recently I've been contacted by two potential doula clients who are very early in their pregnancies. I've never been hired by someone so early in a pregnancy! So I'm having a lot of doula firsts recently.

Next year I'm going to begin earning my continuing education credits for eventual re-certification... Best to start early! Next year will also be the year I start my internship, data collection and thesis writing. Whew!

Happy Holidays, everyone!

Tuesday, December 20, 2011

Comment Turned Post: Medical Anthropology and Midwife Rituals

Medical anthropologist and midwife Melissa Cheyney published an article in the Medical Anthropology Quartlerly called Reinscribing the Birthing Body: Homebirth as Ritual Performance. Apparently this caught the eye of a writer at Science 2.0, Hank Campbell, who decided to bash anthropology and midwifery in an article called Midwife Rituals: Anti-Science Or Just Symbolism?

Campbell seems to fail to understand certain things about anthropology, like the fact that participant-observation is a dominant method of anthropological research. He also calls her analysis of her research "advocacy" when she says "Just as women and their doctors who deliver in the hospital often feel convinced that their birth was the only safe and 'correct' way, women and midwives who deliver at home feel strongly that they have the solution." This is her analysis statement, not a bashing of obstetricians. Additionally, calling aspects of biomedical care "rituals" is not meant to "create false equivalence for female empowerment rituals," as Cambell states. It is a true anthropological concept and theoretical analysis method which has been studied extensively, not simply made up for Cheyney's convenience.

It is a true concept that the female reproductive body has become medicalized in all aspects - menstruation, pregnancy, birth, breastfeeding, menopause, and so forth. The concept that American medicine has of the birthing body is encompassed in the culture of biomedicine and the beliefs of our society. We like to think that it is objective, evidence-based, and the One Truth, but in fact it is only one reality. Robbie Davis-Floyd explored how medicine, obstetrics, and birth in the U.S. is a ritual; a socially constructed rite of passage. If Campbell had read the article carefully, he would have noted that the reason that Cheyney used ritualization as a lens through which to explore homebirth is because it has been a useful tool for reproductive anthropologists in the past. (Rites of passage and rituals have been studied extensively in other areas of anthropology as well). Davis-Floyd showed that birth is "a reflection of a larger patriarchal and technocratic society." Davis-Floyd examined the rituals associated with hospital birth, and Cheyney examined the rituals associated with home birth midwifery. Both are valid anthropological research and theory.

So while, yes, home birth is partly about a rejection of the dominant biomedical tenants about birth and certain types of authoritative knowledge, it is also about embracing a different point of view regarding the way birth is or should be. Biomedicine is only one example of the way birth is or can be. Differing views are not wrong, they are just different, and exploring them for a deeper understanding is what medical anthropologists do best.

The point of this article is not to add to the "which is better, home birth or hospital" debate. The purpose is to explore the rituals involved in home birth midwifery and what they mean. Cheyney believes that what she calls rituals in home birth are intentionally subverting technocracy, and are meant to "reinscribe pregnant bodies and reterritorialize childbirth spaces and authorities." What this means is that home birth midwives are doing the things they do and saying what they say in order to purposefully go against the hegemony of biomedicine and all it says about bodies and where birth should take place and with whom. She says that midwives are, like obstetricians, taking advantage of this liminality of birth to create a certain meaning of childbirth (in the midwives' case, that nature is sufficient; in the physicians', that technology is supreme).

Many of the rituals (“patterned, repetitive and symbolic enactment of cultural beliefs and values") that Cheyney describes include things like including the woman and her family in prenatal care, repetitive birth mantras and other techniques for a drug-free birth, an inversion of the doctor-up, mother-down hierarchy during pushing, and certain postpartum techniques like delayed cord clamping. Cheyney argues that midwives do all these things in order to intentially be diferent from the biomedical model. Its interesting to read her description of them as their own form of "ritual," and I also would not have thought previously about their being used to intentionally be subversive.
Some women do "sidestep obstetric standards of care" and challenge "the hegemony and authoritative knowledge of medicalized birthing care" by choosing birth with a midwive at a center birth or at home. While the idea about which is "better" can be debated until the end of time, the point is that women do make that choice, and have the right to. And though it is not a belief shared by all, it is my belief that women have the right to choose what happens to their bodies and who they hire to provide their health care.

I agree that homebirth is a "medium for the promotion of social change," but I don't think thats the only reason that women choose to birth at home or with a midwife. It has been shown that women who choose home birth are rejecting the technocracy, but this is not always a conscious part of their decision. Furthermore, the reason they do it is not always to be part of political and social change, but simply to make the best choice for themselves and their babies, or because they have no other choice (in the case of the underinsured, for example).

These are my thoughts on the article. Unfortunately, the comments on the Science 2.0 article do not tend to focus on the fact that Campbell's understanding of anthropology is flawed and his analysis of Cheyney's piece is incorrect. Many in the comments section  jump into the home birth vs. hospital and midwife vs. physician debate. So, I am going to weigh-in a bit here:

It is not just mothers, hippies, birth activists, and midwives who are pointing out that the biomedical model of birth is potentially dangerous, it is also physicians and health researchers and scientists. Birth models that include midwives and the midwives' model of care have been shown worldwide to be birth models that work.

So what's the big deal if women are included in all processes, from conception to birth and beyond? Is it such a bad thing if a woman feels empowered, capable, strong and in control? What's the big deal if a woman wants warm water immersion and positive birth statements repeated to her, if it works? Arguments against home birth midwifery tend to call all this "woo woo" or "touchy feely." Women should be able to have this kind of positive care whether or not you're with a physician or a midwife. It has been shown that it matters and that it is a good thing. So why does biomedicine reject it?

I encourage you to put your two cents in over at Campbell's article, even if you're not an anthropologist. The infamous Amy Tuteur has even found it worth her while to do so! Most commenters seem to agree with what he says, and we need to turn the tide.

Monday, December 19, 2011

Just One Bottle?

"Just One Bottle Won't Hurt"-- or Will It?

Marsha Walker, RN, IBCLC

  • The gastrointestinal (GI) tract of a normal fetus is sterile
  • the type of delivery has an effect on the development of the intestinal microbiota
    • vaginally born infants are colonized with their mother's bacteria
    • cesarean born infants' initial exposure is more likely to environmental microbes from the air, other infants, and the nursing staff which serves as vectors for transfer
    • the primary gut flora in infants born by cesarean delivery may be disturbed for up to 6 months after birth (Gronlund et al, 1999)
  • babies at highest risk of colonization by undesirable microbes or when transfer from maternal sources cannot occur are cesarean-delivered babies, preterm infants, full term infants requiring intensive care, or infants separated from their mother
    • infants requiring intensive care acquire intestinal organisms slowly and the establishment of bifidobacterial flora is retarded
    • a delayed bacterial colonization of the gut with a limited number of bacterial species tends to be virulent
    • control and manipulation of the neonatal gut with human milk can be used as a strategy to prevent and treat intestinal diseases (Dai & Walker, 1999)
  • major ecological disturbances are observed in newborn infants treated with antimicrobial agents
    • one way of minimizing ecological disturbances in the NICU is to provide these babies with fresh breast milk (Zetterstrom et al, 1994)
  • breastfed and formula-fed infants have different gut flora 
    • breastfed babies have a lower gut pH (acidic environment) of approximately 5.1-5.4 throughout the first six weeks that is dominated by bifidobacteria with reduced pathogenic (disease-causing) microbes such as E coli, bacteroides, clostridia, and streptococci
    • flora with a diet-dependent pattern is present from the 4th day of life with breast milk-fed guts showing a 47% bifidobacterium and formula-fed guts showing 15%. Enterococci prevail in formula-fed infants (Rubaltelli et al, 1998)
    • babies fed formula have a high gut pH of approximately 5.9-7.3 with a variety of putrefactive bacterial species
    • in infants fed breast milk and formula supplements the mean pH is approximately 5.7-6.0 during the first four weeks, falling to 5.45 by the sixth week
    • when formula supplements are given to breastfed babies during the first seven days of life, the production of a strongly acidic environment is delayed and its full potential may never be reached
    • breastfed infants who receive supplements develop gut flora and behavior like formula-fed infants
  •  The neonatal GI tract undergoes rapid growth and maturational change following birth
    • Infants have a functionally immature and immunonaive gut at birth
    • Tight junctions of the GI mucosa take many weeks to mature and close the gut to whole proteins and pathogens
    • Intestinal permeability decreases faster in breastfed babies than in formula-fed infants (Catassi, et al, 1995)
    • Open junctions and immaturity play a role in the acquisition of NEC, diarrheal disease, and allergy
    • sIgA from colostrum and breast milk coats the gut, passively providing immunity during the time of reduced neonatal gut immune function
    • mothers' sIgA is antigen specific. The antibodies are targeted against pathogens in the baby's immediate surroundings
    • the mother synthesizes antibodies when she ingests, inhales, or otherwise comes in contact with a disease-causing microbe
    • these antibodies ignore useful bacteria normally found in the gut and ward off disease without causing inflammation
  •  infant formula should not be given to a breastfed baby before gut closure occurs
    • once dietary supplementation begins, the bacterial profile of breastfed infants resembles that of formula-fed infants in which bifidobacteria are no longer dominant and the development of obligate anaerobic bacterial populations occurs (Mackie, Sghir, Gaskins, 1999)
    • relatively small amounts of formula supplementation of breastfed infants (one supplement per 24 hours) will result in shifts from a breastfed to a formula-fed gut flora pattern (Bullen, Tearle, Stewart, 1977)
    • the introduction of solid food to the breastfed infant causes a major perturbation in the gut ecosystem, with a rapid rise in the number of enterobacteria and enterococci, followed by a progressive colonization by bacteroides, clostridia, and anaerobic streptococci (Stark & Lee, 1982)
    • with the introduction of supplementary formula, the gut flora in a breastfed baby becomes almost indistinguishable from normal adult flora within 24 hours (Gerstley, Howell, Nagel, 1932)
    • if breast milk were again given exclusively, it would take 2-4 weeks for the intestinal environment to return again to a state favoring the gram-positive flora (Brown & Bosworth, 1922; Gerstley, Howell, Nagel, 1932)
  •  in susceptible families, breastfed babies can be sensitized to cow's milk protein by the giving of just one bottle, (inadvertent supplementation, unnecessary supplementation, or planned supplements), in the newborn nursery during the first three days of life (Host, Husby, Osterballe, 1988; Host, 1991)
    • infants at high risk of developing atopic disease has been calculated at 37% if one parent has atopic disease, 62-85% if both parents are affected and dependant on whether the parents have similar or dissimilar clinical disease, and those infants showing elevated levels of IgE in cord blood irrespective of family history (Chandra, 2000)
    • in breastfed infants at risk, hypoallergenic formulas can be used to supplement breastfeeding; solid foods should not be introduced until 6 months of age, dairy products delayed until 1 year of age, and the mother should consider eliminating peanuts, tree nuts, cow's milk, eggs, and fish from her diet (Zieger, 1999; AAP, 2000)
  •  in susceptible families, early exposure to cow's milk proteins can increase the risk of the infant or child developing insulin dependent diabetes mellitus (IDDM) (Mayer et al, 1988; Karjalainen, et al, 1992)
    • human insulin content in breast milk is significantly higher than bovine insulin in cow's milk; insulin content in infant formulas is extremely low to absent; insulin supports gut maturation
    • in animal models oral administration of human insulin stimulates the intestinal immune system generating active cellular mechanisms that suppress the development of autoimmune diabetes
    • the lack of human insulin in infant formulas may break the tolerance to insulin and lead to the development of type 1 diabetes (Vaarala et al, 1998)
    • the avoidance of cow's milk protein for the first several months of life may reduce the later development of IDDM or delay its onset in susceptible individuals (AAP, 1994)
    • infants who are exclusively breastfed for at least 4 months have a lower risk of seroconversion leading to beta-cell autoimmunity
      • short-term breastfeeding and the early introduction of cow's milk based infant formula predispose young children who are genetically susceptible to Type 1 diabetes to progressive signs of beta-cell autoimmunity (Kimpimaki et al, 2001)
    • sensitization and development of immune memory to cow's milk protein is the initial step in the etiology of IDDM (Kostraba, et al, 1993)
      • sensitization can occur with very early exposure to cow's milk before gut cellular tight junction closure
      • sensitization can occur with exposure to cow's milk during an infection-caused gastrointestinal alteration when the mucosal barrier is compromised allowing antigens to cross and initiate immune reactions
      • sensitization can occur if the presence of cow's milk protein in the gut damages the mucosal barrier, inflames the gut, destroys binding components of cellular junctions, or other early insult with cow's milk protein leads to sensitization (Savilahti, et al, 1993)


    Friday, December 16, 2011

    Transforming Maternity Care

    In case you haven't seen this great video, Maternity Care with a Heart, I encourage you to check it out.

    Childbirth Connection does great work in their campaign to Transform Maternity Care.

    Maternity Care With a Heart from Childbirth Connection on Vimeo.

    Why does maternity care need to be transformed? 

    We pay more for maternity care than any other country, but have higher rates of maternal death, newborn death, and low birth weight than dozens of other nations. We invest too much in overusing high-tech care with no proven benefit and fail to invest in preventive care, or in strategies to address troubling disparities in access and outcomes. Described in 1989 as "the perinatal paradox: doing more and accomplishing less," the crisis in maternity care has fundamentally worsened in the time since. 
    All women and babies deserve maternity care that is woman-centered, safe, effective, timely, efficient, and equitable. Childbirth Connection is working towards this goal.
    To donate to this movement in the season of giving, or donate in someone else's name, go here. All donations will be doubled until December 20th!  
    Join the Transformation is a campaign for Childbirth Connection. Through the Transforming Maternity Care Partnership, Childbirth Connection works to improve maternity care through consumer engagement and health system transformation. We work with all stakeholders to foster implementation of the landmark "Blueprint for Action," and continue to develop high-quality, evidence-based information for women and maternity care professionals. We're deeply engaged in work to identify and endorse new maternity care quality measures and to develop and test new resources for shared decision making. We're also working at the state and national levels to influence policy, and partnering with employers, payers, and health systems to develop new ways of delivering maternity care that foster quality and value. Finally, we're identifying the people and systems making progress on maternity care quality improvement, and helping to spread the word about these models so others can learn from them.

    Wednesday, December 14, 2011

    The Fourth Trimester

    Have you heard of the Fourth Trimester?  Perhaps you can realize what it is from the name, even if you've never heard of it!

    The fourth trimester is the time period after birth, generally within the first 3 months, where the newborn is essentially just as helpless as he or she was while inside the womb. Compared to other mammals, humans are very fragile and immature at birth. Development continues outside of the womb, and the baby still depends on his or her mother for every need. They still require nourishment, warmth, and comfort from their mother's body, and are happiest when they are kept in a position in which they can listen to mom's heart.

    In effect, the fourth trimester is all about recreating the womb experience while the newborn continues to develop his or her brain, breathing, muscles, and other reflexes. Inside the womb, the baby listens to the loud and comforting sound of a heart beat 24/7 and is constantly kept warm and nourished. When an infant is then removed from the warmth, smells and sounds of mother, he/she tends to be very unhappy. Baby will be most calm, quiet and happy when kept on mom's chest (for instance, worn in a sling or baby carrier!) all day long.

    The fourth trimester is not just about the baby, though! The mother also goes through a fourth trimester of pregnancy symptoms including changing hormones, changing body, stress and sleep deprivation. The fourth trimester is a time when both mother and child need to be taken care of. For both, the fourth trimester is a time of adjusting to a new life.

    Understandably, its not possible for all mothers and babies to always be together for the entire fourth trimester. However, as much physical contact as possible is great for recreating what both mom and baby need after childbirth.

    Dad's can help recreate the womb experience, too! Dr. Harvey Karp's Happiest Baby on the Block teaches the 5  S's to soothe infants, and the techniques are easy for any caretaker to use. After all basic needs have been addressed (feeding, clean diaper, etc), these techniques can help trigger a calming reflex: swaddling, positioning him on his stomach or side, shushing loudly in his ear or playing white noise, swinging him to mimic the jiggling motion of the womb, and letting him suck on a pacifier or breast. The swaddling mimics the tight quarters that babies are used to (notice how newborns always tuck their legs up?). Shushing noises mimic the loud sounds that babies hear in the womb, and shaking is like mom's body rocking the baby to sleep. Its all part of the Fourth Trimester technique!

    So now, next time you see a new mom you can tell her "Happy Fourth Trimester!"

    Sunday, December 11, 2011

    "Breastfeed" Song

    Funny video with singing and dancing about breastfeeding by the University of Pittsburgh School of Medicine.  Enjoy!

    Monday, December 5, 2011

    Reimbursement for Doula Services

    I recently attended webinar on how a doula can set things up so that her clients can submit a request to their insurance company to be reimbursed for doula services!

    If you are a member of DONA you can download their Third Party Reimbursement packet for more information. I really enjoyed the webinar, though, because it explained to me face-to-face how to go about something like this. It made it seem a lot less daunting!

    First, a doula needs to obtain an NPI at The taxonomy code actually falls under Nursing Service Related Providers type 374J00000X. NPI is only referring to doula work. The doula must also have a Tax ID#, or use their SSN.

    The doula can help a client fill out a form with their health insurance company. If the insurance co does not have a form, a universal 1500 form can be used. The code for birth doulas is CPT 59400. A diagnosis code is required - V22.2 Intrauterine Pregnancy

    When submitting it is also beneficial to include:  A letter from the client, a description of a doula, the DONA International position paper, Standard of Practice, and Code of Ethics. Additionally, details such as the number of client meetings, number of hours in labor, and exact services provided should be included along with your certification credentials, if any.  A letter from a provider about the benefits of a doula is a plus; more likely to be reimbursed if you can show that your services helped lower costs for the insurance company! For instance, helping a mom to not require an epidural or end up with a cesarean section is a big money saver! 

    At the moment, no company is paying consistently, and none have been covered by Medicaid. Some states do have grant money for doula coverage, so look for those!

    Remember: the doula does not submit the forms, the clients do. Clients pay the doula in full and then submit request to the insurance company to be reimbursed. Claim submissions can be submitted multiple times up to 12 months after the birth. 

    Has anyone successfully been reimbursed for doula services? Share your story!

    In the DONA packet on Third Party Reimbursement they include an interesting section that I am going to include here as food for thought:

    Concerns about third party reimbursement The Third Party Reimbursement Committee will continue to gather information about the potential consequences and challenges to third party reimbursement. At first glance, it may seem to have no drawbacks. However, realistic assessments reveal that third party reimbursement may have costs that are not immediately apparent. The following concerns have been raised.  
    1. Will the reimbursement for doula services paid by third party payers be too low? Will it force doulas to reduce the fees they normally charge for private, self-paying clients? While doulas would not necessarily be required to accept low reimbursements or require clients to make up the difference between reimbursement and the actual fee, it is possible that financial pressure would cause doulas to consider lowering their fees.
    2. What restrictions or responsibilities might be added to the doula’s role by third party payers (e.g., licensing by the state, longer training, proficiency exams, different certification requirements or additional health care training or licensing)? Would doulas be required to carry malpractice insurance and would that make them more likely subjects of lawsuits?
    3. What conditions or requirements might be placed on the consumer in order that her doula’s services will be reimbursed? At least one third party payer has already limited the consumer’s options by covering the cost of birth doula services only if the woman agrees to not request an epidural. Birth doulas cannot be put into a position of preventing women from having an epidural or of supporting only particular choices.  
    It is possible that, if reimbursement were available only for doulas with state licenses, doulas could choose not to seek reimbursement and could remain unlicensed. It is also a remote possibility that it might become illegal for unlicensed doulas to practice in some states. Some hospitals might require certification to support women in their facilities. The benefits of regulation must be balanced against the loss of freedom it entails. 

    If you are looking for liability insurance - CMF Group has the cheapest (called "postpartum" services)

    Thursday, December 1, 2011

    Baby Blues and Postpartum Depression

    What is the difference between "baby blues" and postpartum depression?  Are you at risk for postpartum depression? Is there anything you can do to avoid it? What are the signs to look for, and when?

    Baby Blues:

    Many women have the baby blues in the days after childbirth. This means that they:
    • Have mood swings
    • Feel sad, anxious, or overwhelmed
    • Have crying spells
    • Lose your  appetite
    • Have trouble sleeping 
    • Feeling withdrawn or unconnected
    • Lack of pleasure or interest in most or all activities
    • Loss of concentration
    The baby blues most often go away within a few days or a week. The symptoms are not severe and do not need treatment. These symptoms are a result of having a huge upsurge of hormones, not having very much sleep during labor/in the hospital, and having a new baby to take care of and worry about. Feelings of inadequacy toward new motherhood, lack of self-esteem, a lack of free time and stressful schedules add into all of this.

    Postpartum Depression
    The symptoms of postpartum depression last longer and are more severe than those of baby blues. Postpartum depression can begin anytime within the first year after childbirth., an occurs in 15% of mothers. In addition to the symptoms above, postpartum depression may include:
    •  Thoughts of hurting the baby
    • Thoughts of hurting yourself
    • Not having any interest in the baby
    There is a range with PPD - you may have anything on the range between a mild case, where baby blues symptoms continue after 2 weeks, and a severe case, called postpartum psychosis (very rare). Be sure to talk to a doctor if your symptoms of depression last beyond 2 weeks postpartum.

    Certain factors may increase your risk of depression during and after pregnancy. If you:
    • Are under age 20
    • Currently abuse alcohol, take illegal substances, or smoke (these also cause serious medical health risks for the baby)
    • Did not plan the pregnancy, or had mixed feelings about the pregnancy
    • Had depression, bipolar disorder (for example, manic depression), or an anxiety disorder before your pregnancy, or with a previous pregnancy
    • Had a stressful event during the pregnancy or delivery, including personal illness, death or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or birth defect in the baby
    • Have a close family member who has had depression or anxiety
    • Have a poor relationship with your significant other or are single
    • Have financial problems (low income, inadequate housing)
    • Have little support from family, friends, or your significant other
    If you take medicine for depression, stopping your medicine when you become pregnant can cause your depression to come back. Do not stop any prescribed medicines without first talking to your doctor. Not using medicine that you need may be harmful to you or your baby.

    Women who are depressed during pregnancy have a greater risk of depression after giving birth.

    If you're not sure if you have postpartum depression, you can take this Edinburgh Postnatal Depression Scale quiz online.

    Tips to Reduce Risk of Postpartum Depression:

    Mood changes are common during huge life events. Making sure you have good social support before, during, and after birth, as well as during the "fourth trimester" can make a huge difference in one's ability to deal with these big changes. Don't feel bad about asking for help, getting some free time to yourself, or joining a support group! And don't be afraid to discuss your feelings with your partner. Getting as much rest as you can and not trying to do too much helps a lot! Also, some moms say they've had success consuming their placenta, generally via encapsulation, in improving mood after childbirth.

    These are some resources for moms who think they might have postpartum depression and are looking for more information:

    Postpartum Progress - one of the most widely read blogs on PPD.
    Postpartum Voice - stories, resources, and insights
    Beyond Postpartum blog
    PPD to Joy blog

    HAVE YOU EVER WORKED WITH A MOM WHO HAD PPD, OR HAVE YOU EXPERIENCED IT YOURSELF? What advice would you give a doula on baby blues and PPD?

    Info source: Women'sHealth.Gov and PubMed Health
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