Posts Tagged ‘maternity care’

Maternity care evolves to embrace family

posted on July 1, 2011

By Laura Thomas
Heritage correspondent

Second of two parts 

1978 American Journal of Nursing article authored by KP San Francisco’s then Maternity Coordinator Deloras Jones, RN, BSN.

In the 1970s, Kaiser Permanente responded to the rising influence of feminism and a popular trend calling for home births, drug-free deliveries and family participation by establishing the Family-Centered Perinatal Care Program (FAMCAP) at the San Francisco Medical Center. 

With patients demanding a more natural birthing experience, the Kaiser Permanente family-centered birth program zeroed in on one particular aspect of the trend: Shortening the mother and infant’s postpartum stay in the hospital. KP San Francisco’s then Maternity Coordinator Deloras Jones, RN, BSN, began recruiting participants in 1973 and found many expectant parents were enthusiastic. 

“The parents wanted increased father involvement, less family separation after birth, and treatment of mother and infant as though they were well, not ill,” Jones wrote in “Home After Delivery,” a 1978 article in the “American Journal of Nursing,” after 1,200 families had used the program successfully. 

In the decades after World War II, the length of stay standard for childbirth had risen to as many as 10 days, keeping mothers away from their families and in the sterile environs of the acute care hospital. A picture in a KP newsletter from the late 1940s shows a new mother preparing to leave the hospital after 10 days of rest and recovery. 

Patient education key in shortening hospital stay

As an essential part of the 1970s shortened-stay program, KP began to offer prenatal classes and encouraged the father’s participation in childbirth preparation as well as in labor and delivery. The hospital experience included rooming-in for mother and infant after 24 hours of observation in the nursery, breast feeding training, and infant care classes. 

With an eye to shortening stay, the program focused on protocols for assessing mother and baby’s health and ability to go home within 12 to 24 hours. A nurse was assigned to visit the family at home for three days and to be available for questions and assistance for up to two weeks. 

In 1976, Jones and colleagues Mark J. Yanover, MD, and Michael D. Miller MD, published a report of their study of the experience in the San Francisco family-centered program. They compared a group of 44 low-risk mothers who delivered their babies along the typical routine with 44 others who elected the early discharge program. The researchers concluded that “this method of perinatal care is as safe as that traditionally provided at our medical center.” 

FAMCAP had a major influence over early discharge standards developed for both the American College of Gynecology (ACOG) and the American Association of Pediatricians (AAP) and marked an acceleration of a trend toward shorter hospital stays for postpartum mothers. 

Kaiser Permanente provides tools to help smooth a new mother's transition to home. Photo originally published in the Permanente Journal, Fall 2005.

The shorter stay phenomenon in the 1970s was wholly embraced by cost-conscious health maintenance organizations, often without the follow-up care that was the hallmark of the Kaiser Permanente approach – and became the source of intense national debate in the 1990s. 

Shortened stays too short?

According to figures that came out in Congressional hearings, the median length of stay for postpartum women across the U.S. had dropped almost 50 percent between 1970 and 1992 – from four days to less than two days for a vaginal delivery. “Within the last three years, stays have declined from 48 hours to 24 hours. Some (women) were even required to leave the hospital in as little as eight hours after delivery,” according to Debra Kuper writing in the “Marquette Law Review” in 1997. 

There were increasing reports of kernicterus, a rare and preventable complication of jaundice, and mental retardation due to failure of postpartum mothers to return for Phenylketonuria testing, amongst other tales of women being kicked out of hospitals before adequate assessment of their or their infants’ readiness to go it alone. 

In response, Congress enacted the Newborns’ and Mothers’ Health Protection Act of 1996 to mandate 48-hour stays for vaginal births and 96-hour stays for cesarean births unless mother and physician agree to a shorter stay. Both the national OB-GYN and pediatricians associations revised their standards to reflect the new mandates. 

Nonetheless, shorter hospital stays with more choice and control over the childbirth experience have become the norm for parents across the country. Expectant Kaiser mothers and fathers are now given a birth plan to fill out that allows them to select the delivery room environment, methods of inducing labor and controlling pain, delivery position and various postpartum procedures. 

Recent national trends show the cesarean section rate for first-time low risk mothers climbing – California rates increased from 20 to 26.5 percent from 2000 to 2005. Statistics also show a retreat from the 1980s surge in women wanting vaginal deliveries after cesareans (VBAC) with California rates for repeat cesareans up from 84.4 to 94.3 percent from 2000 to 2005. 

Kaiser Permanente continues to support women who want to deliver vaginally after they’ve had a C-section, and offers programs and procedures that encourage strong mother-baby bonding practices, including breastfeeding. Today, about 75 percent of American new mothers nurse their newborns. 

Honors for KP “baby-friendly” hospitals

Kaiser Permanente Southern and Northern California regions were honored in 2008 by the California Breastfeeding Coalition for leadership in supporting nursing mothers while medical centers in Clackamas, Oregon; Honolulu; and Hayward and Riverside, California, were all been named “baby-friendly hospitals” by the Baby-Friendly Initiative of the World Health Organization. 

Keeping birth “normal” is still a worthy goal for the organization, Fontana midwife and nurse specialist Iona Brunt wrote in 2005 in “The Permanente Journal.” 

“We must empower mothers with the belief that their bodies are made to give birth and, in most circumstances, will do well. We must dissipate the idea that without our high-technology intervention, babies cannot be born healthy and safe.” 

“It makes sense,” she said. “It’s cost-effective and it’s the right thing to do.”

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Empowered women shape modern maternity care

posted on June 19, 2011

By Laura Thomas

Heritage correspondent

First of two articles

Nurse tends newborns in the Oakland Permanente hospital during World War II

Seventy-five years ago, two-thirds of American women gave birth at home with no painkillers, often attended by a family doctor, as the tradition of relying on midwives and practical nurses was falling away.

The practice of modern obstetrics was on the rise and the trend toward the majority of births occurring in hospitals was just around the corner as the American Medical Association met in Kansas City in May 1936 and hotly debated the benefits of new childbirth analgesics and how far to go in relieving the pain of childbirth.

According to Time Magazine, Dr. Gertrude Nielsen of Norman, Okla., denounced such pain killing innovations as twilight sleep – a combination of morphine and scopolamine – and a synergistic anesthesia accomplished by injecting a mixture of morphine and Epsom salts into the muscles and introducing a mix of quinine, alcohol and ether in olive oil into the rectum.

“An analgesic that is perfectly safe for both mother and child has not been discovered,” she told the convention. She asserted that fear of childbirth contributed to pain and called for prenatal education to reduce fear: “That is the modern physician’s duty.”

Part of the tumult over the issue had been provoked by articles in the press describing these new drugs and their use. Dr. Buford Garvin of Kansas City observed: “American obstetrics seems to be becoming a competitive practice to please American women in accordance with what they read in lay magazines.”

Childbirth trends change dramatically in the 1960s and 1970s

We could fast-forward to the 1950s when hospital childbirths had become the norm, the pain of the experience was reduced by epidural anesthesia and women relinquished control over the process to the physician. When Dr. Sidney Sharzer joined Permanente in Southern California in 1956, he became an early proponent of change.

During prenatal consultations Sharzer encouraged women to consider breastfeeding, advice which ran counter to the then-popular American pediatric practice of giving “modern” formula.   At the University of Toronto, where he received his degree, breastfeeding was still considered preferable: “It provided early immunity and was just the right formula in that there were no problems with digestion and it was the right temperature,” he said.

Formula was seen as a convenience, especially for many women who remained in the workforce after World War II, and it allowed fathers to take part in infant care. It was also heavily promoted by the cereal companies who manufactured it. Most of Sharzer’s patients were bombarded “with a lot of propaganda, or advertising, as we call it,” he said, and resisted his advice. “If you bottle-fed, you were liberated. And, in those days, you were not going to whip out your breast at a shopping center.”

“Liberated” women demand natural childbirth

Mother and baby "rooming in" in Kaiser Permanente's Walnut Creek hospital 1953

Ironically, it was the “liberated” women of a later era who demanded a more natural approach to childbirth and support for breastfeeding. Those whispers from the 1930s questioning drug use were getting louder.

“The mid-1960s and early 1970s saw a wholesale consumer revolt against highly structured, hospital-centered prenatal care,” Sharon Levine, MD, Northern California Permanente Medical Group executive, testified before a U.S. Senate committee in 1995. “Rooming in became commonplace. Home deliveries returned. Nurse midwives, who had all but disappeared from the American health system, became increasingly commonplace.

“Maternal-infant bonding became recognized as an essential part of postnatal care. Breastfeeding of infants made a dramatic resurgence,” she said in her testimony against a law to dictate length of hospital stay for new mothers.

Some innovation had already occurred at Kaiser Permanente. In the mid-1950s at Permanente founding physician  Sidney Garfield’s behest, the “rooming-in” program began at new facilities in San Francisco, Walnut Creek and Los Angeles. In these early “dream hospitals,” the nursery had been built adjacent to the maternity rooms with slide-through drawers for the babies to be passed in from the nursery through a soundproof wall.

The baby-in-the-drawer configuration allowed a mother to pull the baby into her room to nurse and hold her child as long as she desired. “It keeps mother and baby closer together. Nurses are able to help the new mothers learn better how to care for their infants,” said a Kaiser Permanente newsletter of the era. Most hospitals of the time kept newborns separate from their mothers, under the care of the nursing staff, except for feeding times. 

Bringing dad into delivery room

Around 1961, when he took over as chief of service at Harbor City Hospital, Sharzer made a couple of bold moves. He decided to bring fathers directly into the birthing room, and he began to encourage women to use the “prepared childbirth” techniques. He was inspired by British doctor Grantly Dick-Read’s book, “Childbirth without Fear,” which advocated the use of breathing techniques to minimize pain and increase the joy of the experience.

Lamaze breathing techniques were introduced in the U.S. by Marjorie Karmel after she gave birth in France assisted by Dr. Fernand Lamaze, who developed his techniques based on Dick-Read’s. She started an organization in 1960 – now Lamaze International – that currently focuses less on birthing methods and more on achieving a natural childbirth without drugs or technological intervention.

Sharzer remembers his struggle to get these ideas accepted: “The consumers were pushing for it and it was the right thing…husbands should see what their wives are going through.” At the time, fathers were ushered into a waiting room or went home to await a phone call and while some were thrilled to be invited to watch the process, others were less so. The nurses would good-naturedly chide a reluctant father. “They’d say he was a lousy husband to desert his wife at a time like this. They would appeal to his better nature and then insult him,” Sharzer said.

Outside of Harbor City, it was an uphill fight. When Sharzer first suggested the notion to his colleagues at the five other Permanente Southern California facilities, he was voted down 5 to 1. There was a lot of hostility from both doctors and nurses who assumed the fathers would try to get in the way by second guessing the medical staff, he said. But even their resistance couldn’t stop the forces of history. Fathers were finally allowed in delivery rooms at all Southern California facilities by the end of the 1960s.

Sharzer moved on to West Los Angeles in the 1970s and became assistant medical director: “It gave me the opportunity to be innovative.” There, he was able to inspire younger and more progressive doctors to go along with the trend toward treating childbirth as a natural process.

Natural birth after C-section?

Sharzer questioned the long-held “once a cesarean, always a cesarean” policy after he observed countless women scheduled for cesarean arrive at the hospital late in labor and give safe births. “If it’s that dangerous, how come these women come in and two minutes after they hit the bed, the baby comes out naturally?” he said.

Doctors feared that the vertical incision made through the large uterine muscle would rupture during contractions and for years women who had had a cesarean were discouraged from having subsequent vaginal births. But an innovation – the transverse incision made across the lower belly – was introduced that reduced the likelihood of rupture and more doctors began to experiment with allowing women to try vaginal births, under close monitoring.

A five-year study of vaginal births after cesarean deliveries in multiple hospitals showed that reverting to a natural birth process could be successful for many women. “Kaiser Permanente conducted the definitive study concluding that vaginal birth after a prior cesarean section is possible and safe … vaginal births are generally safer and less expensive for the mother and infant,” Permanente’s Dr. Levine told senators.*

Sharzer recalls:  “A doctor had to be present all the time and there was a lot of resistance” among the general obstetrical crowd, but at Kaiser Permanente, vaginal birth after cesarean, known as VBAC, was easier to implement because a doctor was always on duty in the maternity ward. “In our setup, it was very good and we were one of the early ones to do VBAC.”

Nurse practitioners deliver prenatal care

In those years, Sharzer also helped establish the first program in Southern California for training nurse practitioners at Cal State Los Angeles and when they graduated, he hired them to work under supervision assisting the doctors with prenatal care.

Retired since 1993, after delivering some 7,000 babies at Harbor City and West Los Angeles, Sharzer attributes the tremendous change in maternity care since 1960 to the Civil Rights Act of 1964: “It also changed the philosophy of equality…and that applied to women in our society.  It had a lot to do with female power.” 

That piece of legislation guaranteed equal rights to women as well as African-Americans. But women, especially those active in the civil rights and anti-war movements, found themselves relegated to supportive roles to male leadership and many split off and created the feminist movement, founding the National Organization for Women, among others. Health care and childbirth became a major arena in women’s struggle for equality and power over their lives.

Next time: How Kaiser Permanente responded to member demands for shorter postpartum hospital stays.

*Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study. Obstet Gynecol 1990: 76(5 pt 1):750-4.

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19th century Fabiola ladies championed health care for all

posted on March 6, 2011

Fabiola Hospital in its heyday

By Laura Thomas
Heritage correspondent   

Kaiser Permanente Oakland stands today on one of the busiest intersections in the city, destined to bustle even more with the new medical center rising in place of the MacArthur-Broadway indoor mall.   

What many may not realize is that the groundwork for the Kaiser Permanente complex was laid – both literally and figuratively – in Oakland’s early years by a group of high society women of the Fabiola Association.   

In 1887, it was at that same corner, then New Broadway and Moss Avenue, on 2 ½ acres of land covered with oak, eucalyptus and locust trees donated by Anthony Chabot, that the Oakland Homeopathic Hospital and Dispensary constructed a splendid turreted Victorian building. They named it the Fabiola Hospital after a wealthy woman who built a public hospital in 4th century Rome.   

It looked more like a railroad baron’s mansion than what we might think of as a medical building, but it was in line with what those 19th century matrons thought was best for sick people – an environment that was home-like and comforting.   

Privileged women strive for underprivileged

Bucolic setting of original Fabiola hospital

The group had been organized by Kate Kirkham 10 years before. She witnessed a carriage accident and was horrified to learn the victims would be taken 10 miles to a San Leandro hospital, the nearest hospital at the time. She collected $50 donations from 18 women of her circle – local water developer Chabot was a friend of hers – and opened the group’s first facility on Market Street.   

They formed the Fabiola Association to support their work, which focused on providing medical care to anyone who needed it. In its early years, the association members were proponents of homeopathic care.   

Once the hospital went up, the association members established a nursing school that accepted men (an oddity at the time), a diet kitchen, and a visiting nurse service. They began a program of expansion that didn’t abate until the Great Depression hit in the 1930s.   

Fabiola grew to meet community needs

Interior of maternity cottage late 19th century

Fabiola’s expansion was much like the evolution of the modern-day Kaiser Permanente’s complex. Before 1900, Fabiola annexed a Queen Anne-style cottage to the main building for the nurses’ quarters, and then added a facility for children and a maternity “cottage.” Over the following 20-plus years, the hospital spread across Broadway with the takeover of a Red Cross facility and the building of a graceful Spanish-style nursing home designed by Julia Morgan.   

A new surgical building went up in 1907 along Moss Avenue and Howe Street. The final spate came in 1923, accompanying a building boom across the city, when the Fabiola ladies built another nurses residence at 3797 Piedmont Ave., with a tennis court.   

The year ended with the completion of a modern 50-bed maternity hospital at the corner of Moss Avenue and Broadway appointed with, according to the Oakland Tribune, “antique walnut, rich rugs and cretonne hangings.”   

The much-touted maternity building, you may realize, became home to the first Kaiser Permanente hospital in 1942. But there’s more to this story.   

Both Kirkham and Kaiser dreamed of better access to care

The Kaiser Foundation Health Plan’s mission is built upon the work of earlier generations that saw providing adequate health care as a duty of the society. And people of means often took it on as their personal mission. Henry Kaiser was inspired to set up the Kaiser health plan by his mother’s untimely death, much as Kate Kirkham was prompted by the suffering she witnessed in the accident.   

In the progressive era, women across the country started hospitals and clinics for women, children and the poor. The Fabiola Association was part of the trend. Members insisted in their by-laws that the hospital be managed by women and that the staff doctor always be a woman.   

Fabiola maternity hospital circa 1924

They were privileged women with feminist instincts who financed their work by staging endless parties, teas, rummage sales and a big horse racing event that were covered in detail – down to the gowns each woman wore – in the Oakland papers. Reading between the lines of the Tribune, Herald and Post-Enquirer provides an insight into the social mores and strict sense of personal duty of a century ago.   

Society ladies took care of working nurses

The Fabiola women were fiercely devoted to the welfare of the nurses. In 1902, they were encouraged by the board president to take turns sending their carriages out “at 8 o’clock in the morning to take the night nurses out for an hour or two driving in the quieter parts of our suburbs” to help them relax before going to bed.   

There were power struggles among the ladies who served on the Fabiola board and at least one strike by nurses which necessitated the matrons’ heading over to the hospital to hoist the bed trays up from the kitchen. They were also taken to task by local ministers who berated them for raising money through gambling, with the Fabiola Derby Day at the Oakland Trotting Park.   

Again, owing to their social status, such criticism didn’t stop them. “Oakland’s most exclusive dames are members of Fabiola and they are indignant over Rev. Baker’s strictures,” reported the Tribune in June 1904.   

Each year, the Fabiola Association issued their service statistics. In 1900, they saw 871 patients of which 619 were hospitalized. Of those, only 131 paid the full hospital charges, the rest paid nothing or just what they could afford. By 1930, the hospital saw 4,753 patients, of which 517 received free care.   

Unfortunately, the good works wrought by the Fabiola ladies soon came to a crashing halt. Hard times reduced paying customers and donations dried up. The hospital closed in October 1932. The Tribune’s headline was “Fabiola Ends Experiment in Feminism” and editorialized that the regret felt by Oaklanders for its loss “was akin to grief.”   

Original architectural beauties demolished

Early the following year, the glorious original hospital – a building that would qualify for landmark status had it survived – as well as the children’s annex, nurses home, and the surgical building were all razed. The new maternity hospital was saved in hopes the operation could be resurrected.   

Instead, the Fabiola Association turned over all its assets to Samuel Merritt Hospital in 1940 with the stipulation that it be used for those unable to afford hospital care, and the women went to work for another decade to aid that effort. The real estate, including the hospital, was estimated at a $75,000 value.   

Fabiola maternity hospital renovated and reopened as the first Permanente Foundation Hospital circa 1942

The hospital was considered still quite modern with its reinforced concrete construction, and Henry Kaiser and Dr. Sidney Garfield were quite pleased to find it in 1942 when they were running out of room to treat shipyard workers at the Richmond Field Hospital. They paid $333,000 for the land and renovations and reopened it in August.   

The Fabiola building served as the core of the original Kaiser Permanente complex during the war and early days of the public health plan. Many additions and renovations on the site characterized Oakland’s flagship facility’s growth over the past 65 years.   

At one time, the Fabiola was painted pink, Henry Kaiser’s favorite color, and in its last iteration was encased in aluminum, one of Kaiser Industries’ main industrial products. The 1923-built, four-story building was torn down in 2005 as part of the Oakland Medical Center rebuild project currently under way.   

Kaiser Permanente carries on Fabiola’s original mission

Few Oaklanders remember the old hospital now, though scores were born in the homey maternity cottage, including my father in 1920. The new Fabiola building on Howe Street is the last reminder of that “institution of real Christian socialism” – as defined by its president Mrs. J.P.H. (Catherine) Dunn at its closing – that was the original Fabiola.   

If in later years Henry Kaiser was accused of being a “socialist” for putting forth a prepaid, group health plan, he stands shoulder to shoulder with Kate Kirkham and her successors in realizing his shared humanity with those in need but without means.   

One hundred and thirteen years separate the pastoral beauty that surrounded the 19th century Fabiola Hospital from the current scene: pavement, numerous traffic signals and striped crosswalks that knit together Kaiser Permanente’s modern complex. But the legacy of thoughtful health care and community benefit is what abides.

For more about Kaiser Permanente’s community benefit programs, go to http://tinyurl.com/4fcswsh

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