Posts Tagged ‘Breastfeeding’

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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KP’s ‘Baby in the Drawer’ Helped Turn the Tide Back to Breastfeeding Babies after World War II

posted on August 23, 2010

By Tom Debley
Director of Heritage Resources

Since this is National Breastfeeding Awareness Month, you may have read that Kaiser Permanente believes that one of the most important ways a mother can promote the health of her baby is to choose to breastfeed exclusively.

That’s a position that is based on more than a half-century of tradition that began in the 1950s with Kaiser Permanente as one of the leaders in reversing early 20th century trends that led American women to more commonly bottle-fed their babies.

The story also is one of the most popular in Kaiser Permanente lore: The Baby in the Drawer.

The "Baby in the Drawer" hospital room from 1953 was featured a half century later as a replica in a 2004 Oakland Museum of California special exhibit on the life and impact of Henry J. Kaiser, in this case in co-founding of Kaiser Permanente with Dr. Sidney R. Garfield.

The story begins one evening in the early 1950s when several doctors and their families were socializing at the home of Dr. John G. Smillie, an early Permanente Medical Group pediatrician. Smillie told founding Kaiser Permanente physician Sidney R. Garfield he had read an interesting article about the now famous Yale University School of Medicine research experiments with rooming-in for mothers and babies.

Well, this was a prime example of the kind of innovation Garfield fostered, always scanning the environment for new ideas or research findings and quickly applying them to the care of  his growing Kaiser Permanente patient population.  Garfield was in the process of designing three brand new hospitals for San Francisco, Los Angeles and Walnut Creek. He locked on to the rooming-in idea, adding the Baby in the Drawer.

Garfield did arranged each mother’s maternity room in a circle around an adjacent nursery. A bassinet for the infant was set in an ordinary metal file drawer built into the wall separating the mother’s room and the nursery.

“When the mother wanted to take care of the baby,” Garfield explained, “she’d pull the drawer out and there was the baby. (If) she wanted to put it back in the nursery,  she could put it back in. That was a great hit.”

This allowed a newborn to be adjacent to its mother while also being under the direct supervision of the medical staff. A simple light signal would tell the nurse whether a baby was in the nursery or in its mother’s room.

Because Garfield believed strongly in research and innovation, the Baby in the Drawer proved to be one of the best illustrations of his further belief that these principles could keep care cost-effective, bring better patient outcomes and make Kaiser Permanente a better place to work. The reasons: the Baby in the Drawer reduced an estimated seven out of 10 steps for the maternity nurses, large numbers of mothers chose to breastfeed as a result of the system, and it improved bonding between baby and mother.

That it was, as Dr. Garfield put it, “a great hit” has been borne out by history.

When Ora Huth, an oral historian in the Regional Oral History Office at the University of California at Berkeley, interviewed Dr. Smillie in 1985 as part of a series with Kaiser Permanente pioneers, he told her the Baby in the Drawer story.  Huth interrupted him to announce she had used the Baby in the Drawer system in San Francisco.

“I thought it was such a great idea,” Huth says in the published oral history.
“Now you know where the idea came from,” the late Dr. Smillie responded.
In 2004, when the Oakland Museum of California did a special exhibition on the life of Henry J. Kaiser, co-founder of Kaiser Permanente with Dr. Garfield, it included a life-size replica of the Baby in the Drawer hospital room.

Today, whenever I give a talk about this concept I’m almost always guaranteed that someone in the audience will come up to me afterward to announce, “I was a Baby in the Drawer.” It’s equally likely that the person was breastfed as an infant because Dr. Garfield was helping to turn the tide away from bottle feeding after World War II.
I’m sure Dr. Garfield would be smiling if he could see the Kaiser Permanente News Center website item: Kaiser Permanente’s Care Delivery and Research Support Breastfeeding to Promote Healthy Families.

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