Globalization and Breastfeeding

International Journal of
Childbirth Education
Normalizing Breastfeeding
The official publication of the International Childbirth Education Association
VOLUME 33 NUMBER 4 OCTOBER 2018

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opportunity for their baby.
We will be providing you with:
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• “Stem Cell Insider” newsletter featuring current topics
• Educational video and other materials to use

in childbirth classes
• Referral benefits for educators
• Other exciting benefits!
For more information about this

partnership please visit us at
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International Journal of
The official publication of the

Childbirth Education
VOLUME 33 NUMBER 4 OCTOBER 2018
International Childbirth Education Association
Indexed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Managing Editor
Debra Rose Wilson,
PhD MSN RN IBCLC AHN-BC CHT
Associate Editor
Columns
Elizabeth Smith, MPH ICCE IBCLC RLC The Editor’s Perspective – Breastfeeding is the Gold Standard
by Debra Rose Wilson, PhD MSN RN IBCLC AHN-BC CHT.................................................. 4
Assistant to the Editor
Dana M. Dillard, MS PhDc Across the President’s Desk – What is the “International Code of Marketing Breastmilk Substitutes”?
Debbie Finken, MSc PhD by Debra Tolson, RN BSN ICCE IBCLC CPST, President, ICEA............................................... 5
Tiffany Yoder, MSN RN FNP-BC
Book Review Editor

William A. Wilson, MBA
Primary Research
Supporting African American Mothers following a Stillbirth: Relationship Quality Matters
Peer Reviewers by Samantha Francois, PhD.................................................................................................. 6
Debbie Sullivan, PhD MSN RN CNE
Deborah Weatherspoon, PhD MSN RN CRNA COI Views of Breast Feeding Versus Bottle Feeding Among Middle Eastern and
Joy Magness, PhD APRN-BC Perinatal Nurse-BC Caucasian women in Ontario, Canada
Karen S. Ward, PhD RN COI by Shumail Hakimi, MPH, Hadi Danawi, PhD MPH, and Janice Ruggles, MD................... 10
Marlis Bruyere, DHA M Ed BA B Ed
Dana Dillard, MS PhDc
Debbie Finken, MSc PhDc
Elizabeth Smith, MPH ICCE IBCLC RLC
Features
Jessica Eckenrode, MSN RN Promoting Breastfeeding in African-American Women
Amy Sickle, PhD by Courtney Nyange, DNP MSN RN................................................................................... 14
Cover Photography Globalization and Breastfeeding: Regional Differences in Developing Areas
Kandi Anderson Photography by James G. Linn, PhD, and Michele Rocha Kadri, MA........................................................ 17
Graphic Designer
Laura Comer In Practice
Lactation: Defense for Maternal Health
Articles herein express the opinion of the au- by Erin Kathryn Williams, BSN, and Elizabeth Smith, MPH ICCE IBCLC RLC..................... 23
thor. ICEA welcomes manuscripts, artwork, and
photographs, which will be returned upon request We need a Standardized Approach to Use of Nipple Shields
when accompanied by a self-addressed, stamped by Teri McGowen, RN, and Elizabeth Smith, MPH ICCE IBCLC RLC................................... 26
envelope. Copy deadlines are February 1, May 1,
August 1, and October 1. Articles, correspon- Pregnancy and Intimate Partner Violence
dence, and letters to the editor should be ad- by Lee Stadtlander, PhD...................................................................................................... 28
dressed to the Managing Editor: [email protected]
The International Journal of Childbirth Educa- Utilizing Levine’s Conservation Model in Second-Stage Labor Care
tion (ISSN:0887-8625) includes columns, an- by Renece Waller-Wise, MSN RNC-OB CNS CLC CNL LCCE FACCE.................................. 32
nouncements, and peer-reviewed articles. This
journal is published quarterly and is the official Adverse Outcomes in Adolescent Pregnancy
publication of the International Childbirth Educa- by Brelinda Johnson, MS..................................................................................................... 36
tion Association (ICEA), Inc. The digital copy of
the journal (pdf) is provided to ICEA members. Naming the Stillborn Baby
www.icea.org/content/guide-authors provides by Telvis M. Rich, PhD, Anthony Hill, PhD, and Jason A. Billings, MSN............................... 39
more detail for potential authors.
Advertising information (classified, display, or The Cost of Free Pregnancy Apps: Credibility and Privacy Concerns
calendar) is available at www.icea.org. Advertising
is subject to review. Acceptance of an advertise-
by Joanna C. Zimmerle, EdD............................................................................................... 41
ment does not imply ICEA endorsement of the Permission to Love: Celebrating Your Rainbow Baby after a Reproductive Loss
product or the views expressed.
The International Childbirth Education Asso- by Turenza Smith, PhD LMSW, Wanda Davidson, PhD, and Karen Roberson, PhD.............46
ciation, founded in 1960, unites individuals and
groups who support family-centered maternity
care (FCMC) and believe in freedom to make deci- Book Reviews
sions based on knowledge of alternatives in family-
centered maternity and newborn care. ICEA is a The Real Guide to Life as a Couple
nonprofit, primarily volunteer organization that reviewed by Jennifer Cooke, MSN APRN FNP-C ................................................................49
has no ties to the health care delivery system. ICEA
memberships fees are $95 for individual members Mayo Clinic Guide to a Healthy Pregnancy (2nd, ed.).
(IM). Information available at www.icea.org, reviewed by Kathy Zimmerman, PhD MSN APRN APHN-BC FNP-BC CCH ...................... 50
or write ICEA, 110 Horizon Drive, Suite 210,
Raleigh, NC 27615. Battling Over Birth: Black Women and the Maternal Health Care Crisis
© 2018 by ICEA, Inc. Articles may be reprinted reviewed by Tiffany Yoder, MSN FNP-BC RN .......................................................................51
only with written permission of ICEA.
Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 3

The Editor’s Perspective
Breastfeeding is the
Gold Standard
by Debra Rose Wilson, PhD MSN RN IBCLC AHN-BC CHT
According to the latest U.S. data from the Cen- Global goals for breastfeeding
ters for Disease Control and Prevention [CDC] (2018) practices are also short of targets,
most infants receive some breastmilk, but most are not and include early initiation of
exclusively breastfed or are not breastfed for as long as breastfeeding, exclusive breast-
the mother desires. There continues to be a considerable feeding under 6 months old,
variation between states or regions in the U.S. with the breastfeeding at 1 year old, and
far northeast and northwest sections having the highest breastfeeding at 2 years old.
rates of infants breastfed at 6 months, and the southeast Changing the norm to breast- Debra Rose Wilson
U.S. with the lowest rates. Disparities exist between feeding is tasked to each of us.
socioeconomic levels, and between non-Hispanic black Supporting a breast-feeding mother in public with a wink
women and non-Hispanic white and Hispanic women. or other positive feedback is a start. Educating the public
The most common reasons to stop breastfeeding early are every time you see a teachable moment can be part of
issues with lactation / latching, concerns about nutrition, the change. I have been a lactation consultant for coming
medications, unsupportive work environment, cultural or up on twenty-five years and am continually amazed with
family norms, and unsupportive hospitals. new research on the magic of breastmilk and the bond of
According to the World Health Organization’s breastfeeding. Yet, we still have so much work to do.
[WHO] Global Breastfeeding Scorecard concerning poli- Peace,
cies, all 2030 targets are far short of goals, most under Debra
halfway (2018). These targets include funding, reduction
Centers for Disease Control and Prevention. (2018). Facts. Retrieved
of formula marketing, maternity leave, births in Baby-
from https://www.cdc.gov/breastfeeding/data/facts.html
Friendly facilities, Infant and Young Child Feeding (IYCF)
World Health Organization. (2018). Global Breastfeeding Scorecard
counseling and community IYCF programs, breastfeeding for 2018. Retrieved from http://www.who.int/nutrition/publications/
program assessment, and collection of breastfeeding data. infantfeeding/global-bf-scorecard-2018.pdf?ua=1
Brief Writer’s Guidelines for the ICEA Journal

Articles should express an opinion, share evidence- nique, describe personal learning of readers, or describe a
based practice, disseminate original research, provide a birth experience. Keep the content relevant to practitioners
literature review, share a teaching technique, or describe and make suggestions for best practice. Current references
an experience. support evidence-based thinking or practice.
Articles should be in APA format and include an Feature Articles – Authors are asked to focus on the
abstract of less than 100 words. The cover page should application of research findings to practice. Both original
list the name of the article, full name and credentials of data-driven research and literature reviews (disseminat-
the authors and a two to three sentence biography for ing published research and providing suggestions for
each author, postal mailing addresses for each author, and application) will be considered. Articles should be double
3 to 5 keywords. Accompanying photographs of people spaced, four to twelve pages in length (not including title
and activities involved will be considered if you have page, abstract, or references).
secured permission from the subjects and photographer.
For more information for authors please see our
In Practice Articles – These shorter articles (mini-
website at www.icea.org.
mum 500 words) express an opinion, share a teaching tech-
4 | International Journal of Childbirth Education | Volume 33 Number 4 October 2018

Across the President’s Desk
What is the
“International Code of
Marketing Breastmilk
Substitutes”?
by Debra Tolson, RN BSN ICCE IBCLC CPST, President, ICEA
Do you know what the “International Code of Market- • All information on artificial feeding,
ing Breastmilk Substitutes” is? Have you heard the verbiage including labels, should explain the
“WHO Code compliant”? Did you know that the Interna- benefits of breastfeeding and the
tional Code of Marketing Breastmilk Substitutes was written costs and hazards associated with
by the World Health Organization (WHO)? artificial feeding.
The International Code of Marketing Breastmilk Substi- • Unsuitable products should not
tutes was developed by the WHO to “level the playing field” be promoted for babies including
with advertising of well-funded formula companies and is formulas, bottles, nipples, and Debra Tolson
part of the Baby Friendly Ten Steps to Successful Breastfeed- pacifiers.
ing. It supports breastfeeding as the first choice for infant ICEA supports the International Code of Marketing
feeding. The basic principle states any and all companies Breastmilk Substitutes. All of our educational programs,
who manufacture, distribute and market infant feeding “sup- marketing, and conferences will only promote or display
plies” should abide by the WHO Code recommendations. A materials from companies that are Code compliant. Ev-
summary of the code includes: erything ICEA is involved in runs through the filter of this
• No advertising of breastmilk substitutes to families code. These are important questions to ask when you are a
• No free samples, gifts or supplies in the health care system member of any organization or seeking certification from
• No promotions of products through health care facilities, an organization! Make sure you have knowledge to make an
including no free or low-cost formula. informed decision!
• No contact between marketing personnel and mothers. Flourishing for ICEA,
• No words or pictures idealizing artificial feeding on the Debra Tolson, RN, BSN, ICCE, IBCLC, CPST
labels or product. ICEA President
• Information to health workers should be scientific and
factual only.
Follow ICEA Online!

ICEA is on Facebook: participate in discussions, link with members worldwide, find
out about ICEA events! www.facebook.com/ICEApage
ICEA is on Twitter: send us a Tweet, get our Tweets, reTweet to your colleagues.
@ICEA_org

Primary Research
Supporting African American Mothers

following a Stillbirth:
Relationship Quality Matters
by Samantha Francois, PhD
Abstract: Stillbirths in the United States ties in birth outcomes continue to be a population health
problem even though there has been a consistent decline
have declined considerably over the past in infant and fetal mortality1 in the United States over the
decades with closer monitoring in preg- past 20 years. African American mothers continue to have
nancy. However, African American moth- double the rate of infant deaths compared to other racial/
ethnic groups in the United States of America (U.S.) (Healthy
ers continue to experience stillbirth rates
People 2020, 2017). In 2014, African American mothers ex-
twice that of White mothers and other perienced 10.9 infant deaths per 1,000 live births compared
racial/ethnic groups. Research has linked to 3.9 to 4.9 deaths for Asian/Pacific Islander, White, and
stillbirths in African American mothers Hispanic mothers (Healthy People 2020, 2017). The current
paper examines whether social support in the form of a qual-
to socioeconomic factors, lack of prena- ity relationship with a partner lessens the impact of negative
tal care, risky behaviors, and stressful birth outcomes on the mental health of African American
life events. The current study examined mothers.
African American mothers also continue to experi-
the effect of partner relationship quality
ence more adverse birth outcomes that can lead to infant
on the association between stillbirth and mortality compared to White mothers and other racial/eth-
depressive symptoms in African American nic groups, specifically low infant birth weight and preterm
mothers and found that mothers who births. African American mothers had a preterm birth rate of
13.4 compared to 8.9 for White mothers and 9.1 for Hispan-
experienced stillbirth and reported good ic mothers in 2015 (Martin, Hamilton, Osterman, Driscoll,
relationships with a current partner had & Mathews, 2017). Similarly, African American mothers’ rate
lower depressive symptoms. Implications of low birth weight infants was 13.5 in 2015, compared to
6.9 for Whites and 7.2 for Hispanics (Martin et al., 2017). Lu
of findings for pregnancy and childbirth and Halfon (2003) cite research that examines explanations
providers are discussed. of the persistent racial disparities, specifically, low socio-
economic status (parent educational attainment, household
Keywords: stillborn, African American mothers, relationship quality, income, or occupational status) at the time of pregnancy,
depression risky behaviors during pregnancy (cigarette, alcohol, and
drug use), and delayed or inadequate prenatal care. However,
The death of a child may be one of the most emotion- study findings reveal that African American mothers experi-
ally difficult experiences of a woman in her lifetime. The sud- ence infant mortality at a higher rate than Whites even when
den death of an expected child prior to birth may cause even
more emotional pain and negative mental health outcomes.
1 Fetal death refers to the intrauterine death of a fetus prior to delivery.
Stillbirth and miscarriage, defined by the Centers for Disease
Fetal mortality is generally divided into three periods: early (less than 20
Control and Prevention as the death or loss of a baby before completed weeks of gestation), intermediate (20–27 weeks of gestation),
or during delivery is more common among African American and late (28 weeks of gestation or more) (MacDorman & Gregory, 2015).
mothers (MacDorman & Gregory, 2015). Racial dispari-
continued on next page

Supporting African American Mothers following a Stillbirth than Whites. Importantly, the history of racism and its asso-
continued from previous page ciated stressors experienced by African Americans in the U.S.
are being more seriously considered as a potential important
factor to understand the high rates of stillbirth and other
socioeconomic factors, risk behaviors, or prenatal care are negative birth outcomes experienced by African American
the same, which suggests the influence of other factors (Alio, mothers (Alio et al., 2010).
et al., 2010; Lu & Halfon, 2003). In a population-based study, Hogue et al. (2013)
The national fetal mortality rate remained around 6.0 examined the relationship between stressful life events and
fetal deaths at 20 weeks of gestation or more per 1,000 live stillbirths across race and ethnic groups and found that as
births and fetal deaths from 2006 to 2013. However, in 2013, the number and types of stressful life events increased, the
African American mothers had double (10.5 fetal deaths) odds of stillbirth increased. Among the strongest stressful life
the stillbirth rate of Whites (4.9 fetal deaths), Asian/Pacific events associated with stillbirth were having a lot of bills to
Islanders (4.7 fetal deaths), and Hispanics (5.2 fetal deaths) pay, going to jail or having a partner who went to jail, having
(MacDorman & Gregory, 2015). Moreover, Willinger, Ko, a partner who did not want a pregnancy, and being involved
and Reddy (2009) found that African American mothers in a physical fight (Hogue et al., 2013). In this same study,
have a two-fold increased risk of stillbirth from 20 to 40 African American women were more likely to report stressful
gestation weeks compared to White mothers. Similar to life events than White and Hispanic women; African Ameri-
the causes and correlates of infant mortality, fetal death has can women were more likely to have experienced incarcera-
been explained by mother’s socioeconomic status, prenatal tion (of partner or self ), separation or divorce, and being
care, risky behaviors, and short intervals between pregnan- in a physical fight (Hogue et al., 2013). Given the influence
cies. However, research has also examined the effect of of relational difficulties on stillbirths for African American
stressors and stressful life events that uniquely affect African women, the current study examines how supportive or qual-
Americans as a whole, and African American mothers in ity relationships mitigate the negative effects of experiencing
particular (Alio et al., 2010; Hogue et al., 2013; Kavanaugh a stillbirth on the mental health of these women. Moreover,
& Hershberger, 2005; Lu & Halfon, 2003). Multiple factors through identifying African American women who are
compounded by unique stressors experienced by African experiencing stressful life events, childbirth educators might
American mothers put them at significant risk for adverse lessen the effect of negative social determinants and reduce
birth outcomes, including stillbirth and its associated the disparity in stillbirths.
negative physical, mental, and emotional outcomes. Thus, Kavanaugh and Hershberger (2005) examined stress-
practitioners who assist women in pregnancy and birth and ful life events experienced by African American parents
provide services to African American populations have a re- that contributed to a stillbirth and how parents dealt with
sponsibility to know and understand the range of factors that the loss. African American mothers in the study who had a
affect outcomes for this population, particularly interper- stillbirth reported stressors related to economic hardships
sonal, social, and systemic stressors, in order to contribute to and feeling abandoned or unsupported by their partners
the elimination of the persisting high rates of fetal and infant during the pregnancy or surrounding the time of the loss.
mortality among African Americans. Likewise, mothers and fathers in the study reported feeling
stress related to unfair treatment by medical care staff during
Background the pregnancy and around the time of the loss (Kavanaugh
Alio et al. (2010) applied an ecological framework to & Hershberger, 2005). The study found that both African
understand the Black-White disparity in stillbirths (and American mothers and fathers reported irritability, suicidal
other adverse birth outcomes). Factors that influence infant thoughts, feelings of guilt, and loss of control following a
and fetal mortality among African Americans include fam- stillbirth (Kavanaugh & Hershberger, 2005). African Ameri-
ily, community, and societal factors. Maternal health and can fathers reported feeling unsure of how to support their
socio-economic status impact child health and fetus viability; partners, while the mothers hoped fathers would express
however, in the context of racial disparities, inconsistent their emotions related to the loss (Kavanaugh & Hershberg-
findings related to poverty and education (SES), maternal er, 2005). This study illustrates the importance of supportive
risky behavior and genetic factors led the researchers to relationships with a partner and with medical care staff
examine the effect of life stressors and racism (Alio et al., during pregnancy and following a stillbirth, particularly for
2010). Single motherhood, more prevalent among African African Americans who may unduly experience stressful life
Americans, and its related financial and social stress nega- events.
tively impacts African American birth outcomes more so continued on next page

Supporting African American Mothers following a Stillbirth with depressive symptoms. African American mothers in the
continued from previous page study sample who reported a good relationship with their
first child’s father (r = -.188, p < .01) or a current partner (r =
-.942, p < .01) were less likely to have depressive symptoms.
Current Study Finally, analyses were done to test for the buffering effect of
The current study examined how social support in the relationship quality on the relationship between stillbirth
form of relationship quality with a current partner mitigates and depressive symptoms (see Figure 1). African American
the effect of experiencing stillbirth on depressive symptoms mothers who experienced a stillbirth had lower depressive
in African American mothers. The research hypothesized that symptoms when they also reported a high quality relation-
1) the occurrence of stillbirth will be positively associated ship with a current partner (t = 111.89 (df=1), p < .01). Thus,
with depressive symptoms in African American mothers; 2) a good relationship with a current partner mitigated the ef-
relationship quality will have an inverse relationship with fect of experiencing a stillbirth on African American mothers’
depressive symptoms, such that African American mothers depressive symptoms.
reporting a poor relationship with child’s father or a current
partner will have higher scores on depression scales, and 3)
relationship quality will moderate the relationship between
Figure 1. Relationship quality moderates the
stillbirth occurrence and depressive symptoms, such that relationship between stillbirth and depression
African American mothers who have experienced a stillbirth
and report a good relationship with a current partner will QUALITY
have lower depressive symptoms.
ß = 3.270***
STILLBIRTH DEPRESSION
Methods ß = -.217***
Data for the current study come from the Fragile Fami-
lies and Child Wellbeing Study, a study that follows a group
of first-time parents and their children to measure parent
and child wellbeing particularly for families with unwed Discussion
parents (Reichman, Teitler, Garfinkel, & McLanahan, 2001). Unquestionably, the death of an expected child can
The study included 4700 families with 3600 unwed couples be difficult for most, but African Americans are at higher
representative of non-marital births in U.S. cities with risk than other racial/ethnic groups for this type of adverse
populations over 200,000 (Reichman et al., 2001). The cur- pregnancy outcome. Although evidence demonstrates that
rent study examined Fragile Families data for the 67 African medical complications and risks, lack of prenatal care, and
American mothers who reported a stillbirth within the last socioeconomic factors contribute to stillbirth, stressful life
two years. The mothers’ depressive symptoms were measured events are also significant risk contributors (Hogue et al.,
using questions from the Composite International Diagnostic 2013; Kavanaugh & Hershberger, 2005; Willinger et al.,
Interview, a standardized instrument to measure depres- 2009). The current study aimed to examine what social or
sion. Mothers’ relationship quality with first child’s father or interpersonal conditions might protect African American
current partner was also measured with a 12-item scale that mothers against negative mental health outcomes after
asked questions such as, “How often does your current part- experiencing a stillbirth. The study results showed that social
ner express affection or love for you? … encourages/helps support in the form of a good relationship with a current
you do things? … really understands your hurts and joys?” partner lessened the negative impact of experiencing a still-
followed by response choices of “often, sometimes, or never.” birth on mental health. African American mothers who had
a stillbirth and current partner who showed them affection,
Results supported and encouraged them, and understood their hurts
Study findings revealed that having a stillbirth was and joys had fewer depressive symptoms than mothers who
correlated with depressive symptoms (r = -.200, p < .000) reported a poor quality relationship with a current partner.
such that African American mothers in the study sample This finding has implications for childbirth educators and
who reported having a stillbirth in the past two years were health professionals who serve African American mothers
more likely to have higher scores on the depression measure- and families.
ment scales, indicating more depressive symptoms. Also as
hypothesized, relationship quality had an inverse relationship continued on next page

Supporting African American Mothers following a Stillbirth Health People 2020 (2017, December 15). Maternal and Child Health
National Snapshots. Retrieved from https://www.healthypeople.gov/2020/
continued from previous page topics-objectives/topic/maternal-infant-and-child-health/national-snapshot.
Hogue, C. J. R., Parker, C.B., Willinger, M., Temple, J.R., Bann, C.M., Silver,
R.M., … Goldenberg, R.L. (2013). A Population-based Case-Control Study
First, pregnancy and childbirth educators and health of Stillbirth: The Relationship of Significant Life Events to the Racial Dispar-
care professionals should assess the presence of stressors in ity for African Americans. American Journal of Epidemiology, 177(8), 755–767.
the mother’s life, recognize the ways that she copes, assist https://doi.org/10.1093/aje/kws381
her to activate effective coping strategies, and make appro- Kavanaugh, K., & Hershberger, P. (2005). Perinatal Loss in Low-Income Af-
priate referrals as needed. Second, pregnancy and childbirth rican American Parents. Journal of Obstetric, Gynecologic, & Neonatal Nursing,
34(5), 595–605. https://doi.org/10.1177/0884217505280000
educators and health care professionals should implement
Lu, M. C., & Halfon, N. (2003). Racial and Ethnic Disparities in Birth
additional measures of empathy, communication, education,
Outcomes: A Life-Course Perspective. Maternal and Child Health Journal,
and, when appropriate, social support referrals to optimize 7(1), 13-30.
the health of these mothers. These efforts can go a long way MacDorman, M. F., & Gregory, E. C. W. (2015). Fetal and perinatal mortal-
to preventing stillbirth and other adverse outcomes among ity: United States, 2013. National Vital Statistics Reports, 64(8), https://www.
African American mothers. This study also supports the cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_08.pdf.
importance of childbirth educators’ and health care profes- Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Driscoll, A. K., &
sionals’ actions and interventions when African American Mathews, T. J. (2017). Births: Final data for 2015. National Vital Statistics
Reports, 66(1), https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf.
mothers do experience a stillbirth. Foremost, childbirth
educators and health care providers can increase mothers’ Reichman, N. E., Teitler, J. O., Garfinkel, I., McLanahan, S. S. (2001). Fragile
Families: Sample and Design. Children and Youth Services Review, 23(4/5),
coping abilities during times of a death by providing a sup- 303-326.
portive environment for mothers that includes opportunities
Willinger, M., Ko, C. W., & Reddy, U. M. (2009). Racial disparities in
for their partner to be supportive and resources to support stillbirth risk across gestation in the United States. American Journal of
the partner. Obstetrics and Gynecology, 201(5), 469.e1-469.e8. https://doi.org/10.1016/j.
ajog.2009.06.057
References Dr. Samantha Francois is an Assistant Professor in Social Work

Alio A. P., Richman A. R., Clayton H .B., Jeffers D. F., Wathington D. J., &
Salihu H. M. (2010). An ecological approach to understanding black-white
and teaches graduate courses at Tulane University. Dr. Francois
disparities in perinatal mortality. Maternal & Child Health Journal, 14(4), has researched microsystem risk and protective factors that affect
557-566. https://doi.org/10.1007/s10995-009-0495-9 African American population outcomes for 20 years.
Call for Papers for the ICEA Journal

You are encouraged to write a paper for the journal. Please consider sharing your knowledge and expertise
Here are some upcoming themes. The list of topics and with ICEA members. Deadline to submit articles for
themes for articles that are being sought to submit for the April issue (Disability) is December 15, 2018.
peer review include:
Military Families Email your paper to [email protected]
Delivery Options and Trends Author guidelines can be found at:
Unexpected Outcomes http://icea.org/about/icea-journal/guide-for-authors/
Birth Around the World

Folk Practices
Birthing Through Time
Breath Work
Disability

In Practice
Views of Breast Feeding

Versus Bottle Feeding
Among Middle Eastern and Caucasian
women in Ontario, Canada
by Shumail Hakimi, MPH, Hadi Danawi, PhD MPH, and Janice Ruggles, MD
Abstract: Breast milk contains the ma- cross-sectional studies were designed to understand why
these women are choosing or in favour of one method over
jority of nutrition that an infant needs. the other.
Substituting or combining formula is
not necessary unless medically advised. Introduction
A difference in feeding patterns between Public health breastfeeding promotion programs have
mothers of Middle Eastern and Caucasian been active for a very long time. Recently, Northwest On-
tario had taken a step towards proactive engagement. This
descent was observed in North-western engagement has spurred discussion about the importance
Ontario. Mothers of Middle Eastern de- of breastfeeding vs. formula feeding in hospital sites, social
scent are in favour of combining breast media and doctors’ clinics. A growing body of research
demonstrated that while breastfeeding is increasingly
milk with bottle feeding, while Caucasian viewed as important for the health of all babies, mothers
mothers prefer breastfeeding for the first of Middle Eastern descent still combine bottle-feeding or
six months. We used a retrospective study use of supplementary formula while breastfeeding (Durham
to investigate reasons behind this discrep- Region, 2017). The availability of infant formula and ease of
accessibility exacerbate the situation. World Health Organi-
ancy. A better understanding was gained zation (WHO) and United Nations International Children
from the results leading to recommend Emergency Fund (UNICEF) promote breastfeeding as being
educational intervention before, during the one and only best way to provide the infants with the
nutrients they need. WHO and UNICEF recommend exclu-
and after giving birth. sive breastfeeding for the first six months after birth (WHO
2015; UNICEF, 2015).
Keywords: breastfeeding practices, breastfeeding discrepancies Breastfeeding mothers are always concerned whether
their newborn is getting enough nutrition. New mothers
Objectives need to be assured that colostrum contains all the nutri-
The objective of this article is to better understand the ents their baby needs in the first few days of life as well as
factors leading to various feeding patterns of mothers of important antibodies for development of their babies’ im-
different ethnic backgrounds regarding breastfeeding versus mune system. Certain exceptions to this include babies with
bottle-feeding or combination of both. Understanding the additional medical need such us low blood sugar, dehydra-
pattern can be insightful for public health program develop- tion, jaundice, weight loss exceeding 10% of body weight
ment. Based on direct observation, it appears there is some or any other medical condition for which a physician deems
reluctance to solely breastfeed. Various retrospective and supplementation as necessary.
Views of Breast Feeding Versus Bottle Feeding
continued from previous page
What is Colostrum
Colostrum is the yellowish, thick fluid that is produced
by the mother right after delivery. Colostrum is high in
IgA antibody, lactoferrin, leukocytes, and developmental
factors such as epidermal growth factor. It also contains low
concentrations of lactose, high concentrations of sodium and
magnesium (Ballard & Morrow, 2014; Kulski & Hartmann,
1981).
Colostrum transition to milk typically occurs anywhere
from day five to two weeks postpartum. Levels of potas-
sium, calcium and lactose increase in the milk of all lactating
mothers around this time. By four to six weeks postpartum, ry stability and reduction of infant crying (Moore, Anderson,
human milk is considered fully mature and remains in this and Bergman, 2007).
mature phase throughout lactation (Kulski & Hartmann,
1981).
Purpose
The purpose of this review article is to understand the
Nutrition in mother’s mature milk views of mothers of Middle Eastern descent and Caucasian
Mother’s milk contains all the nutrition infants need up mothers, regarding either solely breastfeeding their infants,
to six months of age. Mother’s milk contains protein, whey using supplemental formula feeding, or a combination of
and casein, as well as lactoferrin, secretory IgA, Lysozome, breastfeeding and formula feeding.
Difidus factor, fats, vitamins and carbohydrate (lactose)
(Ballard & Morrow, 2013). Breast milk is always at the right
temperature, fresh and safe for the new born. Breast milk is Method
nutritionally perfect for the human infant, and its nutritional A retrospective, cross-sectional chart review was done,
composition promotes survival and healthy development using one obstetrician practice in Ontario, Canada. It was
(Ballard & Morrow, 2013; Oftedal, 2012). designed to understand the difference in feeding patterns
“The nutritional composition of human milk and its between mothers of Middle Eastern descent versus mothers
bioactive factors include cells, anti-infectious and anti- of Caucasian descent. This cross-sectional study included
inflammatory agents, growth factors, and prebiotics. Unlike chart review over a two-year period between July 2016 and
infant formula, which is standardized within a very narrow July 2018.
range of composition, human milk composition is dynamic, The services provided in the clinic study included
and varies within a feeding, diurnally, over lactation, and be- prenatal, intrapartum and postnatal care. Pregnant women
tween mothers and populations (Rouge Valley Health System are seen between 10-12 weeks of gestation. The first pre-
[online], 2017).” natal visit is the longest appointment, designed to gather
Soft food can be introduced after the age of six months, and enter all necessary medical and social information of
while continuing to breastfeed. Breastfeeding should contin- the patient. In addition, expectant mothers are provided
ue up to age two, with introduction of different solid food. with full information package which contains: 1) hospital
administration forms, 2) regional public health information,
3) breastfeeding template including prenatal breastfeed-
Improving breastfeeding outcome ing classes, 4) breastfeeding booklet, and 5) Healthy Babies
Research has documented beneficial effects of direct Healthy Children, Ontario’s information.
skin-to-skin contact right after delivery and lasting for one Prenatal breastfeeding classes provide education on
to two hours. Skin to skin contact should continue during what to expect during the first few days after the baby is
breastfeeding sessions for increased emotional safety and born, how to breastfeed confidently, as well as how baby
attachment of both mother and infant, as well as better can properly latch on to mothers’ breasts. Most importantly,
breastfeeding outcomes. Studies have also indicated that
skin-to-skin contact may increase an infant’s cardio-respirato- continued on next page

Views of Breast Feeding Versus Bottle Feeding Data Collection
continued from previous page During the six to eight weeks’ postpartum visit, each
patient answered questions from a pre-existing postpartum
the lactation nurses educate mothers on the importance of data collection form. This form included questions regard-
breastfeeding and common challenges mothers may face. ing breastfeeding practices among other relevant questions
Also, mothers will be taught how to overcome those chal- regarding their postpartum recovery. Data were collected and
lenges (Rouge Valley Health System, 2017). analysed.
There are 12 to 14 regular prenatal visits from the first Two hundred and twenty charts were pulled and
prenatal appointment till delivery. However, if there are any reviewed. Sixty charts represented women of Middle Eastern
complications during the pregnancy, then the number of descent and 73 women were from Caucasian descent. Based
visits can increase as necessary. If serious complication arises on the postpartum questioner, we found that of 60 mothers
during pregnancy, the patients are referred to high-risk preg- of Middle Eastern descent only 16 (26%) solely breastfed
nancy centre. Postpartum visits are scheduled for six to eight their infant, while 36 (60%) used a combination of breast-
weeks postpartum. Breastfeeding advice and encouragement feeding and formula and only 8 (13%) were solely formula
are given throughout the entire pregnancy period, right after feeding. In mothers of Caucasians descent (n-73), 41 (56%)
delivery as well as during the patients’ hospital stay. Dur- were solely breastfeeding, 24 (32%) used a combination of
ing the patients’ hospital stay, women are provided 24-hour breastfeeding and formula and 8 (11%) exclusively relied on
support from lactation consultants as well as obstetrical formula feeding.
nurses. In addition, women are provided in-home support, if
necessary, by public health nurses to encourage mothers to Chart 1. Comparison of Caucasian and Middle
breastfeed. During home visits, fathers also receive beneficial
guidance on how to participate in the breastfeeding process
Eastern mother’s breastfeeding practices.
(Ballard & Morrow, 2014). The motive behind all this sup-
port is to promote breastfeeding over formula feeding across
the population among Canadian women of all ethnicities.
According to the British Broadcasting Corporation
(BBC), Toronto Canada is the most multicultural and diverse
city in the world (BBC, 2017). Pickering Ontario consists of
Middle Eastern, Asian and Caucasian women, among women
of various other ethnic backgrounds. At the time of birth,
it has been observed that there may be a difference in how
Middle Eastern mothers prefer to feed their babies as com-
pared to Caucasian mothers. While Middle Eastern mothers
appear to prefer both formula and breastfeeding in combina-
tion, Caucasian mothers appear to prefer sole breastfeeding.
During the postpartum timeframe, women were asked
about their reasons they choose both formula and breast- Chart 2. Infant stomach capacity
feeding as their preferred method. Infant’s satiety appeared
to be the overwhelming theme. Most mothers of Middle
Eastern descent believed their infants are not full if solely
breastfed, or their milk production is not enough.
Study population
A retrospective cross-sectional chart review was done
from July 2016 to July 2018. The population sample came
from a random chart pull from the practice of the Obstetri-
cian in Northwest Ontario, Canada.
Views of Breast Feeding Versus Bottle Feeding
Table 1. Infants stomach Capacity, indicates Women need to be taught accurate information about
their babies’ needs to create positive and healthy social
that on day 1, infant’s stomach cannot hold change for both the mother and her newborn.
more than 5-7 ml, every 2-3 hours.
References
British Broadcasting Corporation. (BBC, 2017). Toronto: The city of 140
Infant’s Age Stomach Comparison languages. http://www.bbc.com/travel/story/20170728-canadas-city-of-
140-languages
Best Start Meilleur Depart. (2017). Breastfeeding guidelines for consultants.
Day 1 Cherry https://www.beststart.org/resources/breastfeeding/pdf/breastfdeskref09.pdf
Durham Region. (2017). Feeding your baby. https://www.durham.ca/en/
health-and-wellness/feeding-your-baby.aspx
Day 3 Walnut Kulski JK & Hartmann PE. (1981). Changes in human milk composition
during the initiation of lactation. Aust J Exp Biol Med Sci. 59(1):101–114.
Moore ER, Anderson GC, & Bergman N. (2007). Early skin-to-skin contact
for mothers and their healthy newborn infants. Cochrane Database System
1st Week Plum Review, 3. DOI: 10.1002/14651858.CD003519
Oftedal OT. (2012). The evolution of milk secretion and its ancient origins.
Animal: An International Journal of Animal Bioscience, 6(3):355–368.
1st Month Large Chicken Egg Ballard, O. & Morrow, A. L. (2013). Human milk composition: Nu-
trients and bioactive factors. Pediatric Clinics of North America, 60(1),
49-74. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3586783/#R6.
Educating mothers on their new-born infant’s capacity
Rouge Valley Health System. (2017). Breastfeeding Support. Retrieved from:
to feed should be a priority. As shown above, the stomach http://www.rougevalley.ca/breastfeeding-support.
size of a new-born is the size of a cherry (Table 1, Chart 2). UNICEF. (2015). Nutrition: Breastfeeding. Retrieved from: https://www.
This demonstrates that an infant on day one needs only unicef.org/nutrition/index_24824.html
about 5-7 ml of fluid every two to three hours for a mini- World Health Organization. (2015). Infant and young child feeding.
mum of eight feeds per day (Best Start Meilleur Depart., Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/infant-
2017). By day three, the size of infant’s stomach is almost the and-young-child-feeding
size of a walnut. It can only hold 22-27 ml at a time. By the

first month, the baby can hold about 80-150 ml of milk at
Shumail Hakimi holds a Master’s in Public Health and is pursu-
a time. The proceeding information depends on the baby’s
ing a career in medicine.
health and weight.
Hadi Danawi, PhD MPH is trained in Public Health with a PhD

Conclusion in Epidemiology from the University of Texas at Houston and
The belief system that mothers of Middle Eastern a Master’s degree in Environmental Health from the American
descent have regarding feeding practices warrants further University of Beirut, Dr. Danawi has an international expertise
studies. The findings of this chart review supported our in various Public Health issues in the U.S., Middle East and Af-
supposition that sole breastfeeding uptake is much higher in rica. Dr. Danawi currently serves as a full-time faculty at Walden
Caucasians women as compared to Middle Eastern women. University, College of Health Sciences teaching and mentoring
It also supported our observation that middle eastern women doctoral dissertations.
are more likely to combine breastfeeding and formula as their
method of choice to feed their infants precipitated by various Janice Ruggles, BA MD FRCSC has been in private practice as
ethnic beliefs which need to be addressed. As evidenced by a general community Obstetrician/Gynaecologist in southern
information from WHO and UNICEF, sole breastfeeding is Ontario, Canada, for over 19 years. She’s been an Assistant Clini-
best for babies’ nutrition; under optimal circumstances given cal Professor at McMaster University, where she also attended
there is no medical complication for the baby. medical school and undertook her Residency training.

Features
Promoting Breastfeeding
in African-American Women
by Courtney Nyange, DNP MSN RN
Abstract: Breastfeeding has many benefits food allergies, and stimulates the growth of positive bacteria
in the digestive tract (Schlenker & Gilbert, 2015; Christopher
for both mothers and infants. Despite & Krell, 2014; Walker, 2014). Despite these noted benefits,
these noted benefits, national breast- national breastfeeding rates are still below the Healthy
feeding rates are still below the Healthy People 2020 goal related to the proportion of infants who
are ever breastfed (United States Department of Health and
People 2020 goal related to the propor-
Human Services, 2017). In particular, African-American
tion of infants who are ever breastfed. women historically and consistently lag behind in breast-
In particular, African-American women feeding rates when compared to their White and Hispanic
historically and consistently lag behind counterparts. From 2011-2013, breastfeeding rates for White
and Hispanic women were 78.3% and 84.8% respectively,
in breastfeeding rates when compared to compared to 60.1% for African-American women (National
their White and Hispanic counterparts. Center for Health Statistics, 2017) The purpose of this article
Several studies have identified factors is to explore factors influencing breastfeeding in African-
American women and strategies for promoting breastfeeding
that contribute to low breastfeeding rates
in African-American women.
in African-American women. Closing this The American Academy of Pediatrics recommends
gap depends on our ability to address exclusive breastfeeding for the first six months of life, followed
those factors. The purpose of this article by continuation of breastfeeding for one year or longer as
complementary foods are introduced (American Academy of
is to explore factors influencing breast- Pediatrics, 2012). Data from the Centers for Disease Control
feeding in African-American women and and Prevention (CDC, 2013) indicate that African-American
strategies for promoting breastfeeding in women lag behind their White and Hispanic counterparts
in initiating breastfeeding and continuing to breastfeed at
African-American women. six months and twelve months. In 2008, the prevalence of
breastfeeding initiation among African-American women was
Keywords: breastfeeding, African-American women, breastfeeding in 58.9% compared with 75.2% and 80% for White women and
African-American women, benefits of breastfeeding
Hispanic women respectively (CDC, 2013). In this same year,
Breastfeeding has many benefits for both mothers and 30.1% of African-American women breastfed at six months
infants. Benefits of breastfeeding for the mother include, but compared to 46.6% of White women and 45.2% of Hispanic
are not limited to: facilitation of post-partum weight loss, women. Additionally, 12.5% of African-American women
stimulation of uterine contractions to control bleeding, lower breastfed at twelve months compared to 24.3% of White
risk for ovarian, breast and endometrial cancers and type women and 26.3% of Hispanic women. Although the percent-
two diabetes, facilitation of bonding with the infant, and a age of African-American women who initiate breastfeeding
reduction of risk for post-partum depression. Benefits for and continue breastfeeding at six months and twelve months
the infant include, but are not limited to: contributes to the has increased, much work still needs to be done to ensure that
development of a strong immune system, promotes optimal the gap is decreased (CDC, 2013). In order to promote breast-
mother-infant bonding, reduces the risk of stomach upset, feeding in African-American women and ensure that these
diarrhea, constipation, and colic, provides protection against recommendations are met, a closer look at factors affecting
Promoting Breastfeeding in African-American Women
breastfeeding in African-American women is warranted.

An integrative literature review of factors related to
breastfeeding in African-American women revealed that
social influences, women’s perceptions of human milk, and
the quality of information provided by health care providers
influenced breastfeeding rates in African-American women
(DeVane-Johnson, Woods-Giscombe, Thoyre, Fogel, & Wil-
liams, 2017). Social influences found to impact breastfeeding
in African-American women include socioeconomic status
(SES) and social/family support. Women with higher SES
tend to breastfeed at higher rates than women with lower
SES. Additionally, employment during and after childbirth
impact breastfeeding rates. African-American women tend
to have lower paying service-sector jobs and tend to have
shorter maternity leave when compared with women of
other races/ethnicities. Returning to work has been shown to
be a common reason for women not to breastfeed (DeVane-
Johnson, et al., 2017). All of these factors play a significant
role in the decision to breastfeed, and African-American
women are at a disadvantage in all of these areas.
Social support factors that play a key role in initiating
and continuing breastfeeding in African-American women
include the opinions, values, and beliefs about breastfeed-
ing of the women’s families, romantic partners, and friends.
Family opinions, values, and beliefs about breastfeeding have
been shown to be the most important to African-American women are provided with accurate and quality information,
women’s breastfeeding success (DeVane-Johnson, et al., they can make informed decisions that positively affect the
2017). Perceptions of breastfeeding have been shown to health and well-being of themselves and their newborns.
be a significant factor in determining a woman’s desire to A look at attributes of positive deviant women, women
breastfeed. African-American and White women tend to feel who practice beneficial behaviors in spite of being at risk for
uncomfortable and embarrassed to breastfeed in public. Ad- unhealthy behaviors, reveals factors that positively influence
ditionally, cultural and personal feelings regarding their own African-American women’s decision to breastfeed (Barbosa,
breasts were identified as factors influencing the decision to Masho, Carlyle, & Mosavel, 2017). As previously indicated,
breastfeed (DeVane-Johnson, et al., 2017). low income impacts breastfeeding practices in African-
Adequate education and support influence a woman’s American women (DeVane-Johnson, et al., 2017). However,
decision to breastfeed. In several studies, African-American one study reveals that in-spite of having low-income, some
women reported receiving little or inadequate information African-American women still choose to breastfeed their
related to breastfeeding. Some women even reported being infant. These women are considered positive deviant women.
discouraged to breastfeed or not receiving any informa- More schooling, breastfeeding intention, positive breastfeed-
tion at all related to breastfeeding. Researchers also found ing and unfavorable formula feeding attitudes, high self-
that African-American women were more likely to be given efficacy, positive hospital and WIC experiences, and greater
formula feeding information from Women, Infants, and comfort breastfeeding in public were attributes identified
Children (WIC) counselors and were less likely to receive among these African-American women who breastfed for
breastfeeding information than White women (DeVane- four months or more. Attributes of African-American women
Johnson, et al., 2017). These findings speak to the quality who chose to formula feed included the intention to formula
of information provided by health care providers. When

Reducing Stress in Infants: Kangaroo Care Gabriels, K., Brouwer, A. J., Maat, J., & van den Hoogen, A. (2015). Kan-
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Dr. Courtney Nyange is a neonatal intensive care unit (NICU)
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psyneuen.2010.01.013
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Globalization and
Breastfeeding:
Regional Differences in Developing Areas
by James G. Linn, PhD, and Michele Rocha Kadri, MA
Abstract: This article examines the re- 2017). Beginning in the 1950s, new mothers in industrial-
ized nations began to adopt bottle feeding as the norm and
lationship between globalization and enter the labor force in large numbers. These developments
breastfeeding in developing and advanced greatly changed traditional attitudes and behaviors regard-
industrial nations. Current research and ing breastfeeding. Consequently, many children were never
breastfed, or experienced BF for only a short period of time
international and U.S. policies on breast-
(Van Esterik, 2002). Wide-scale adoption of formula feeding
feeding are analyzed to show the influ- and rejection of historic BF practices was also reported for
ence of global industrialization, urban- many developing areas, including Africa and the Americas,
ization and modernization on patterns in the 1980s and 1990s (Adair, Barry, & Guilky 1993). Global
economic and demographic changes brought women into
of breastfeeding. Comparisons are drawn the modernizing labor market and formerly rural families
between historic changes affecting breast- into growing metropolises (Quinlan, Quilan & Flinn, 2003).
feeding in Africa and Latin America. As rates of BF initiation and duration of BF dropped in
advanced and developing nations, international programs to
Case studies of successful campaigns to
reverse these trends were initiated (Perez-Escamila, 2003).
promote increased breastfeeding in Bo- These campaigns have contributed to gradual increases in
livia and Kenya are discussed. Further, breastfeeding in the U.S. (but not Europe) and in some
recommendations are made for essential developing countries (Wolfe, 2003; UNICEF/WHO, 2015;
Lutter & Morrow, 2013). However, there are substantial
structural reforms in public funding, differences in rates of BF between developing regions of the
healthcare, family leave, and work site world – this is particularly the case between Africa and the
flexibility for working mothers to support Americas (UNICEF, 2016). Also, there are intra-population
variations in BF (initiation, frequency, duration, and comple-
higher levels of breastfeeding. mentary feeding) in modernizing rural populations (Veile,
Martin & McAllister, 2013). Overall, despite past and recent
Keywords: globalization, breastfeeding, childbirth education efforts to increase breastfeeding in industrialized and devel-
oping societies, BF rates globally and regionally remain well
Introduction below public health goals (Wagstaff, et al., 2006; WHO,
Breastfeeding (BF) provides essential nutrients neces- 2011; World Bank 2017). Regrettably, countries are not ad-
sary for infant growth, protects children from many illnesses, equately protecting, promoting, and supporting breastfeed-
promotes neurocognitive development, and increases mother ing through adequate funding and progressive policies.
and child bonding. Further, it decreases mothers’ risk for
breast cancer and reduces families’ and communities’ health-
care costs (UNICEF & World Health Organization [WHO],

Globalization and Breastfeeding mortality in areas (primarily developing countries) where
continued from previous page there is high poverty, poor sanitation, and limited healthcare
are initiation of BF at birth and exclusive BF until 6 months
(Anatolitou, 2012). A total of 93 countries have collected in-
The Rationale for Global Promotion/Expansion formation on exclusive breastfeeding up to six months since
2012. Another 27 countries measured exclusive breastfeeding
of Breastfeeding between 2007 and 2011. However, 55 mostly high income/
In the twenty-first century, globalization has impacted
industrialized nations, do not collect internationally com-
most people living in rural and urban places in developing
parable data on exclusive BF. Data for the United States on
societies and in industrialized countries. This has trans-
initiation of BF at birth and exclusive BF up to 6 months has
formed traditional breastfeeding practices. Nevertheless, the
been published for 2007-2008 (UNICEF, 2016).
WHO remains focused on the great infant health benefits of
Globally, about 44% of newborn infants initiate breast-
BF. It currently recommends exclusive breastfeeding for six
feeding during the first hour after birth. Worldwide, approxi-
months and BF with complementary food up to 24 months
mately 40% are exclusively fed breast milk up to 6 years of
(WHO, 2011). The specific rationales for these recommenda-
age (UNICEF, 2016). More importantly, when the averages
tions and programs supporting worldwide promotion and
are broken down we find large differences in frequencies of
expansion of BF, especially in developing nations, are listed
BF across countries. These disparities are very pronounced
below.
between nations in Africa and the Americas. In Africa, 20%
• Because breast milk contains unique nutritional,
of the countries have an exclusive breastfeeding rate of 60%
immunological, and hormonal components, which
as opposed to only 6% of the countries in the Americas.
contribute to infant growth and well-being, scaling up BF
Worldwide, frequencies of continued breastfeeding to
globally could potentially save over 800,000 children per
one year are much higher (74%) than exclusive BF to six
year who are five years of age and younger (Garcia, et al.,
months. In Africa, almost 70% of nations have high rates of
2011; Victora, et al., 2016).
continued breastfeeding to one year, but in the Americas,
• Infants who breastfeed have greater resistance to
only 4 countries report high (60%) frequencies of BF. At two
infectious and non-communicable diseases and are less
years, frequencies of continued BF worldwide fall to 45%. In
likely to be overweight or obese in later life (Kramer &
Africa, about 20% of countries at 24 months observe high
Kakuma, 2004; Rollins, et al., 2016).
continued BF, however, no country in the Americas report a
• Almost one half of diarrhea episodes and one third
high rate of breastfeeding after 2 years (UNICEF, 2016).
of respiratory infections could be prevented in low
and middle-income societies through more effective
breastfeeding (Victora, et al., 2016). Why do Africa and the Americas Have Different
• BF also provides protection to women from breast cancer
(UNICEF/WHO, 2017).
Rates of Breastfeeding?
Substantial differences in Africa and the Americas in
• Children who are breastfed for longer durations are
exclusive breastfeeding to six months of age and continued
more likely to have higher IQs, which can translate
breastfeeding with complementary foods to 24 months
into improved academic performance and economic
reflect historic patterns of globalization and development
achievement (Victora, et al., 2016).
in both regions (Hite & Roberts, 2008). Prior to extensive
• Nations with low BF rates lose an estimated 300 billion
colonization and industrialization, indigenous people in
dollars in productivity and income each year (Rollins, et
Africa and Latin America lived in rural settings where they
al., 2016).
subsisted through hunting, gathering, fishing, and limited
agriculture. Ethnographic studies of remaining traditional
Global Measurement and Current Rates of peoples in both regions report high levels of BF initiation,
regular infant driven “on demand” feeding, long periods of
Breastfeeding exclusive breastfeeding and continued BF with other foods
WHO promotes internationally comparable measure-
until two years (Sellen & Smay, 2001). We can assume that
ment of initiation of breastfeeding at birth, exclusive BF in
these patterns of BF in remaining traditional peoples reflect
the first six months of life, and continued BF and comple-
historic patterns of the same. (They also reflect current
mentary food (CF) up to 24 months (UNICEF, 2016). The
WHO breastfeeding recommendations).
key dimensions here in terms of prevention of neo-natal
Globalization and Breastfeeding Bolivia and UNICEF. Breastfeeding and other efforts focused
continued from previous page on the health and nutrition of children and adolescents have
made a special effort to reach the vulnerable impoverished
Bolivians living in rural and urban communities (UNICEF
However, large scale European colonization of the Bolivia, 2017). The most recent available WHO data indicate
Americas began in the 1500s and did not occur in Africa that the rate of breastfeeding in Bolivia place it among the
until the 19th century. In the Americas, the processes of highest performing countries in the Americas. Early initiation
industrialization, urbanization, and modernization be- of BF was at 61%, exclusive breastfeeding of children under
gan much earlier than in Africa. Consequently, today at a 6 months was 54% and continued breastfeeding at one year
regional level, women in the Americas are more likely to be was 82%.
urban, educated, employed in the formal market economy, When USAID launched its “Breastfeeding for Child
and to reject traditional BF practices than women in Africa. Survival Strategy” in 1990, which encouraged its health,
Although, some recent studies show that there are some population, and nutrition programs to recognize breastfeed-
women in the Americas who have more education and ing as a critical dimension, the BF program was implemented
who have been influenced by modern ideas and values who in Kenya with similar objectives to the program in Bolivia.
embrace BF (Chaparro & Lutter, 2010; Veille, Martin, & Over time, the government of Kenya has also partnered
McAllister, 2013). with WHO to sustain and increase traditional rates of BF
and help increasing numbers of Kenyan women entering
Historical Examples of Successful Breastfeeding the formal work force. Since the mid-2000s, Kenya has
had a massive drive with the primary goal of increasing the
Programs in Africa and Latin America percentage of children under 6 months who are exclusively
To revive dropping rates of breastfeeding in the Ameri-
breastfed. Two core initiatives have helped make this cam-
cas and to sustain and increase traditional frequency of BF
paign a success – the Baby Friendly Hospital Initiative and
in Africa, international donors and national governments
the Baby Friendly Community Initiative (Kimani, 2015). The
beginning in the 1980s began large scale promotional cam-
Baby Friendly Hospital Initiative, which was pioneered in the
paigns (Lutter & Morrow, 2013). Two of the most successful
Americas by the Pan American Health Organization has ten
campaigns were in Bolivia and Kenya.
steps to ensure successful breastfeeding:
Concerns about the decline in breastfeeding rates and
1. Have a written breastfeeding policy that is routinely
the high rates of mortality stemming from artificial feeding
communicated to all healthcare staff
in Bolivia and elsewhere in the Americas began to be ex-
2. Train all healthcare staff in the skills necessary to
pressed by health researchers in the mid 1970s and through-
implement the policy
out the 1980s (USAID, 2001). However, a major initiative
3. Inform all pregnant women about the benefits and
in Bolivia to provide a full range of support to breastfeeding
management of breastfeeding
programs, e.g. systematic in-country assessments followed by
4. Help mothers initiate breastfeeding within a half-hour of
breastfeeding strategies and implementation, was not fully in
birth
place until the early 1990s. This was funded under the Unit-
5. Show mothers how to breastfeed and how to maintain
ed States Agency for International Development (USAID)
lactation even if they are separated from their infants
“Breastfeeding for Child Survival Strategy” (USAID, 1992).
6. Give newborn infants no food or drink other than breast
The program promoted and supported breastfeeding within
milk unless medically indicated
existing national child survival, health, population, and
7. Practice rooming-in: allow mothers and infants to remain
nutrition programs. Specifically, BF was incorporated into
together 24 hours a day
ongoing efforts in diarrhea disease control, immunization,
8. Encourage breastfeeding on demand
nutritional improvement, child spacing, prenatal care, health
9. Give no artificial pacifiers to breastfeeding infants
care, financing, and food aid. The goal of the USAID sup-
10. Foster the establishment of breastfeeding support groups
ported BF activities was to increase the percentage of infants
and refer mothers to them on discharge from the hospital
that are immediately and exclusively breastfed, that received
or clinic.
appropriate complementary foods in addition to breastfeed-
The Baby Friendly Community Initiative distributed
ing from six months, and to continue BF for two years or
information about the benefits of breastfeeding, helped to
longer. Since the early 2000s, breastfeeding promotion in
establish and sustain breastfeeding support groups, and pro-
Bolivia has been the responsibility of the Government of

Globalization and Breastfeeding and provide information for improving them. Specifically,
continued from previous page the measures gather country specific data on the amount
of BF dedicated funding, enacted legislation regulating
the promotion of breast milk substitutes, laws guarantee-
vided lactation counselors for local breastfeeding mothers. In ing paid maternity leave and job site BF functioning, Baby
2017, the Kenyan National Demographics and Health Survey Friendly Hospitals, active breastfeeding counselors in clinics
reported that 61% of mothers of children aged less than and the community, and monitoring and publication of BF
6 months were exclusively breastfeeding. This percentage rates. Currently no country has scored highly on all of the
exceeds the World Health Assembly and WHO goal of 50% programmatic and policy indicators, and only six countries
of mothers exclusively breastfeeding infants under 6 months have received adequate scores on more than one-half of the
of age. Also, the most recent published WHO data on Kenya indicators (UNICEF & WHO, 2017).
shows that early initiation of breastfeeding was at 58% and
that continued BF at one year was at 86%. Despite these
outstanding statistics in exclusive Breastfeeding for children What Is the United States Doing to Promote
under 6 months and continued BF at one year, health policy Breastfeeding?
makers realize that they have considerable challenges in While the official position of the United States govern-
the work place to sustaining and increasing these measures ment has been supportive of breastfeeding and increasing
of breastfeeding success. Programs need to be established breastfeeding nationwide, which is in concert with the
guaranteeing Kenyan women in the work force paid mater- WHO/UNICEF lead Global Breastfeeding Collective; like
nity leave and flexible work arrangements so that they can most advanced industrial countries, BF participation is low,
breastfeed their children when they are on the job (Kimani, and its goals for breastfeeding promotion are modest (Center
2015). for Disease Control [CDC], 2010). This situation is best
described in the Healthy People 2020 Report, which was
Proposed Global Action to Promote Greater published by the U.S. Department of Health and Human
Services (DHHS) in December of 2010 (DHHS, 2010). Sev-
Worldwide Breastfeeding eral national breastfeeding objectives with data baselines and
Although national campaigns in support of breastfeed- 2020 targets for improvement were listed: (1) Percent of in-
ing, like those waged in Bolivia and Kenya, have resulted fants who were breastfed exclusively at 6 months, 14% with
in measurable increases in exclusive BF for infants under a target of 25%; (2) Percent of infants who were breastfed at
6 months and continued BF for infants at one year, these one year, 23% with a target of 34%; (3) Percent of employers
programs needed to be institutionalized so that their benefits providing work site lactation support stations, 25 % with a
can be sustained. This will require collective global action, target of 38%; (4) Percent of breastfed newborns who receive
which is especially important for developing nations that formula supplementation within the first 2 days of life, 24 %
often depend on international (and local) resources to be with a target of 14%; (5) Percent of live births occurring in
successful over time. facilities that provide recommended care for lactating moth-
The World Health Assembly, which is an advisory group ers and their babies, 3 % with at target of 8%.
for the WHO, recognizes this need. They have proposed a Following the Healthy People 2020 Report, which speci-
goal for the WHO of increasing the frequency of exclusive fied national objectives for breastfeeding, the Surgeon Gen-
breastfeeding for infants under 6 years of age to 50% (to be eral issued a call to action to set forth the roles and respon-
attained in every nation) by 2025. To reach this objective, sibilities of clinicians, employers, communities, researchers,
the Global Breastfeeding Collective, which is a partnership of and government leaders to increase the rate of breastfeeding
non-governmental organizations (NGOs), academic institu- (CDC, 2011). In this authoritative statement, the situation of
tions, and public and private donors that are led by UNICEF mothers who wanted to breastfeed was described, and the
and WHO, has set seven measurable priorities that are “key barriers” to BF were noted. It was observed that most
assumed to be essential for advancing national breastfeeding (75 %) of mothers initially try to breastfeed but by the third
programs (WHO, 2014). The priorities focus on the need for month after giving birth, more than two thirds of them were
more funding for breastfeeding programs, terminating the already using formula and by six months postpartum more
promotion of breast milk substitutes, supporting the rights than one-half of mothers had given up on BF. Further, it was
of working women, delivering necessary healthcare services, stated that breastfed one-year olds were a rarity (23%) in the
building support in the community for BF, and implement-
ing monitoring systems to assess the efficacy of programs
Globalization and Breastfeeding with major structural changes in hospital services, family
continued from previous page leave, and work site support of nursing mothers, we cannot
expect significant and sustained gains in breastfeeding either
in developing countries or advanced industrial societies. The
United States. This statement also showed an awareness that specific reforms that are essential for successful promotion
mothers in the United States, like their counterparts in other of breastfeeding are: (1) universal establishment of “baby
advanced industrial nations and developing countries, lived friendly” hospitals; (2) paid family leave for mothers of 16 to
in a globalized economy that on one hand encouraged and 18 weeks; (3) flexible work site changes including paid breaks
empowered all women to enter the formal workforce but on for nursing and breast pumping and private and protected
the other hand required that most families have two full time lactation sites for nursing employees; and (4) well-funded
“bread winners” to have a good quality of life. positions for lactation consults in the community.
To increase the rate of breastfeeding, the Surgeon Gen- Regardless of the realization of these structural reforms
eral suggested that several “key barriers” had to be addressed affecting breastfeeding, childbirth educators will continue
including: (1) a lack of accurate knowledge on how to initiate to play a crucial role in educating mothers on the potential
breastfeeding; (2) lactation problems that are not treated; (3) benefits of breastfeeding and the challenges they will face in
poor social support from fathers, grandmothers, and other attempting to breastfeed their infants.
family members; (4) social norms that stigmatize breastfeed- The author wishes to thank Professor Kwabena Poku
ing as an alternative rather than routine way of feeding; (5) of the University of Ghana-Legon and Professor Jacirema
embarrassment of women who feel that they must conceal Goncalves of the Federal University of Amazonas School of
breastfeeding; (6) lack of maternity leave and returning to Nursing for reviewing this manuscript.
full-time work; and (7) healthcare systems and providers that
do not support BF. Although the Surgeon General demon-
strated an accurate understanding of the socioeconomic References
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Lactation: Defense for
Maternal Health
by Erin Kathryn Williams, BSN, and Elizabeth Smith, MPH ICCE IBCLC RLC
Abstract: Breastfeeding is beneficial for women who carry the BRCA1 gene, the protective properties
of breastfeeding are even greater. Those in this category who
mothers as well as babies. Both breast breastfed for a year or more saw a 37% reduction in breast
and ovarian cancers are seen more fre- cancer risk (Schwarz & Nothnagle, 2015). For women with a
quently in women who do not breastfeed. first-degree relative who had breast cancer, moms who breast-
fed cut their risk of the disease by 60% (Harmon, 2010).
Mothers who do not exclusively breastfeed
Women who reported breastfeeding for any period
for at least 1 month increase their risk of of time saw a 32% decrease in their risk of ovarian can-
developing Type II diabetes. Lactation has cer (Schwarz & Nothnagle, 2015). The protective benefits
been shown to prevent cardiovascular dis- increase with the amount of time that a woman breastfeeds
in her lifetime. These kinds of results were expected due to
ease. Discontinuing breastfeeding in order ovulation suppression from exclusive breastfeeding. However,
to lessen perinatal mood and anxiety the benefits of ovarian cancer reduction are seen even after
disorders may instead exacerbate symp- exclusive breastfeeding discontinues. It is suspected that
this continued benefit is due to reduced levels of luteinizing
toms. Breastfeeding is economical and has
hormone and other gonadotropins that are possible causes of
environmental benefits. ovarian cancer over time (Li et al., 2014). The ovarian cycle
length is also altered in breastfeeding women and can lead
Keywords: breastfeeding, benefits of breastfeeding, risks of not to less frequent ovulation. The benefits of breastfeeding on
breastfeeding ovarian cancer prevention increase up to two years after birth
(Li et al., 2014).
Introduction
Most people are aware that breastfeeding has health Type II Diabetes and Obesity
benefits for infants but might not be aware of the evidence A growing body of evidence shows that mothers who do
showing that breastfeeding is also beneficial for mothers. The not exclusively breastfeed for at least 1 month increase their
American Academy of Pediatrics (AAP) recommends that risk of developing DM-II (Schwarz et al., 2010). This increase
infants be exclusively breastfed for the first six months of life is independent of race, body mass index (BMI), or level of
and breastfeeding continue for at least a year (Eidelman & activity later in life. A significant decrease in the acquisition
Schanler, 2012). Just as with babies, maternal health benefits of DM-II was seen in women who had consistently breastfed
increase as the total duration of breastfeeding increases. The for as little as one month following birth. However, the great-
risks from not breastfeeding include breast cancer, ovarian est benefit was seen when women breastfed for a minimum
cancer, type two diabetes (DM-II), obesity, and cardiovascu- of 6 months (Schwarz et al., 2010).
lar disease later in life (Harmon, 2010; Li et al., 2014). The reason behind DM-II acquisition when lactation
is missed is not fully understood. Hypotheses are based on
Cancer studies of women with gestational diabetes (GDM) and
Both breast and ovarian cancers are seen more frequently on animal studies. The theories include the possibility of
in women who do not breastfeed. Schwarz and Nothnagle improved glucose and lipid metabolism with lactation or a
(2015) reviewed 47 different studies and concluded that link to an increase in the body’s sensitivity to insulin with
invasive breast cancer rates decrease by greater than 4% lactation (Schwarz et al., 2010).
for each year that a woman breastfeeds in her lifetime. For

Lactation: Defense for Maternal Health A recent study (Kirkegaard et al., 2018) shows a de-
continued from previous page creased risk of hypertension and cardiovascular disease as a
result of less abdominal obesity in women who breastfeed.
This study found that any breastfeeding for longer than 4
Lactation has also been shown to be linked with months resulted in a 20-30% lower risk for hypertension and
reduced obesity, including visceral obesity, and smaller CVD. These results applied to women classified as normal
maternal waist circumferences later in life (Schwarz & Noth- weight, underweight and overweight. This study included a
nagle, 2015). These factors also contribute to a decrease in follow-up at 7 years postpartum which still found a decrease
DM-II. A large cross-sectional study of over 740,000 women in hypertension and CVD.
reported that post-menopausal BMI was decreased by 1% for Further studies have reported that mothers who don’t
every 6 months that a woman breastfed (Bobrow, Quigley, breastfeed are five times more likely to have scarring of the
Green, Reeves, & Beral, 2013). This was independent of aorta and calcium deposits - early markers of cardiovascular
socioeconomic status, residence, smoking status, or level of disease (Schwarz, 2015; Harmon, 2010). Breastfeeding can
physical activity. Bobrow et al. (2013) reported that a 1% also have a greater positive effect on a woman’s lifelong
reduction in BMI would markedly decrease obesity-related blood pressure levels than diet and exercise can (Schwarz,
diseases and associated healthcare costs. This 1% reduction 2015).
of BMI has also been linked with a 1% reduction in all-cause
mortality (Bobrow et al., 2013).
Perinatal Mood and Anxiety Disorders (PMAD)
When it comes to PMAD, it is frequently recom-
Cardiovascular Disease mended that women stop breastfeeding in order to protect
Heart disease is the number one cause of death for their own mental health. However, this is not evidence-based
women in the United States, accounting for about one- information and may actually increase or exacerbate symp-
fourth of all female deaths (Centers for Disease Control and toms. Kathleen Kendall-Tackett (2018) has done extensive
Prevention, 2017). Multiple studies have shown that lactating research on the effects of breastfeeding and depression. It is
can help prevent cardiovascular disease in women who have not always clear how each individual woman will respond,
given birth. In a 20-year study of women without any history but we do know that breastfeeding has a lot of positive
of heart disease, shorter lactation periods were associated benefits for a new mom. One of the biggest is in sleep and
with the formation of atherosclerotic plaques (Gunderson sleep quality. Babies are going to wake at night regardless of
et al., 2015). Schwarz and Nothnagle (2015) reported that feeding type. Women who are breastfeeding in a supportive
women experienced a 28% decrease in the development of environment will fall asleep more quickly after feeding due
cardiovascular disease when they breastfed for a period of to the increase in oxytocin from the feed. They will then get
seven to 12 months following their first birth. Also, a cumu- extra and better-quality sleep which decreases catecholamine
lative breastfeeding duration of two years or more has been and has a positive impact on overall health. The suggestion
shown to lower a woman’s risk of coronary heart disease by to wean can trigger deeper feelings of failure exacerbating
23% (Schwarz & Nothnagle, 2015). the situation. It is best when a mom is having struggles with
mood and/or anxiety to work with both healthcare profes-
sionals and lactation professionals to find the best solution.
Economic Benefits
Although the focus of this paper is on the health ben-
efits of breastfeeding for women, when looking at health it is
important to remember all aspects of health. When a baby
is breastfed, he or she is less likely to be sick than a formula
fed baby. This benefit transfers to mom and the rest of the
family. Additionally, there is a cost savings for breastfeeding.
Formula products can cost an estimate of $816.48-$3,163.86
for one year (Kellymom, 2016). The high cost of formula can
lead to increased stress and less money for mom to make
healthy eating choices.
Lactation: Defense for Maternal Health Women’s Health.org. (2018). Business Case. Retrieved June 24, 2018, from
https://www.womenshealth.gov/breastfeeding/breastfeeding-home-work-
continued from previous page and-public/breastfeeding-and-going-back-work/business-case
Centers for Disease Control and Prevention. (2017). Women and heart
disease fact sheet. Retrieved August 30, 2018, from https://www.cdc.gov/
Environmental Benefits dhdsp/data_statistics/fact_sheets/fs_women_heart.htm
Finally, it is important to look at the positive impact on Eidelman, A. I., & Schanler, R. J. (2012). Breastfeeding and the use of
the environment when breastfeeding vs the use of formula human milk. Pediatrics, 129(3). Retrieved from http://pediatrics.aappublica-
products. By decreasing pollution and waste, the population tions.org/content/129/3/e827
as a whole is healthier. Formula products increase pollution Gunderson, E. P., Quesenberry, C. P., Ning, X., Jacobs, D. R., Gross,
M., Goff, D. C., . . . Lewis, C. E. (2015). Lactation duration and midlife
and waste through manufacturing, packaging, transportation, atherosclerosis. Obstetrics and Gynecology, 126(2), 381-390. Doi: 10.1097/
bottles/nipples, and trash. All of these are reduced through AOG.000000000000919
breastfeeding. Harmon, K. (2010). How breastfeeding benefits mothers’ health. Scientific
American. Retrieved August 30, 2018, from https://www.scientificamerican.
com/article/breastfeeding-benefits-mothers/
Summary Kellymom. (2018). Financial costs of not breastfeeding…or cost benefits
Breastfeeding versus formula feeding may still be seen of breastfeeding . Retrieved August 30, 2018, from https://kellymom.com/
by some as simply a lifestyle choice (Women’s Health. pregnancy/bf-prep/bfcostbenefits/
org, 2018). However, studies of women’s long-term health Kendall-Tackett, K. (2018). Breastfeeding. Retrieved August 30, 2018, from
outcomes are showing the life-long benefits of allowing the http://www.kathleenkendall-tackett.com/Articles-breastfeeding.html
body to lactate following pregnancy and birth. When it is Kirkegarrd, H., Bliddal, M., Stovring, H., Rasmussen, K. M., Gunderson,
physically possible, breastfeeding should be encouraged and E. P., Kober, L., … Nohr, E. A. (2018). Breastfeeding and later maternal
risk of hypertension and cardiovascular disease- The role of overall and
supported by healthcare providers and all others who seek
abdominal obesity. Preventive Medicine, 114, 140-148. doi: 10.1016/j.
to support women to live their healthiest lives. This may ypmed.2018.06.014.
include changes in policy, such as designation as a Baby Li, D., Du, C., Zhang, Z., Li, G., Yu, Z., Wang, X., . . . & Zhao, Y. (2014).
Friendly Hospital (Baby Friendly USA, 2018) or incorpora- Breastfeeding and ovarian cancer risk: A systematic review and meta-analysis
tion of the 10-Steps for Successful Breastfeeding and social of 40 epidemiological studies. Asian Pacific Journal of Cancer Prevention,
15(12), 4829-4837. Doi: http://dx.doi.org/10.7314/APJCP.2014.15.12.1829
norms to make breastfeeding a priority. It takes work to
make changes but the major health benefits that women will Schwarz, E. B. (2015). How mothers can nurse themselves healthy [Video
file]. Retrieved from https://www.youtube.com/watch?v=o2XjA4wA4TI
enjoy will be well worth it.
Schwarz, E. B., Brown, J. S., Creasman, J. M., Stuebe, A., McClure, C. K.,
Van Den Eeden, S. K., & Thom D. (2010). Lactation and maternal risk of
Implications for perinatal health professionals type 2 diabetes: A population-based study. American Journal of Medicine,
123(9), 863. Doi: 10.1016/j.amjmed.2010.03.016
As a childbirth educator, lactation professional, or doula
you are in a unique position to help educate women about Schwarz, E. B., & Nothnagle, M. (2015). The maternal health benefits of
breastfeeding. American Family Physician, 91(9), 206-204.
the benefits of breastfeeding for both babies and mothers.
Often, care providers in clinics or hospitals have so much
material to cover that breastfeeding information and support
get shortened to just the basics. As an allied health profes- Erin Kathryn William has a BSN and has worked for 8 years
sional, you have the opportunity to not only help educate in both labor & delivery and newborn care. She is currently in
the mom and her support system on the benefits but you the doctoral program at the University of Utah, studying to be a
can teach them how to make it work. Providing tips for women’s health nurse practitioner and midwife.
support people and problem solving for moms when they
encounter challenges are both invaluable. Elizabeth Smith, MPH ICCE IBCLC RLC has been working in
Women’s and Children’s Health since 1998. Her focus since 2000
has been in the perinatal period. She is the Coordinator of the
References Perinatal Education Program and the Baby Friendly Coordina-
Baby Friendly USA. (2018). About Us. Retrieved June 24, 2018, from tor for University of Utah Health. She sits on many committees/
https://www.babyfriendlyusa.org/about-us
boards working with mom’s, babies, and families. She has been
Bobrow, K. L., Quigley, M. A., Green, J., Reeves, G. K., & Beral, V. (2013). on the Board of Directors for ICEA for the past 3.5 years.
Persistent effects of women’s parity and breastfeeding patterns on their body
mass index: Results from the Million Women Study. International Journal of
Obesity, 37(5), 712-717. Doi: 10.1038/jio.2012.76

We need a Standardized
Approach to Use of
Nipple Shields
by Teri McGowen, RN, and Elizabeth Smith, MPH ICCE IBCLC RLC
Abstract: The use of nipple shields is An overuse of offering nipple shields for mothers who
are having difficulty with latching has been observed. This
not new. They have been used for many may be due to the lack of time, staffing, and/or education
years but there is a current trend for of postpartum nurses. Nipple shields have been used for de-
more frequent use on many postpartum cades and do have a purpose. Mothers with inverted or sore
nipples may find that a nipple shield helps them to get past
units. Unfortunately, their use does not
an initially challenging time in lactation. A shield may help
increase the longevity of breastfeeding premature infants get a good latch until the mouth grows.
but instead often results in early termi- Shields may be beneficial for babies with impaired suck or
nation of breastfeeding and/or supple- physical challenges (Parkes, 2000). Their use may also exac-
erbate an already stressful time for the mother and make her
mental feeding. Quality improvement feel like she has failed in her new role as a mother (Kronberg,
on evidence-based lactation practices in Foverskov, Nilsson, & Maastrup, 2017).
the postpartum unit increases successful Previous studies found that nipple shields are related to
reduced milk intake for the infant, reduced milk supply, and
breastfeeding and decreases the use of
nipple damage (Parkes, 2000). By 2 months postpartum 17%
nipple shields. of mothers who use nipple shields had weaned the infant
and 59% were using formula. This would imply that nipple
Keywords: nipple shields, breastfeeding rates, breastfeeding longevity shields may be associated with weaning before the mother
and baby were ready (Eglash, Ziemer, & McKechnie, 2010).
Identifying A Clinical Problem: Problem Routine use of nipple shields is discouraged. Rather
than assuming that nipple shields are safe until proven oth-
Statement erwise, healthcare providers should limit their use (Eglash,
In the past the skills of breastfeeding were passed from Ziemer, & McKechnie, 2010) and consider implementing
one generation to the next. Girls watched their aunts breast- other strategies that support breastfeeding success. This will
feed their cousins. Mothers taught daughters, grandmothers lead to decreased stress in the mother and allow suckling and
taught granddaughters, and neighbors and friends helped proper latching, increasing the numbers of women who are
and encouraged each other to become successful at breast- successful with lactation which will lead to meeting national
feeding. Breastfeeding was the norm; bottle feeding was rare. and international breastfeeding goals (Eglash, Ziemer, &
Many factors have led to increased bottle/formula use for McKechnie, 2010).
many decades. “Sadly, because of several generations of not
breastfeeding or not breastfeeding in public…. knowledge
or technique…. has become lost” (Cadwell, 2007). This has Evidence-Based Intervention
left the role of teaching the skills of breastfeeding to the One of the goals of Healthy People World Health 2020
postpartum nurse or a lactation specialist. (Eglash, Ziemer, & is for 60% of American women to exclusively breastfeed
McKechnie, 2010)
We need a Standardized Approach to Use of Nipple Shields increase suckling will help. Faculties need to have specific
continued from previous page guidelines and for the use of nipple shields so they are not
over-used.
Care of the childbearing family involves education,
their babies for six months (Hanna, Wilson, & Norwood, breastfeeding support, proper latch, and learning the early
2010). Although 75% of mothers in the United States initiate feeding cues of a baby. Latching before the baby becomes
breastfeeding only 13% continue exclusive breastfeeding at distressed, ensuring a wide, deep latch, and monitoring
6 months, many of these weaning before they had planned infant voids are the best approaches. Childbirth educa-
or hoped (Wagner, Chantry, Dewey, & Nommsen-Rivera, tors, doulas, nurses, physicians, and lactation professionals
2013). Many factors lead to women not meeting their breast- working together on education and consistent support can
feeding goals. A big indicator of breastfeeding success is early increase the duration of exclusive breastfeeding.
evidence-based support and education. The routine use of
nipple shields has an impact on early success and is a factor
in long term success. References
Nipple shields are commonly used in many countries. Eglash, A. Ziemer, A. & McKechnie, A. (2010). Health Professionals’ At-
titudes and Use of Nipple Shields for Breastfeeding Women. Breastfeeding
They are seen to prevent and rest sore nipples, ease the latch Medicine, 5(4), 147-151. https://doi.org/10.1089/bfm.2010.0006
for flat nipples, reduce oversupply, and help a struggling
Flacking, R., & Dykes, F. (2017). Perceptions and experiences of using a
newborn attach to the breast for the first time (Flacking & nipple shield among parents and staff-an ethnographic study in neonatal
Dykes, 2017). They are most often used for term and near- units. BMC Pregnancy and Childbirth, 17(1), 1-8. doi:10.1186/s11284-016-
term infants in the first week of life as well as for preterm 1183-6
infants, despite many concerns regarding nipple shields’ Hanna, S., Wilson, M., & Norwood, S. (2013). A Description of Breastfeed-
safety and success. But using nipple shields for all feedings is ing Outcomes Among US Mothers Using Nipple Shields. Journal Midwifery
Women’s Health, 29(6), 616-621.
associated with more than three times higher odds of cessa-
Kronberg, H., Foverskov, E., Nilsson, I., & Maastrup, R. (2017). Why do
tion of exclusive breastfeeding before week 17 (Kronberg, et
mothers use nipple shields and how does this influence duration of exclusive
al., 2017). breastfeeding? Maternal and Child Nutrition, 1, 1-13. doi:10.1111/mcn.12251
While they have a role in breastfeeding support, nipple McKechnie, A. C., & Eglash, A. (2010). Nipple Shields: A Review of the
shields are not always a good option for inexperienced or Literature. Breastfeeding Medicine, 5(6), 309–314. http://doi.org/10.1089/
insecure mothers. Health care professionals should consider bfm.2010.0003
the mother’s desires and personality when deciding to offer Schanler, R. J., & Potak, D. C., (2018). Initiation of breastfeeding. Retrieved
their use. (Ridgeway, et al., 2016). March 5, 2018, from https://www-uptodate-com.ezproxy.lib.utah.edu/
Evidence-based guidelines for nipple shield use are lack- Wagner, E. A., Chantry, C. J., Dewey, K. G., & Nommsen-Rivera, L. A.
ing and need be developed. (Eglash, Ziemer, & McKechnie, (2013). Breastfeeding concerns at 3 and 7 days postpartum and feeding
status at 2 months. Pediatrics, 132(4), 865-875. doi:10.1542/peds.2013-0724
2010). The use of nipple shields is controversial and study
results are contradictory (Flacking & Dykes, 2017). There-
fore, use of nipple shields should be considered an unknown
risk and their use should be limited until further evidence Teri McGowen, RN received a Bachelor of Science in Nursing
demonstrates safety (McKechnie & Eglash, 2010). at the University of Utah College of Nursing May 2018. Previ-
ous to earning this degree, she received a Bachelor of Science in
Healthcare Management from DeVry University February 2010.
How can we make a difference? She has been working in the medical field for over 30 years as a
Early breastfeeding education to the childbearing family Medical Assistant. With a strong interest in Women’s and Chil-
has been shown to contribute to increased breastfeeding dren’s Health, she is excited to now be employed on the Maternal
(Ridgeway, et al., 2016). In the early breastfeeding experi- Newborn Care Unit for University of Utah Health.
ences, many issues concerning breastfeeding can be ad-
dressed with reassurance and further education. Postpartum Elizabeth Smith, MPH ICCE IBCLC RLC has been working in
nurses and lactations consultants receiving more education Women’s and Children’s Health since 1998. Her focus since 2000
will assist with this process. Our expectations of how soon has been in the perinatal period. She is the Coordinator of the
an adequate feeding will be accomplished might be incorrect Perinatal Education Program and the Baby Friendly Coordina-
and it may be two to three weeks before breastfeeding is well tor for University of Utah Health. She sits on many committees/
established (Schanler & Potak, 2018). Reassurance that this boards working with mom’s, babies, and families. She has been
is normal behavior and tips on how to improve latch and on the Board of Directors for ICEA for the past 3.5 years.

Pregnancy and Intimate
Partner Violence
by Lee Stadtlander, PhD
Abstract: Millions of pregnant women al., 2011). The severity of violence may sometimes escalate
during pregnancy or the postpartum period (Brownbridge et
are abused each year around the world. al., 2011; Cheng & Horon, 2010).
Interpersonal violence (IPV) affects physi-
Pregnancy and IPV
cal and mental health, both short and The prevalence of IPV during pregnancy varies greatly
long term. It is associated with alcohol internationally. A World Health Organization 19-country-
and drug abuse, eating and sleep disor- study (Devries et al., 2010) showed that the prevalence of
IPV during pregnancy was 3.8%-13.5% in Africa, 2.0%-
ders, physical inactivity, poor self-esteem,
5.0% in the United States, 1.8%-6.6% in Europe and 2.0%
posttraumatic stress disorder, self-harm, in Australia. IPV has been associated with poor pregnancy
unsafe sexual practices, suicide, and weight gain, infection, anemia, tobacco use, stillbirth, pelvic
homicide. IPV has also been associated fracture, placental abruption, fetal injury, preterm delivery,
and low birth weight (Brown, 2009, Committee on Health
with adverse pregnancy outcomes such as Care for Underserved Women, 2017).
preterm birth, low birthweight, and be- United States data from a 2009-2010 survey (U.S. Dept.
ing small for gestational age. This article of Health, 2013) indicated that 3.2% of women reported
that they had been pushed, hit, slapped, kicked, choked, or
provides background information on physically hurt in some other way during their most recent
pregnancy and IPV, as well as screening pregnancy. Nearly 7% of teen mothers reported IPV during
questions that may be used to support pregnancy compared with fewer than 2% of mothers older
clients, and offers resources for childbirth than 30 years of age. Rates of IPV during pregnancy for
mothers with less than 12 years of education were 4.5%
professionals. compared with 1% in those with more than 16 years of
education. Overall, the highest prevalence of IPV during
Keywords: intimate partner violence, domestic violence pregnancy was reported in non-Hispanic American Indian/
Alaska Native and non-Hispanic black women (6.5% and
Pregnancy and Intimate Partner Violence 5.8%, respectively), and the lowest prevalence was seen
Intimate partner violence (IPV) is defined as “the willful among non- Hispanic Asian women (1.5%).
intimidation, physical assault, battery, sexual assault, and/ The Effects of IPV
or other abusive behavior as part of a systematic pattern IPV affects both physical and mental health, these
of power and control perpetrated by one intimate partner effects can be direct (such as those sustained from injury
against another” (National Coalition Against Domestic and physical violence) or those that occur indirectly (e.g.,
Violence, 2015, para.1). It includes physical violence, sexual chronic health problems resulting from prolonged stress;
violence, threats, and emotional/ psychological abuse. It is an Chisholm, Bullock, & Ferguson, 2017). The adverse effects
international issue, for example, 50-60% of women in Ethio- may persist for years, even if IPV stops (Alejo, 2014). Func-
pia experience IPV in their lifetimes (Berhane, 2004); in In- tional disorders (conditions for which there is no identifiable
dia 34% of women have experienced physical abuse (Begum, medical cause and are difficult to diagnose) are common
Donta, Nair, & Prakasam, 2015), in the United States more in survivors, these include such disorders as irritable bowel
than 10 million people are abused victims annually (Black et
Pregnancy and Intimate Partner Violence does not deserve to be hurt, can be extremely empowering to
continued from previous page a woman in a vulnerable position (Bloom et al., 2011).
The American College of Obstetricians and Gynecolo-
gists (Committee on Healthcare for Underserved Women,
syndrome and other gastrointestinal symptoms, fibromyalgia, 2012) recommends screening for IPV at the first prenatal
various chronic pain syndromes, and overall poor health. visit, at least once per trimester, and at the postpartum
Mental health disorders include high levels of depression checkup. Studies have shown that patient self-administered,
and thoughts of suicide and attempted suicide. IPV is also or computerized screenings are as effective as clinician
associated with alcohol and drug abuse, eating and sleep interviewing in terms of disclosure, comfort, and time spent
disorders, physical inactivity, poor self-esteem, posttraumatic screening (Ahmad et al., 2009; Chen et al., 2007). Screen-
stress disorder (PTSD), self-harm, and unsafe sexual practices ing for IPV should be done privately. Health care providers
(Chisholm et al., 2017). should avoid questions that use stigmatizing terms such as
In a study using the Edinburgh Postnatal Depression “abuse,” “rape,” “battered,” or “violence” (see sample ques-
Scales, nearly 50% of pregnant women subjected to IPV tions below) and use culturally relevant language instead.
exceeded the cutoff score for depression (Alhusen, Ray, They should use a strategy that does not convey judgment
Sharps, & Bullock, 2015). Violent maternal deaths are also and one with which they are comfortable. Written protocols
associated with IPV. The National Death Reporting System will facilitate the routine assessment process. Even if abuse is
shows that the reported rates for pregnancy-associated not acknowledged, simply discussing IPV in a caring manner
suicide and homicide were 2.0 and 2.9 deaths per 100,000 and having educational materials readily accessible may be
live births, respectively, with differences observed in inci- of tremendous help. Providing all clients with educational
dence by maternal age and race/ ethnicity. A total of 54.3% materials is a useful strategy that normalizes the conversa-
of pregnancy associated suicides involved intimate partner tion, making it acceptable for them to take the information
conflict that appeared to contribute to the suicide (Palladino, without disclosure. Other suggestions from the American
Singh, Campbell, Flynn, & Gold, 2011). Homicide has been College of Obstetricians and Gynecologists (Committee on
reported as a leading cause of maternal mortality, with the Healthcare for Underserved Women, 2012) include:
majority perpetrated by a current or former intimate partner • Screen for IPV in a private and safe setting with the
(El Kady, Gilbert, Xing, & Smith, 2005). woman alone and not with her partner, friends, family, or
IPV has also been associated with adverse pregnancy caregiver.
outcomes such as preterm birth, low birthweight, and being • Use professional language interpreters and not someone
small for gestational age. These newborns are also at an associated with the client.
increased risk of developmental and behavioral issues (Ch- • At the beginning of the assessment, offer a framing
isholm et al., 2017). statement to show that screening is done universally and
not because IPV is suspected. Also, inform clients of the
Recognizing IVP as a Childbirth Professional confidentiality of the discussion and exactly what state/
Childbirth professionals are in a unique position to assist country law mandates that a health care provider must
clients, as these professionals tend to be trusted and can see disclose.
women privately. However, for childbirth professionals to • Incorporate screening for IPV into the routine medical
become effective in helping clients in IPV relationships, they history by integrating questions into intake forms so that
must accept two premises (Taft & Hooker, 2017). The first all clients are screened regardless of whether abuse is
premise is that IPV is a serious public health issue, rather suspected.
than a private one, and falls within the purview of the health • Establish and maintain relationships with community
professional. The second premise is that no one, under any resources for women affected by IPV.
circumstances, deserves to be physically, sexually, or emotion- • Keep printed take-home resource materials such as safety
ally abused. Professionals must maintain empathy and sup- procedures, hotline numbers, and referral information
port for women, refrain from judgment, and remember that in privately accessible areas such as restrooms and
escaping from IPV is a process not a discrete event (Taft & examination rooms. Posters and other educational
Hooker, 2017). Professionals should never insist that women materials displayed in the office also can be helpful.
leave an abuser but support them in the process. When the • Ensure that staff receives training about IPV and that
woman judges she has sufficient resources, is safe and confi- training is regularly offered.
dent to leave, she will do so. Statements by a health profes-
sional to the IPV survivor that she is a worthwhile person and continued on next page

Pregnancy and Intimate Partner Violence
continued from previous page Intimate Partner Violence Resources
Hotlines
Example Intimate Partner Violence Screening • National Domestic Violence Hotline 1-800-799-
SAFE (7233) http://www.thehotline.org/
Questions • Rape Abuse & Incest National Network (RAINN)
Framing Statement: Hotline 1-800-656-HOPE (4673) Web Sites
“We’ve recently started talking to our clients about • Futures Without Violence (previously known as
some issues related to safe and healthy relationships because Family Violence Prevention Fund) for survivors
it can have a large impact on your health.” and offers free technical assistance specifically
for health care providers and settings www.
Confidentiality:
futureswithoutviolence.org
“Before we get started, I want you to know that every-
• National Coalition Against Domestic Violence
thing we discuss today is confidential, meaning that I won’t
www.ncadv.org
talk to anyone else about what is said unless you tell me
• National Network to End Domestic Violence www.
that… (insert the laws in your state/ country about what is
nnedv.org
necessary to disclose).”
• National Resource Center on Domestic Violence
Sample Questions www.nrcdv.org
“Has your current partner ever threatened you or made • Office on Violence Against Women (U.S.
you feel afraid?” (Some alternatives: threatened to hurt you or Department of Justice) www.usdoj.gov/ovw
your children if you did or did not do something, controlled Free Posters/ Photos for IPV Awareness
who you talked to or where you went, or gone into rages) • https://www.pinterest.com/
“Has your partner ever hit, choked, or physically hurt pin/561261172283367831/?lp=true
you?” (“Hurt” includes being hit, slapped, kicked, bitten, • https://www.shutterstock.com/search/
pushed, or shoved.) stop+domestic+violence
For women of reproductive age:
“Has your partner ever forced you to do something sex-
ually that you did not want to do, or refused your request to
previous acts of violence, estrangement from partner, threats
use condoms?” Alternative: “Does your partner support your
to life, threats with a weapon, previous nonfatal strangulation,
decision about when or if you want to become pregnant?”
and partner access to a gun (Campbell, Glass, Sharps, Laughon,
“Has your partner ever tampered with your birth control
& Bloom, 2007). Clients should be offered information that
or tried to get you pregnant when you didn’t want to be?”
includes community resources (mental health services, crisis
For women with disabilities: “Has your partner ever hotlines, rape relief centers, shelters, legal aid, and police con-
prevented you from using a wheelchair, cane, respirator, tact information) and appropriate referrals. Professionals should
or other assistive device?” not try to force clients to accept assistance or secretly place
“Has your partner ever refused to help you with an information in her purse or carrying case because the perpetra-
important personal need such as taking your medicine, get- tor may find the material and increase aggression.
ting to the bathroom, getting out of bed, bathing, getting Assistance in responding to IPV is often best found
dressed, or getting food or drink or threatened not to help through a local domestic violence agency or shelter. When
you with these personal needs?” abuse is identified, it is often very useful to offer a private
phone for the client to use to call a domestic violence
agency. Controlling partners often monitor cell phone call
Contingency Planning logs and Internet usage. Offering a private phone to call a
A protocol with all the information needed to perform
shelter or hotline is a simple but important part of support-
an IPV assessment and resources should be kept available for
ing a victim of violence. For example, the National Domestic
personnel. If a woman indicates she is in a violent relationship,
Violence hotline is a multilingual resource that can connect
the childbirth professional should acknowledge the trauma and
a client to local domestic violence programs, help with safety
assess the immediate safety of the woman and her children
planning, and provide support.
while assisting her in the development of a safety plan. Risk fac-
tors for intimate partner homicide include having experienced continued on next page
Pregnancy and Intimate Partner Violence Chen, P. H., Rovi, S., Washington, J., Jacobs, A., Vega, M., Pan, K. Y., et
al. (2007). Randomized comparison of 3 methods to screen for domestic
continued from previous page violence in family practice. Annals of Family Medicine, 5, 430-435.
Cheng, D. & Horon, I. L. (2010). Intimate-partner homicide among preg-
nant and postpartum women. Obstetrics and Gynecology, 115, 1181-1186.
References Chisholm, C., Bullock, L., & Ferguson, J. (2017). Intimate partner violence
and pregnancy: epidemiology and impact. American Journal of Obstetrics and
Ahmad, F., Hogg-Johnson, S., Stewart, D. E., Skinner, H. A., Glazier, R. H., Gynecology, 217(2), 141-144.
& Levinson, W. Computer-assisted screening for intimate partner violence Committee on Health Care for Underserved Women (2012). Committee
and control: a randomized trial. Annals of Internal Medicine, 151, 93–102. opinion: Intimate partner violence. Obstetrics & Gynecology, 119, 412-417.
Alejo, K. (2014). Long-term physical and mental health effects of domestic Devries, K. M., Kishor, S., Johnson, H., Stockl, H., Bacchus, L. J., Garcia-
violence. Themis: Research Journal of Justice Studies and Forensic Science, 2, Moreno, C., et al. (2010). Intimate partner violence during pregnancy:
82-98. Analysis of prevalence data from 19 countries. Reproductive Health Matters,
Alhusen, J., Ray, E., Sharps, P., & Bullock, L. (2015). Intimate partner 18(36), 158-170.
violence during pregnancy: maternal and neonatal outcomes. Journal of El Kady, D. E., Gilbert, W. M., Xing, G., Smith, L. H. (2005). Maternal and
Women’s Health, 24, 100-107. neonatal outcomes of assaults during pregnancy. Obstetrics & Gynecology,
Begum, S., Donta, B., Nair, S., & Prakasam, C. P. (2015). Socio-demographic 105, 357-363.
factors associated with domestic violence in urban slums, Mumbai, Maha- National Coalition Against Domestic Violence (2015). Domestic violence
rashtra, India. Indian Journal of Medical Research, 141(6), 783–788. fact sheet. https://www.speakcdn.com/assets/2497/domestic_violence.pdf
Berhane, Y. (2004). Ending Domestic Violence against Women in Ethiopia. Palladino, C., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homi-
The Ethiopian Journal of Health Development, 18(3), 131-132. cide and suicide during the perinatal period: Findings from the National
Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Violent Death Reporting System. Obstetrics and Gynecology, 118, 1056-1063.
Merrick, M. T., Chen, J. & Stevens, M. (2011). The national intimate partner Taft, A. & Hooker, L. (2017). Domestic and family violence. In G. Thomson
and sexual violence survey: 2010 summary report. Retrieved from http:// & V. Schmied (Eds.), Psychosocial resilience and risk in the prenatal period:
www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf Implications and guidance for professionals (pp. 90-105). NY: Routledge.
Bloom, J. G., Bullock, L., Sharps, P., Longhon, K., & Parker B. J. (2011). US Department of Health and Human Services (2013). Intimate partner vio-
Intimate partner violence during pregnancy. In J. Humphreys & J. Campbell lence and pregnancy. Available at: https://mchb.hrsa.gov/chusa13/perinatal-
(Eds.), Family violence and nursing practice (pp. 155-179). NY: Springer. risk-factors-behaviors/pdf/ipvp.pdf
Brown H. L. (2009). Trauma in pregnancy. Obstetrics and Gynecology, 114,
147-60.
Brownridge, D. A., Taillieu, T. L., Tyler, K. A., Tiwari, A., Chan, K. L., & Lee Stadtlander is a researcher, professor, and coordinator of the
Santos, S.C. (2011). Pregnancy and intimate partner violence: risk factors, Academic Psychology Doctoral Program at Walden University. As
severity, and health effects. Violence Against Women, 17(7), 858-881.
a clinical health psychologist, she brings together pregnancy and
Campbell, J. C., Glass, N., Sharps, P., Laughon, K., & Bloom, T. (2007).
Intimate partner homicide: Review and implications of research and policy. psychological issues.
Trauma Violence & Abuse, 8, 246-269.
2018 ICEA Officers & Board of Directors

Officers Education
Tamela Hatcher, M.Ed ICCE LCCE ICD IAT
PostPartum Doula – Michelle Hardy (above)
ANCC Committee – Barbara Crotty
President Email: [email protected] IATs – President-Elect
Debra Tolson, RN BSN ICCE IBCLC CPST ICEA Mentor Program –
Email: [email protected] Conferences
Michelle Hardy (above)
Ange Anderson, ICCE
President-Elect Email: [email protected] United States Breastfeeding Committee
Bonita Katz, BA RN ICCE ICD IAT (USBC) Representatives from ICEA:
Email: [email protected] Marketing
Donna Walls (since 2010)
Colleen Weeks, LCCE FACCE CLE CSE RTS
Treasurer Myra Lowrie (since 2011)
Email: [email protected]
Michelle Hardy, MS.Ed LMT ICCE ICD Elizabeth Smith (since 2017)
ICPD IAT(CE-D-PD) International Relations
Email: [email protected] Deryse van Aardt
Secretary
Email: [email protected] Staff
Vonda Gates, RN BSN ICCE CD IAT Director-at-Large Executive Director
Email: [email protected] Bonita Broughton, ICCE CD IAT Aby Henneberry
Vacaville, CA Email: [email protected]
Conference Coordinator
Directors Sarah Gillian
Communications and Public Policy Committees
Elizabeth Smith, MPH ICCE IBCLC RLC Marketing Coordinator
Email: [email protected] Education Sub-Chairs:
Allison Winter
CBE – Vonda Gates (above)
Lactation Email: [email protected]
Birth Doula – Kelli Barr-Lyles,
Donna Walls, RN BSN ICCE IBCLC MA IAT-CE-D ICPE

Utilizing Levine’s
Conservation Model
in Second-Stage Labor Care
by Renece Waller-Wise, MSN RNC-OB CNS CLC CNL LCCE FACCE
Abstract: Childbirth educators should be concepts that specify a systematic guideline to deliver
nursing care. Utilization of a conceptual framework adds
aware of nursing interventions in ob- excellence to high-quality nursing care (Waller-Wise, 2013).
stetric care to prepare clients for options The indicator of a good theory is one that assists the nurse to
that the expectant family may encounter. understand the setting of care and provision of interventions.
The critical evidence of a theory’s usefulness is its applica-
Nursing interventions may be based on
tion to nursing care, or the ability to apply the theory to care
conceptual or theoretical frameworks. (Levine, 1988). Levine’s conservation model of nursing care is
Nursing conceptual frameworks guide one such theory (Levine, 1967).
nursing practice by providing descriptions, A clinical nurse specialist (CNS) is a licensed registered
nurse who is educated at the graduate level, possessing
propositions, and integrated concepts that either a master’s or doctoral degree. Women’s health CNSs
specifies a systematic guideline to deliver have three spheres of impact, which are the patient/woman,
nursing care. This article will describe nurse/nursing practice, and the organization/system. One of
the competencies of a CNS is to plan evidence-based care
Levine’s Conservation Model and its usage
for individuals, families, communities, and populations (As-
by a women’s health clinical nurse spe- sociation of Women’s Health Obstetric and Neonatal Nurses
cialist in the planning of care for women & National Association of Clinical Nurse Specialists, 2014).
during second-stage labor. This article will provide an example of the use of a theory,
Levine’s Conservation Model, by a women’s health CNS in
the planning of care for women during second-stage labor.
Keywords: childbirth education, nursing theory, Levine’s conservation
model, clinical nurse specialist, nursing care plan
Levine’s Conservation Model
Childbirth educators as birthing professionals must be Levine (1996) began developing her model by proposing
aware of nursing interventions throughout the full spectrum that the goal of nursing care was to restore wholeness to the
of obstetric care. This is in order to be able to prepare clients person. Levine (1967) also opined that integrity and whole-
for the full range of options that the expectant family may ness were synonymous, and described that the way in which
encounter (Riffle, 2014). Nursing interventions may be based a person returns to wholeness is by adaptation within the
on conceptual or theoretical frameworks. In some hospitals person’s internal and external environments: The internal en-
this may be because the hospital has obtained Magnet status vironment is the physiologic processes within the body, and
from the America Nurses Credentialing Center, a designa- the external environment is the setting in which the nurse
tion that exemplifies the highest standards of nursing care. structures interventions. The nurse may alter the external
One of the stipulations for Magnet status is the utilization of environment as an intervention to restore wholeness (Levine,
conceptual frameworks to guide nursing care (Waller-Wise, 1969). Nursing interventions for the person may be of two
2013). types: therapeutic or supportive. Therapeutic interventions
Nursing conceptual frameworks guide nursing practice
by providing descriptions, propositions, and integrated continued on next page
Utilizing Levine’s Conservation Model
aid in adaptation, while supportive interventions maintain

the current state of being (Levine, 1967).
Conservation Principles
Levine (1967) postulated four conservation principles,
consisting of conservation of energy, structural integrity,
personal integrity, and social integrity. To provide person-
centered care, the nurse specifically provides interventions
for conservation in these four areas, which in turn leads to
wholeness of the individual (Levine, 1967).
Conservation of energy. Most nursing interventions
from their social setting, so family involvement, engagement,
are devised to conserve energy for the patient. All the physi-
and education are important aspects of care. The interactions
ologic activities of the body are built on creating or utilizing
with the nurse, and in fact all hospital personnel or birth
energy. The nurse strives to conserve energy when possible,
workers, are social in nature. Nurses must initiate therapeutic
so that the necessary energy can be used to fight illness,
interpersonal relationships with the individuals and attend
ensure proper physiologic response, or tolerate activities
to the religious and spiritual needs of person, which is a
needed to restore health (Levine, 1967).
connection to the person’s social community. Finally, nurses
Conservation of structural integrity. The next realm
must plan to avoid sensory deficits, which can be equated to
of interventions revolves around conservation of structural
social isolation (Levine, 1967).
integrity or wholeness. When there is structural change, then
Simultaneously, the patient has at least four types of
there is also functional change. The structural change results
defensive organismic responses. These four responses, which
in, as Levine (1967) described, an organismic response. The
are physiologic and aid in adaptation, are the response to
nurse must organize interventions in a way that assists the
fear, inflammation response, stress response, and sensory
patient to adapt to structural changes to restore function
response (Levine, 1969). The response to fear in labor will be
and that, on their own, aid in protecting the integrity of the
discussed in more detail later in this paper.
structures of the physiology of the patient (Levine, 1967).
Conservation of personal integrity. The third prin-
ciple of conservation is that of personal integrity. Levine Nursing Care Plan During Second-stage Labor
(1967) stated that the person must be regarded not only The plan of care begins with three therapeutic inter-
as an organism with a body, but also as one that possesses ventions during second-stage labor, which are based on a
mind, soul, and emotions—the psychosocial aspects of clinical practice guideline first used at The Ottawa Hospital
personhood. With acknowledging these aspects of person- (Sprague, Oppenheimer, McCabe, Graham, & Davies, 2008).
hood, the nurse must attend to the self-image, self-concept, Clinical practice guidelines are a prescribed grouping of, or
and self-awareness of the individual. The nurse must first ap- bundling of, interventions used to decrease variation in care
proach the person with a nonjudgmental attitude, accepting and improve the quality of care provided. Generally speak-
the person for who she or he is. In fact, the nurse must also ing, clinical practice guidelines are underused in planning
accept the person when the person chooses to disregard the care of women in labor (Keiffer, 2015).
advice or interventions of the nurse. Next involves engage- The therapeutic interventions from this clinical practice
ment of the patient in education, and informed or shared guideline are timing of pushing effort, type of pushing effort,
decision-making. Interventions to conserve personal integrity and positions during second-stage labor (Sommerness et al.,
can be as simple as allowing the patient privacy and advocat- 2017). One outcome variable of interest is obstetrical anal
ing for the person’s rights, yet the interventions can become sphincter injuries (OASIs), which are third or fourth degree
much more complicated when the nurse is attempting to lacerations of the perineum occurring during birth. Also, of
restore psychological wholeness (Levine, 1967). interest is type of birth—spontaneous, vacuum-assisted, or
Conservation of social integrity. Finally, the nurse the incidence of cesarean births occurring during the second-
must act to conserve the patient’s social integrity. Humans stage of labor. The labor nurse will provide interventions that
are social creatures. The person cannot be viewed as separate

Utilizing Levine’s Conservation Model compresses to the perineum during second-stage labor has
continued from previous page demonstrated a reduction in severe trauma to the perineum
during birth, thus preserving the structural integrity of the
perineum (Dahlen, 2012).
provide wholeness or integrity utilizing the four principles of The third principle is that of conservation of personal
conservation, as stated by Levine (1967). integrity (Levine, 1967). Personal integrity is demonstrated,
The first principle of conservation is that of energy in part, as self-image (Levine, 1996). Interventions to pre-
conservation (Levine, 1967). The labor nurse will conserve serve personal integrity may be as simple as providing for
the laboring woman’s energy to be expended only as neces- privacy during care. Being a person in the hospital, especially
sary. This will be accomplished by a supportive intervention during labor, diminishes privacy as strangers see the woman
of delaying pushing effort until the fetal head is visible at at a most vulnerable, intimate time. Fostering as much
the vaginal introitus, or when the urge to push is present personal privacy for the woman as possible aids in restoring
with a fetal station of +2 or lower and a fetal head position her personal integrity (Levine, 1969, 1996). However, a larger
that is occiput anterior, right occiput anterior, or left occiput issue involved in conserving the personal integrity entails
anterior. This will allow for passive descent and rotation of conserving the patient’s self-image. Iles et al. (2017) reported
the baby prior to beginning the pushing effort. If the urge to that more than half of the women in their study reported
push is not present, pushing will be delayed for a maximum changes in self-image related to experiencing an OASI
of 2 hours before pushing effort will commence (Sommer- during birth. One-third of the women in this same study
ness et al., 2017). In this way, the patient’s energy will be reported feeling less attractive owing to the OASI with birth,
conserved so that when it is time to push, the pushing will and one-fifth reported lowered self-esteem due to the OASI
be more effective. The nurse will provide a supportive inter- at the time of birth (Iles et al., 2017). Lower self-image can
vention to enhance the woman’s own urge to push, utilizing be associated with anxiety, depression, and decreased quality
an open-glottis, self-directed pace with minimal breath- of life. Therefore, in providing therapeutic and supportive
holding (DiFranco & Curl, 2014). interventions to prevent OASIs, the nurse is also conserving
The second principle is that of conservation of struc- personal integrity, by decreasing the likelihood of psychologi-
tural integrity (Levine, 1967). One of the outcome variables cal, sexual, or quality of life dysfunction (Iles et al., 2017).
of interest is the reduction of OASIs, which is conserving The final conservation principle is that of social integ-
the structural integrity of the vagina, perineum, and anal rity (Levine, 1967). The first intervention that restores or
sphincter. The nurse, in providing supportive interventions conserves social integrity is that of an interpersonal relation-
of delayed pushing and pushing with the physiologic urge ship with the woman. During second-stage labor the nurse
to push, is aiding in preserving the structural integrity of the remains with the woman, assessing, educating and interven-
patient (Keriakos & Gopinath, 2015). A second intervention ing, as needed (Levine, 1967). In addition, the hallmark
is assisting or encouraging position changes every 30 minutes work of Sosa, Kennell, Klaus, Robertson, and Urrutia (1980)
during second-stage labor. Likewise, the therapeutic inter- highlighted the importance of continuous labor support. The
vention of changing frequently from upright to side-lying to intervention of staying with the woman throughout labor has
promote rotation and descent through the pelvis is aimed shown improvements in the outcomes of fewer cesareans and
at maintaining the patient’s structural integrity (DiFranco fewer instrumental births, among other benefits. Likewise,
& Curl, 2014). A supportive intervention of applying warm the nurse can encourage participation of the woman’s sup-
port team, whether that be partner, family, or doula. Each
member of the patient’s support team aids in maintaining
the patient’s social integrity (Green & Hotelling, 2014).
Therefore, these interventions can influence the outcome of
type of birth.
Levine (1969) discusses organismic responses within
varying levels in which the first level of response is fear.
When women feel safe, secure, and unthreatened during
labor, the normal cascade of hormones are in play. However,
when women experience fear or feel unsafe, insecure, or
Utilizing Levine’s Conservation Model Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-based nursing
practice. Philadelphia, PA: F. A. Davis Company.
Green, J., & Hotelling, B. A. (2014). Healthy birth practice #3: Bring a loved
one, friend, or doula for continuous support. The Journal of Perinatal Educa-
tion, 23, 194-197. http://dx. doi.org/10.1891/1058-1243.23.4.194
threatened during labor, the hormones of the fight-or-flight
response takes over. This is a mammalian response to fear Iles, D., Khan, R., Naidoo, K., Kearney, R., Myers, J., & Reid, R. (2017). The
impact of anal sphincter injury on perceived body image. European Journal
during labor. The hormones of labor are superseded by of Obstetrics and Gynecology and Reproductive Biology, 212, 140-143. http://
the hormones of epinephrine and norepinephrine, which dx.doi.org/10.1016/ j.ejobgrb.2017.03.024
decrease contractions and slow labor, to allow the mam- Keiffer, M. R. (2015). Utilization of clinical practice guidelines: Barriers
mal to be able to move to a safe location where labor will and facilitators. Nursing Clinics of North America, 50, 327-345. https://doi.
org/10.1016/j.cnur.2015. 03.007
resume. Therefore, the labor nurse also provides therapeutic
interventions within an external environment that creates Keriakos, R., & Gopinath, G. (2015). Obstetric anal sphincter injuries. Journal
of Acute Disease, 4, 259-265. http://dx.doi.org/10/1016/j.joad.2015.04.014
a place of safety to allow the normal labor hormones of the
internal environment to function at the optimal level, thus, Levine, M. E. (1967). The four conservation principles of nursing. Nursing
Forum, 6, 45-59. https://doi.org/10.1111/j.1744-6198.1967.tb01297.x
decreasing the patient’s organismic response of fear and al-
lowing labor to progress normally (Buckley, 2015). Therefore, Levine, M. E., (1969). The pursuit of wholeness. American Journal of Nursing,
69, 93-98. https://doi.org/10.1097/00000446-196901000-00031
these interventions can also influence the outcome of type
of birth. Levine, M. E. (1988). Antecedents from adjunctive disciplines: cre-
ation of nursing theory. Nursing Science Quarterly, 1, 16-21. https://doi.
org/10.1177/089431848800100106
Conclusion Levine, M. E. (1996). The conservation principles: A retrospective. Nursing
Providing nursing care that is evidence-based and Science Quarterly, 9, 38-41. https://doi.org/10.1177/089431849600900110
consistent protects individuals from adverse outcomes (Som- Riffle, E. M. (2014). Fetal heart rate assessment best practice. International
Journal of Childbirth Education, 29, 55-58. Retrieved from http://icea.org/
merness et al., 2017). Utilizing theory in the practice of care,
about/icea-journal/
often called praxis, is the goal to eliminate gaps between re-
Sommerness, S. A., Gams, R., Rauk, P. N., Bangdiwala, A., Landers, D. V.,
search and theory formation (Fawcett & Garity, 2009). Many Avery, M. D., …Shields, A. (2017). The perinatal birth environment: Com-
of the nursing interventions applied to the plan of care for munication strategies and processes for adherence to a standardized guide-
second-stage labor described in this paper are interventions line in women undergoing second-stage labor with epidural anesthesia. The
Journal of Perinatal and Neonatal Nursing, 31, 41-50. https://doi.org/10.1097/
taught in childbirth classes. However, childbirth educators JPN.0000000000000224
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Sosa, R., Kennell, J., Klaus, M., Robertson, S., & Urrutia, J. (1980). The
works informing the interventions in labor provided by the effect of a supportive companion on perinatal problems, length of labor, and
labor nurse. This paper has demonstrated the use of Levine’s mother-infant interaction. The New England Journal of Medicine, 303, 597-
conservation model by a women’s health CNS in planning 600. https://doi.org/10.1056/nejm19800 9113031101
nursing care during second-stage labor to protect women Sprague, A. E., Oppenheimer, L., McCabe, L., Graham, I. D., & Davies, B.
L. (2008). Knowledge to action: Implementing a guideline for second stage
from adverse outcomes. Likewise, this paper has given child-
labor. The American Journal of Maternal-Child Nursing, 33, 179-186. https://
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References
Association of Women’s Health Obstetric and Neonatal Nurses & National
Association of Clinical Nurse Specialists (2014). Women’s health clinical nurse
specialist competencies. Washington, DC: Author. Renece Waller-Wise is a licensed women’s health clinical nurse
Buckley, S. (2015). Hormonal physiology of childbearing: Evidence and specialist and the program director for Teach You! Childbirth
implications for women, babies, and maternity care. Retrieved from http:// in Dothan, AL. Renece has been teaching childbirth education
www.national partnership.org/research-library/maternal-health/hormonal-
classes for more than thirty years. She is currently pursuing a
physiology-of-childbearing.pdf
Doctor of Nursing Practice degree.
Dahlen, H. G. (2012). Perineal warm compress reduces risk of third- and
fourth-degree tears and should be part of second stage care. Evidence Based
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DiFranco, J. T., & Curl, M. (2014). Healthy birth practice #5: Avoid giving
birth on your back and follow your body’s urge to push. The Journal of Peri-
natal Education, 23, 207-210. http://dx.doi.org/10.1891/1058-1243.23.4.207

Adverse Outcomes in
Adolescent Pregnancy
by Brelinda Johnson, MS
Abstract: The transitional stage of adoles- on the biological and psychological changes that affect a
pregnant adolescent that leads to the death of a fetus, as well
cence is complex with changes occurring as highlight interventions that may assist adolescents, their
biologically, psychologically, and socio- support systems, and childbirth educators.
logically. Pregnancy adds another layer of
complication to the physical and mental Biological
development of the adolescent. Pre-term Adolescents who conceive within two years of men-
arche are at higher risk for complications during and after
births, stillbirth, and neonatal death are pregnancy (Ganchimeg et al., 2014). A major concern with
not uncommon in pregnant adolescents. adolescent pregnancy is the immaturity of the adolescent’s
This provides an opportunity for child- body and the overlap of biological growth of the adolescent
mother and growing fetus.
birth educators and health profession- Pregnant adolescents have higher risk of anemia,
als working with adolescents to educate hypertension, preeclampsia, preterm births, and depression
themselves on adolescent development. (Cinar & Menekse, 2017). Eclampsia, puerperal endometritis,
Implementing interventions that support infections, and caesarean section were higher among adoles-
cent mothers than older mothers. Teenage pregnancies are
adolescent mental development related to more often associated with neonatal death than stillbirths,
sexual behavior, reproductive health, and due to the fetus growth restrictions associated with teenage
bereavement care is beneficial to aid in gestation (Cnattingius & Stephansson, 2002). The age of the
adolescent influences complications; the younger the ado-
decreasing the adolescent pregnancy rates lescent the higher risk of preterm birth. Although adolescent
around the world. pregnancies may be at more jeopardy for neonatal deaths,
stillbirths are vastly prevalent within adolescent pregnancies.
Keywords: adolescents, stillbirth, biological, psychological
Pregnant adolescents have higher risk
Introduction of anemia, hypertension, preeclampsia,
Adolescence is a transitional stage from childhood to
adulthood that ranges in ages from 10 – 19 years old, thus preterm births, and depression
adolescent pregnancy is defined as those ages mentioned
(Ganchimeg et al., 2014). During this transitional stage Flenady et al. (2016) stated, stillbirth is a world health
biological, psychological, and sociological changes occur concern that has rates double of neonatal mortality (p. 691).
rapidly. The development of the frontal lobe of the brain Additionally, while neonatal mortality has declined, stillbirth
plays a role in decision making and impulse control. The rates remain consistent. Stillbirth affecs developed and unde-
surge in hormones, the search for identity, and the need to veloped countries, as well as every age, ethnicity, and social
feel accepted by others impact the adolescent’s choices and class. Stillbirth rates are two to three times higher for women
could be a factor in the number of adolescent pregnancies that are from south Asia or Africa than those of White wom-
throughout the world. According to the World Health Orga- en who live in European countries (Flenady et al., 2016). A
nization (WHO) about 16 million girls between the ages of multi-country research study found stillbirth to be a high risk
15 and 19 give birth every year (2012). This article will focus continued on next page
Adverse Outcomes in Adolescent Pregnancy for adolescents that are preparing for adulthood. Develop-
continued from previous page ing a firm sense of self is the essential factor to a healthy
adolescence and provides opportunities to explore different
expressions of self.
for all adolescent ages, but adolescent mothers ages 16 and Exploring different expressions of self may lead the
17 were more at risk (Ganchimeg et al., 2014). Klein (2005) teenager to participate in risky behaviors. Having unprotect-
reported about 14 percent of adolescent pregnancies end in ed sexual intercourse may be one of these risky behaviors.
miscarriage or stillbirth in the United States. As stillbirths When pregnancy is a result of the adolescents’ experimen-
occur all over the world, this matter should not be taken tation with sex, the adolescent’s life drastically changes.
lightly, especially when pregnancies might be prevented. Becoming pregnant as an adolescent confounds the struggle
to identity oneself as an individual and accomplish many
• Pregnant adolescents have higher risk of aniema, adolescent milestones (Turnage & Pharris, 2013). As, the la-
hypertension, preeclampsia, preterm births, bel of pregnant has its own connotations and interferes with
depression and other health factors (Cinar & the activities that come with the label adolescent/teenager.
Menekse, 2017). Questions and concerns become directed at the develop-
• Teenage pregnancies are often associated with ing fetus, not the developing teenager. While struggling to
neonatal death than stillbirths, due to the fetus answer “I am good at?” “I am happy that I can?” “I want
growth restrictions associated with teenage to become?,” the adolescent must focus on the developing
gestation (Cnattingius & Stephansson, 2002). fetus not personal psychological growth needs. Instead, the
• Stillbirths affect developed and undeveloped adolescent must answer external questions that ask how she’s
countries, as well as every age, ethnicity, and social caring for her pregnant body, how often the fetus moves,
class. etc. These questions may appear to ignore the adolescent’s
• As stillbirths occur all over the world, this matter personal wants and needs, as they focus on what she’s doing
should not be taken lightly, especially when these to impact fetal growth and safety. The adolescent’s body is
pregnancies can be prevented. developing as her upcoming role of mother is also starting
to take shape. This change in role requires the adolescent to
look beyond self-needs.
Psychological
Moving from childhood into adolescence is one of the Where they might need help
most difficult transitions a person makes (Gibson & Gib- Sadness complements every stillbirth and often causes
son, 2016). Along with biological, physical, and emotional grief for the mother, father, family, and all those caring for
changes, for the teenager, parental and societal expecta- the family (Homer, 2016). Unplanned economic issues arise
tions and responsibilities also change. Unlike a child, the due to arrangements for the funeral, purchasing of burial
adolescent is expected to have greater problem-solving and plots, and missed days at school and work may affect the ad-
decision-making skills. Adolescents are expected to use olescent mother, father, and family. Stillbirths care costs were
moral reasoning when making decisions. However, the ado- 10 to 70 percent more than babies born alive (Heazell et al.,
lescent’s problem-solving, decision-making, and moral rea- 2016). Social problems such as decreasing self-confidence
soning skills are continuing to develop. Therefore, parental and departure from social activities are common for the
and societal expectations may be beyond their adolescent’s mother (Cinar & Menekse, 2017). Quality communication,
developmental capacity. Further, the adolescent’s skills are education and training for all healthcare professions working
based on having opportunities to solve their own problems, with families of stillbirths must be improved (Flenady et al.,
make decisions and then experience the positive or negative 2016).
outcome of chosen decisions, and having opportunities to Collaborative approaches from health workers, child-
analyze how their decisions impact others. birth educators, social workers, obstetrician and gynecolo-
As the child progresses through adolescence, they gists is essential to improve adolescent reproductive health
take with them lessons they’ve learned about themselves, (Thonni, Dandavate, Bijjaragi, & Askar, 2017). Formal sex
interactions with others, and their moral compass. Peer and education would be beneficial for all adolescents but due
romantic relationships become the prime interrelationships, to socioeconomic status affecting communities, youth in
while less time is spent with parents (Gibson & Gibson, underclass communities have less resources for educational
2016). Autonomy and independence is a valuable marker

Adverse Outcomes in Adolescent Pregnancy References
continued from previous page Cinar, N. & Menekse, D. (2017). Affects of adolescent pregnancy on health
of baby. Open Journal of Pediatrics & Neonatal Care, 2(1), 20-23.
programs (Kohler, Manhart, & Lafferty, 2008). Therefore, Cnattingius, S. & Stephansson, O. (2002). The epidemiology of stillbirth.
Seminars in Perinatology, 26(1), 25-30.
programs provided in underprivileged communities may
be facilitated with less quality instruction and materials. Flenady, V., Wojcieszek, A.M., Middleton, P., Ellwood, D., Erwich, J.J., Co-
ory, M., . . . Khong, T.Y., (2016). Stillbirths: Recall to action in high-income
Klien (2005) encourages the education of adolescents and countries. Lancet, 387, 691-702. DOI: 10.1016/S0140-6736(15)01020-X
their parents on topics of sexual development, sexuality, Ganchimeg, T., Ota, E., Morisaki, N., Laopaiboon, M., Lumbiganon, P.,
decision-making, values, contraception and proper nutrition. Zhang, J., . . .Yamdamsuren, B., on behalf of the WHO Multicountry Survey
Community efforts must be implemented by creating and on Maternal Newborn Health Research Network. (2014). Pregnancy and
childbirth outcome amount adolescent mothers: World health organization
promoting high-quality programs related to delaying sexual multicountry study. BJOG, 121, (Suppl. 1), 40-48.
activity.
Gibson, A., & Gibson, N. (2016). Human growth and behaviour and devel-
Childbirth educators are advocates for adolescent de- opment: Essential theory and application in social work. Thousand Oaks,
velopment and provide proper care at the time of loss. Using CA: SAGE Publications Inc.
the baby’s name, acknowledging the emotions of the parents, Heazell, A.E., Siassakos, D., Blencowe, H., Burden, C., Bhutta, Z.A., Cac-
and providing valuable specific information is imperative. ciatore, J., . . . Dang, N., (2016). Stillbirths: Economic and psychosocial
consequences. Lancet, 387, 604-616. doi: 10.1016/S0140-6736(15)00836-3
Sensitive and empathic health-care professionals can aid in
beginning the healing process of the mother and family. The Homer, C. S. (2016). Supporting women, families, and care providers after
stillbirths.
importance of proper bereavement care is not only beneficial
for the parents but it also helps the health care providers Lancet, 387, 516-517. doi: 10.1016/S0140-6736(15)01278-7
who deal with their own feelings related to the loss of the Klein, J. D., and the Committee on Adolescence. (2005). Adolescent preg-
baby (Homer, 2016). nancy: Current trends and issues. Pediatrics, 116(1), 281 – 286. doi: 10.1542/
peds.2005-0999
Adolescent pregnancy affects families, health care
professionals, educators, government officials, children and Kohler, P. K., Manhart, L. E., Lafferty, W. E. (2008). Abstinence-only and
comprehensive sex education and the initiation of sexual activity and teen
adolescents (Klein, 2005). Access to properly trained profes- pregnancy. Journal of Adolescent Health, 42, 344-350.
sionals for care before, during and after the birth will benefit Thobbi, V.A., Dandavate, V., Bijjaragi, B., & Askar, N. (2017). An analytic
the mother and the baby. Educating healthcare professionals study on maternal and fetal complication as the pregnancy outcome in teen-
on biological and psychological changes that effect pregnant age pregnancy. Al Ameen Journal of Medical Sciences, 10(1), 39-43.
adolescents can reassure better treatment. Trainings or cer- Turnage, B. F., & Pharris, A. (2013, October). Parenting issues based on age
tification programs for healthcare skilled workers on topics of parents. International Journal of Childbirth Education, 28(47), 72-76.
of empathy and bereavement care for adolescent mothers of World Health Organization. (2012). Preventing early pregnancy and poor
stillborn children should be provided to support the overall reproductive outcomes among adolescents in developing countries: A call
to action. Retrieved fromhttp://apps.who.int/iris/bitstream/10665/70814/1/
care of the adolescent and their families (Homer, 2016). WHO_FWC_MCA_12_03.pdf
Implementing comprehensive programs that educate adoles-
cents on sexual behavior, contraceptives and, reproductive
health may create a positive change in low and middle-
Brelinda Johnson holds a Master of Science in Human Science
income communities. It is pertinent to begin reassessing the
with a concentration in Child Development and Family Studies.
importance of care for our adolescent women.
Ms. Johnson previously worked as a high school Family and
Consumer Science teacher. She currently is the Advising Manager
for the College of Behavioral and Health Sciences at Middle Ten-
nessee State University, as well as, an Adjunct Instructor for the
department of Human Sciences.
Naming the
Stillborn Baby
by Telvis M. Rich, PhD, Anthony Hill, PhD, and Jason A. Billings, MSN
Abstract: This article discusses the value others would say that all life is worthy of acknowledgement
and should bear a name, whether experiencing death at birth
of naming and the impact of spiritual or death during the gestation process.
coping for parents of a stillborn. It exam- According to a study conducted by Cacciatore, Ingela,
ines how naming a stillborn affects the and Froen (2008), mothers experienced lower levels of regret
concerning stillbirth when they held and engaged with their
mother, father, and family unit. Addition- stillborn babies immediately after birth. However, 80% of
ally, this article provides recommenda- mothers who did not hold and engage with their babies
tions for practitioners working with fam- experienced extremely high levels of regret for extended time
after the stillborn birth. Based on these findings, there may
ily members after a stillbirth. be a value in embracing and recognizing the stillborn baby
as member of the family, even with a short period of time
Keywords: stillborn, spiritual coping, and prayer allotted to do so.
In the process of engaging and including the baby in the
The anticipation of a new addition to a family is filled
family unit, if for a short period of time, the mother, father,
with joy, hope, and opportunities. The idea of a bouncing
and other family members are creating memories, moments
baby, regardless of gender, may represent an extension of a
of joy, and a connection that only a baby can provide. While
family, the embracing of newness, and creation of new goals
the experience truly differs from the non-stillborn birth, it is
within the family unit. However, the unexpected nature of a
important to provide the fetus a name.
stillbirth negates the joy, hope, and opportunities. Moreover,
One means of strengthening the connection between
the feelings of loss may overshadow the birth of a stillborn
the mother, father, and the family unit, and the baby is to
baby or the loss of a pregnancy.
choose a name. In many instances a baby’s name is chosen
Although 2.6 million stillbirths occur each year (World
prior to the birth. A host of thoughts, beliefs, family history,
Health Organization, 2017), a majority of the research cen-
desired gender, and life experiences can be foundations for a
ters on medical concerns. There’s minimal research on the
baby’s name. Allowing the same creativity, historical per-
impact of having a stillborn on the mother, father, and the
spectives, and thoughts to guide the naming process of the
family system. Each year in the United States, nearly 24,000
stillborn baby is paramount (Bourne, 1977; Stringham, Riley,
stillbirths occur (MacDorman, & Gregory, 2015). Further,
& Ross, 1982; Surkan, Radestad, Cnattingius, Steineck, &
nearly 98% of all stillbirths occur in low to middle income
Dickman, 2008). Scholars studying the relationship between
countries; however, it is rare that global entities with the
mothers and stillborn babies overwhelmingly recommend
power of influence, including the United Nations, mentions
naming the baby as means of acknowledgement. For some
this important segment of our society (Lawn, Yakoob, Haws,
individuals/parents, naming the stillborn acknowledges the
Soomers, & Darmastadt, 2009). Therefore, it is important
importance of this pregnancy to the family.
to account for the impact of stillbirth deliveries on mothers,
In some instances, the mother, father, and family may
fathers, and families to ensure proper acknowledgment of
choose to name the baby the name already chosen, while
their presence in our society. The process of inclusion centers
others may decide to create a new name. This new name
on assigning a naming the stillborn.
may be based on the bond formed after the stillbirth.
According to BabyCenter.com, a family named their
Names Matter stillborn baby “Poppy.” The family stated the name was
Stillborn babies are often the forgotten ones in society. fitting based on the size of the baby equal to a poppy seed,
Their birth and presence in society is viewed as void; and in jest. The same family shared, “We had picked official
thus, never properly recorded. However, all babies born are names.” However, the family sought to offer a new name for
worthy of respect, honor, and acknowledgement as human
beings. While some may argue that a name is for the living, continued on next page

Naming the Stillborn Baby Conclusion
continued from previous page While the challenges abound in stillbirths, there is value
in honoring and valuing presence of the fetus. There is value
in recording the fetus in history with a name. Names are a
the baby based on physical characteristics. Also, the family means of recognizing the fetus as a part of the family for
stated that they will save the original name for their next years to come and provides a point of reference for families.
baby. There is no one right way of getting through naming The use of spiritual coping is a method of dealing with the
and grieving. experience and building a connection between the family
Regardless of rationale, the idea of assigning or choos- and the fetus.
ing a name for the stillborn has value and tremendous merit.
It provides an opportunity to connect the stillborn to the
family and ensures proper reference to the baby for years to References
come. Neighbors, coworkers, and siblings, can have a name Baby Center. (2018). Miscarriage, stillbirth, & infant loss support [Blog Post].
Retrieved from https://community.babycenter.com/groups/a15155/miscarriage_
to reference during such celebrations or reflective times. To stillbirth_infant_loss_support
this end, names matter.
Bourne, S. (1977). Stillbirth, grief, and medical education. British Medical Journal,
There is value in naming the stillborn beyond ensuring 1(6069), 1157.
representation in society. Assigning a name to the stillborn Cacciatore, J., Radestad, I., & Froen, J. (2008). Effects of contact with stillborn
also provides a means of coping with the baby’s transition, babies on maternal anxiety and depression. Birth, 35(4), 313-320.
and loss of life at such an early age. According to Danielson Danielson, K. (2017). Can naming your baby help cope with miscarriage?
Retrieved from https://www.verywell.com/naming-babies-lost-to-miscarriage-or-
(2017), grief is managed through the naming process. The stillbirth-2371712
idea of assigning a name gives mothers, fathers, and family Guenther, M. (1998). The practice of prayer: The new church’s teaching series. New
members a real experience in their roles. The use of a name York: Cowley Publishers.
allows the family to transition cognitively from the term fetus MacDorman, M. F., & Gregory, E. C. (2015). Fetal and perinatal mortality: United
States, 2013. National vital statistics reports: from the Centers for Disease Control
to baby, and from stillborn to a baby who has a family name. and Prevention, National Center for Health Statistics, National Vital Statistics System,
Words have meaning, and thus, a name provides 64(8), 1-24.
meaning to the presence of the stillborn as a member of the Lawn, J. E., Yakoob, M. Y., Haws, R. A., Soomro, T., Darmstadt, G. L., & Bhutta,
Z. A. (2009). 3.2 million stillbirths: Epidemiology and overview of the evidence
family unit. Danielson (2017) posited, there are no rules, review. BMC pregnancy and childbirth, 9(1), S2.
policies, and guidelines to the grief, and process of naming
Stringham, J. G., Riley, J. H., & Ross, A. (1982). Silent birth: Mourning a stillborn
the stillborn. However, there is value in ensuring the baby is baby. Social Work, 27(4), 322-327.
viewed as more than a dead thing. Thus, a name provides the Surkan, P. J., Radestad, I., Cnattingius, S., Steineck, G., & Dickman, P. W. (2008).
opportunity to cope with the loss. One engaging method of Events after stillbirth in relation to maternal depressive symptoms: A brief report.
Birth, 35(2), 153-157.
managing the loss is through spiritual coping.
World Health Organization. (2015). Maternal, newborn, child and adolescent
health: Adolescent development. Retrieved from http://www.who.int/mater-
nal_child_adolescent/topics/adolescence/dev/en.
Final Words
A few recommendations are essential to naming a
stillborn. First, encourage the mother, father, and family unit Dr. Telvis M. Rich is the Director of the Social Work Depart-
ment at Kean University, He holds earned degrees in Social
to connect with the stillborn. They should be encouraged
Work (BSW, MSW), a doctorate in Biblical Studies (PhD), and
to spend time with the stillborn to embrace the physical a doctorate in higher education with a concentration in Human
presence of the stillborn. Additionally, the parents can ensure Development and Organizational Leadership (EdD). Dr. Rich is
celebrations continue in the name of their baby. They can a licensed social worker with a research focus on spiritual coping,
spend time reflecting on the physical similarities between social work education, and workplace inclusion and engage-
family members and the baby. The parents can be encour- ment.
aged to use their baby’s name in conversations with family,
neighbors, coworkers and friends. Using the name allows the Dr. Anthony Hill is the newly appointed Chair of the Social Work
essence of the baby to live in all of the family’s endeavors. Department at Winthrop University in Rock Hill, SC. He holds
For example, if another child is born to the family, feel com- earned degrees in Social Work (MSW, PhD). He is a licensed
fortable discussing the other sibling, the stillborn baby, as the clinical social worker with a research interest in mental health,
spirituality, and financial social work. Dr. Hill serves on the
brother or sister of the other children. Further, use historical,
national board of the National Association of Social Workers.
faith-based, or other means of gathering as positive methods
of celebrating. For example, celebrating the stillborn may Mr. Jason A. Billings is a nurse anesthetist at New York University
include having a memorial service, involvement in a Walk to Hospital. He holds nursing degrees from Mercer University (BSN)
Remember, an annual birthday party, or an annual lighting and the University of Pittsburgh (MSN), and a degree in Organi-
of a candle to honor the memory of the baby. zational Leadership from Vanderbilt University (BS). His research
interest centers on health disparities of diverse populations.
The Cost of Free
Pregnancy Apps:
Credibility and Privacy Concerns
by Joanna C. Zimmerle, EdD
Abstract: Most expectant mothers use third parties (Kotz, Gunter, Kumar, & Weiner, 2016; Overdi-
jkink et al., 2018; Wottrich, van Reijmersdal, & Smit, 2018).
apps to manage and enhance their preg- Thus, researchers have suggested app usage be guided by
nancy experiences. While many pregnancy expectant mothers’ care providers (Fleming, Vandermause, &
apps are free, users do not realize that Shaw, 2014; Robinson & Jones, 2014).
The smartphone has changed how expectant parents
many of these apps are not regulated by
manage the development of pregnancy from conception to
health professionals, nor do they keep us- birth. Apps claim to allow for greater convenience, connec-
ers’ personal data private. Childbirth edu- tivity, efficiency, and digestion of information, and expectant
cators must take the initiative in discuss- parents are likely to view apps as a means to monitor and
improve their pregnancies, health, and their children’s devel-
ing and evaluating pregnancy apps with opment (Johnson, 2014).
clients. This article presents the unique Many apps for pregnancy are personalized to the expect-
needs and characteristics of millennial ant mother with informational articles and tips being the most
common feature and often also including a push notification
and post-millennial mothers, guidelines
function which sends daily or weekly updates to the user
to determine the credibility and useful- (Thomas & Lupton, 2015). Other useful features of pregnancy
ness of apps, and an evaluation of five apps include searchable lists of harmful foods and medica-
popular pregnancy apps currently avail- tions to avoid, exercises to engage in, symptom monitors, kick
counters, and contraction timers. Thus, apps allow the expect-
able on both Android and Apple devices. ant mother to take care of her body and her baby throughout
pregnancy. Some apps also allow women to share experiences
Keywords: smartphone, applications, apps, pregnancy, childbirth with each other through social outlets such as polls and discus-
educator
sion boards, which can be supportive and comforting to new
mothers especially (Thomas & Lupton, 2015).
All over the world, the average smartphone user spends
about two hours per day using 10 applications (apps) and
operates over 30 apps per month, according to study done Millennial and Post-Millennial Motherhood
from 2015-2017 (App Annie, 2017). These numbers indicate In working with mothers today, childbirth educators
smartphone users prefer to manage and enhance their lives must recognize the unique needs of millennial and post-
through apps, and this assumption extends to expectant par- millennial women, not only their reliance on technology but
ents (Johnson, 2014; Lee & Moon, 2016) as there are about also their strong commitments to educational attainment,
2,000 pregnancy apps available for download on Android work expectations, and family responsibilities (Livingston,
and Apple devices (Haelle, 2018). While most pregnancy 2015). Millennial women, those born from 1981 to 1996
apps are free, users often do not realize the content may not (Dimock, 2018) accounted for 82% of U.S. births in 2016
regulated by health professionals (Lee & Moon, 2016; Say- (Livingston, 2018). They are the most educated generation of
akhot & Carolan-Olah, 2016), nor do they realize they “pay” women ever. In decades past, more highly-educated women
for free apps by sharing personal data, which is often sold to continued on next page

The Cost of Free Pregnancy Apps At this time, there is not a specific regulatory framework
continued from previous page or professional entity to ensure the accuracy of content and
features provided by health-related apps. The US Food and
Drug Administration (FDA)only regulates mobile medi-
chose to remain childless, but in recent years, they have cal apps, and pregnancy apps do not fall into this category.
chosen to start their families later (Livingston, 2015). The While England’s National Health Service (NHS) reviews
millennial mom-to-be uses an app to track her fertility and pregnancy apps using a list of criteria to comply with the
pregnancy development, posts photos of her growing baby Data Protection Act, only two apps were located in the NHS
bump on Instagram, pins nursery ideas on Pinterest, and Apps Library at the time of this publication (Kicks Count
researches baby gear on YouTube (Times, 2017). Millenni- and Create Neonatal). Because there is a lack of regulation
als were born in an era of emerging technology and have among pregnancy apps, health professionals should play a
grown accustomed to an ever-increasing digitally-enhanced prominent role in evaluating and recommending specific
environment. apps to expectant parents (Haelle, 2018).
Post-millennials, also known as the iGeneration and To evaluate an app’s credibility and usefulness, the fol-
Generation Z, born from 1997 onward (Dimock, 2018), are lowing guidelines are recommended:
the first generation to never know life without the Internet, • Verify credible developers. Before downloading, find
and they have only just begun having children. While mil- the developer or seller’s information on the app’s page.
lennials adapted to constant connectivity, entertainment, Determine if they are credible by looking for the presence
and communication as they came into their teenage years, of a medical or other professional review board to ensure
post-millennials were born into such innovations. Post-mil- evidence-based content is delivered through the app.
lennials’ reliance on technology extends to their health and Childbirth educators and other health professionals
wellness practices (Demeritt, 2016), so these so-called digital should call attention to the dangers of misinformation
natives will likely look to technology to manage and enhance from non-professionals and uncertain information sources
their pregnancy experiences, and the use of apps will be (Lee & Moon, 2016).
second-nature to them. • Determine user security and privacy. Before downloading,
follow the link to the privacy policy from the app’s page.
Guidelines for Evaluating Pregnancy Apps Almost all privacy policies include a statement indicating
Millennial and post-millennial women are accustomed great care is taken in regard to keeping user data secure
to leveraging the power of the Internet to enable connectiv- but none guarantee security will not be breached. When
ity and instant access to information, yet in their systematic information is shared online, there is always a possibility
review of literature pertaining to Internet use among women of a breach. Users are encouraged to choose strong
seeking pregnancy-related information, Sayakhot and passwords, store login information in a safe place, and
Carolan-Olah (2016) reported most women did not discuss use secure Internet connections (Olmstead & Smith,
the information they retrieved online with their health pro- 2017). The privacy policy of an app further explains
viders. Thus, health providers may not be aware of patients’ data collection, treatment, and sharing. Considering
potentially mistaken beliefs about pregnancy. Moreover, Lee personal and health-related data are particularly sensitive,
and Moon (2016) found most expectant mothers reported pregnancy apps should take care to ensure security
dissatisfaction in the credibility and content of the pregnancy and privacy of users’ information (Kotz et al., 2016;
apps they chose to use throughout gestation. Overdijkink et al., 2018). Childbirth educators must
Besides concerns over the credibility of content in caution clients to read privacy policies to determine if
pregnancy apps, privacy concerns are an issue. In most cases, they feel the value of apps they use is worth the “price”
app users should assume if they are not paying for an app, of their data being shared with third parties. Some
it is because their personal information, whether aggregated pregnancy apps may keep user data private for a price;
anonymously or not, is being sold to third parties (Wottrich this will be stated in the privacy policy.
et al., 2018). Generally, but not always, the reverse is true: • Look for up-to-date, evidence-based content and
If an app requires payment, then the user is paying for their beneficial features. When was the app last updated? On
information to remain private. Expectant mothers should be Android devices, the date is printed on the app page, but
cautioned about the use of their personal data by apps and on Apple devices the date can be found by going to the
related third parties, so they can determine if the cost is worth app page and accessing version history. Who writes app
the price they pay in exposing sensitive information (Kotz et content? Before downloading the app, it may be possible
al., 2016; Overdijkink et al., 2018; Wottrich et al., 2018). continued on next page
The Cost of Free Pregnancy Apps formed and perhaps made needlessly anxious about preg-
continued from previous page nancy issues (Sayakhot & Carolan-Olah, 2016). Therefore,
childbirth educators should begin the conversation in asking
clients about pregnancy apps they are currently using as well
to visit a website associated with the app to preview as provide recommendations for credible and useful preg-
content. At the very least, read the summary of features nancy apps to meet their clients’ needs. This can be achieved
on the app’s page. While information provided about app in one-on-one conversations with clients and in group
developers may seem credible, the information sources childbirth education classes as well as through discourse in
for app content are often not (Lee & Moon, 2016). the social functions of pregnancy apps. Since communication
Determine if the content is evidence based and either with health professionals on apps remains limited (Lee &
written or reviewed by health professionals. Keep in mind Moon, 2016), childbirth educators could become active on
even if content is reviewed by experts, it is not regulated discussion boards in credible pregnancy apps as an outreach
by a professional health board, so inaccuracies may go opportunity to potential clients.
unchecked. Pregnancy apps vary greatly in regard to credibility,
• Check for functionality. Does the app do what it privacy rights, usefulness, and cost. A review of popular
claims to do? Test the reliability of features such as apps, all available on Android & Apple devices, is presented
kick counts and contraction timers. How easy is it to in Table 1. All of the apps reviewed require users to sign up
navigate? The app should function as described by the using email and password in order to use the apps, but they
developer. Informative and useful functions may help have different policies pertaining to the sharing of user data.
reduce hospital visits and relieve anxiety (Tripp et al., Childbirth educators may share these or other apps with
2014). The social networking function of apps is also expectant mothers to educate them about what to look for
important as it allows inexperienced mothers to glean when evaluating apps for their own use.
from more experienced or knowledgeable users; however,
communication with health professionals on apps remains
limited (Lee & Moon, 2016). If interactions between users
and health professionals such as doulas and midwives Conclusion: Points of Emphasis
were enhanced through apps, then users could receive Pregnancy apps have become a new approach
more useful and credible information quickly, thus to meeting the needs of mothers today. Key points of
improving their pregnancy experience. emphasis for childbirth educators include:
• Peruse reviews and number of downloads. Popular apps • Millennial and post-millennial mothers are likely to
are viewed as more credible (Burgers, Eden, de Jong, use apps to manage and enhance their pregnancy
& Buningh, 2016). A high rating and a large number experiences, especially first-time moms.
of downloads leads users to feel more positively about • Information presented in pregnancy apps may not
an app. However, childbirth educators should caution be credible or useful for mothers-to-be.
clients that user reviews in the app marketplace provide • Free pregnancy apps typically require the
some insights, but they typically come from other users, “payment” of user data. Users must feel the app
who may not be as well-informed as health professionals is worth the service it provides in order to give up
(Stoyanov et al., 2015). Furthermore, since new apps are some of their personal information.
added to the app market daily, it is possible for worthy • Childbirth educators should have conversations
apps to go unnoticed. While reviews and download with expectant mothers about pregnancy apps
numbers should not be the only determinants of to ensure reliable and accurate information is
downloading, they help add to an app’s credibility. presented.
• Childbirth educators can take the lead in educating
expectant mothers on issues such as the credibility
Educating Expectant Mothers about Pregnancy of pregnancy apps by initiating conversations with
Apps clients, offering group classes, and participating in
Childbirth educators may improve clients’ pregnancy pregnancy apps’ discussion boards.
experiences by recommending appropriate pregnancy apps.
Most women perceive online information to be accurate and
useful, but because few women discuss information found on
the Internet with health professionals, they may be misin-

Table 1. Pregnancy Apps
App Name Security
and Developer and Privacy Content, Features, Functionality, and Cost
Glow Nurture User data is collected to inform • Content is derived from consultations with medical advisors
Pregnancy Tracker, Upward Labs Holdings’ practices, whose profiles are listed at https://glowing.com/about
developed by aggregated reports, and ads. User • Some articles are free, but upgrading to a paid plan provides
Upward Labs Holdings, data is not shared with third parties additional readings
Inc. and Glow Inc. except in an aggregate format • Take polls and participate in discussions with other users
combined with other user data. • Daily log to track vitamins, water, sleep, weight, exercise, Kegels,
mood, spotting, cramps, morning sickness, and more
• Medical log to track heart-rate, blood pressure, cervix, and
ultrasound photo
• Cost: Free to download; in-app purchases for premium features
range from $7.99 for monthly access to $47.99 for yearly access
and $59.99 for lifetime access
Ovia Pregnancy Tracker, User data is collected to inform Ovia • Content is researched and written by a team of in-house writers and
developed by Ovia Health practices, aggregated reports, and ads. reviewed by a medical advisory board and Chief Medical Officer
User data may be shared with third • Due date calculator and countdown
parties in an aggregate format for • Customizable health tracker
scientific research. Customer support • Food and medication safety lookup
and digital health coaches may be • Symptom lookup
privy to user data in order to respond • Pregnancy tracker for weight, symptoms, nutrition, vitamins,
to user- initiated inquiries. medications, sleep, mood, and exercise
• Dynamic pregnancy timeline with articles, information, and feedback
• Milestone tracking for belly pictures and ultrasounds
• Ability to add photos, videos, and notes
• Kick counter
• Contraction timer
• Ability to connect with other users anonymously through
community-wide polls
• Ability to connect with health care professionals; some users may
access personalized content with select health insurance plans
• Cost: Free.
Pregnancy Tracker by User data is collected to inform • Informative articles come from BabyCenter Medical Advisory Board
BabyCenter, developed BabyCenter practices, aggregated • Inside the womb childbirth videos
by BabyCenter L.L.C. reports, and ads. User data may be • Interactive fetal development images
shared with third parties after • Due date calculator
obtaining user consent. • Contraction timer
• Kick tracker
• Pregnancy calendar
• Baby bump photo diary
• Cost: Free
Pregnancy + and User data is collected to inform • Content is created by Health and Parenting Ltd. with leading
Pregnancy ++, developed Health and Parenting Limited’s healthcare professionals
by Health and Parenting practices, aggregated reports, and ads. • Daily pregnancy information and tips
and Philips Consumer User data may be shared with third • Pregnancy timeline
Lifestyle parties after obtaining user consent. • Schedule reminders for appointments
• Personal diary
• Pregnancy weight log
• Diet, exercise, and labor information
• Cost: Pregnancy + is free; Pregnancy ++ is $3.99 for premium
features including Kick Counter, Contraction Timer, Birth Plan,
and Hospital Bag Checklist.
What to Expect User data is collected to inform • Content is based on peer-reviewed medical journals and
and Baby Tracker, Everyday Health’s practices, recommendations from the American College of Obstetricians,
developed by Everyday aggregated reports, and ads. User Centers for Disease Control and Prevention, and American
Health, Inc. data will be shared with third Academy of Pediatrics, as well as the What to Expect books
parties; consent may be withdrawn by Heidi Murkoff.
by unsubscribing from third • Many articles, tips, and videos provided daily
party emails. • Information on tests and screenings
• Personalized pregnancy tracker shows baby’s development daily
and weekly
• Best product guides
• Registry checklist
• Photo journal
• Community discussion boards customizable by location, if desired
• Cost: Free
The Cost of Free Pregnancy Apps
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and Uhealth, 6(4), e109. doi:10.2196/mhealth.8834

Permission to Love:
Celebrating Your Rainbow Baby
after a Reproductive Loss
by Turenza Smith, PhD LMSW, Wanda Davidson, PhD, and Karen Roberson, PhD
Abstract: Women and couples who experi- According to the Centers for Disease Control and
Prevention (CDC, 2017), it is estimated that stillbirths affect
ence a reproductive loss may have greater approximately 1% of all pregnancies in the United States.
levels of psychological and emotional While this percentage may be considered relatively low, the
distress that may not go away even after fact remains that reproductive loss is a sad reality for many
a new pregnancy. Undetected or unad- couples and their families. Reproductive loss can have signifi-
cant effects on the couple’s overall well-being. Consequently,
dressed grief related to reproductive loss for many of these couples, any pregnancy following a repro-
produces emotions that can have a nega- ductive loss can be devastating, creating a sense of emotional
tive impact on a new pregnancy, and sub- turmoil often making it very difficult to plan for future preg-
sequent birthing and delivery experiences. nancies. This paper will examine the psychological effects of
pregnancy after a reproductive loss and the type of challenges
This article provides information on re- that may occur with a new pregnancy as well as the possibility
productive loss, and its psychological and of successful childbirth, also known as the rainbow baby: the
emotional effects. Information to help beautiful rainbow that shows up after the storm.
childbirth educators’ aid grieving parents
in the healing process is also provided. Prevalence of Reproductive Loss
Losing a pregnancy can be one of the most catastrophic
Keywords: reproductive loss, miscarriage, stillbirth, rainbow baby experiences that a woman or a couple can experience during
their lifetime. To effectively provide services to this popula-
tion, it is important that one must first establish a general
Introduction understanding about the nature of the problem. Soon after
The trauma of reproductive loss (miscarriage or still- experiencing a reproductive loss, mothers and or couples
birth) does not simply disappear with a new pregnancy and will begin their journey to find answers. While overall infant
a subsequent birth. Although healing may begin before or mortality rates continue to drop nationally over the last
following a successful pregnancy, research notes a correla- few decades, the number of stillbirths remain fairly stable
tion between marked levels of anxiety with subsequent and almost equal to the number of deaths of infants who
pregnancies due to anticipated fears of another unsuccessful die before their first birthday (Harmon, 2011). It is esti-
pregnancy (Brookington, Macdonald, & Wainscott, 2006; mated that one out of 160 pregnancies or approximately
Jaffe & Diamond, 2011). Stillbirth occurs in approximately 26,000 pregnancies result in a stillbirth annually nationwide
1.2% of pregnancies in comparison to the 15%-20% of veri- (Harmon, 2011). Additionally, an estimated 80% of miscar-
fied pregnancies that end in miscarriage (Leon, 2008; Prager, riages occur during the first trimester (Reagan & Rai, 2000).
Dalton, & Allen, 2017). While both miscarriage and stillbirth Actual rates of miscarriage may be higher since many women
describe a pregnancy loss, they differ in according to when have miscarriages very early in their pregnancy and may not
the loss occurs. In the United States, a miscarriage is defined be aware of the pregnancy. While research indicates that
as loss of a baby before the 22nd week of pregnancy (before stillbirth can happen to any race or ethnicity, there may be a
a viable birth can occur, i.e., the ability to survive outside of higher risk factor toward stillbirth for black women (Mukher-
the womb even with intense medical care), whereas a still- jee, Edwards, Baird, Savitz & Hartman, 2013). While there
birth is loss of a baby after 22 weeks of pregnancy, referred are inferred reasons for the higher rate of stillbirths for black
to as early (between 22 to 27 weeks), late (between 28 to 36 women such as socio-economic status, research findings sug-
weeks), or term (between 37 to 40+ weeks) (Anderson, Nils-
son, & Adolfsson, 2012; CDC, 2017). continued on next page
Permission to Love: Celebrating Your Rainbow Baby successive pregnancies and deliveries. Consequently, for a
continued from previous page mother/couple who has endured this type of physical and emo-
tional pain, depression and anxiety are more likely to be present
during their next pregnancy as well as after a successful delivery
gest that there are other immutable characteristics (e.g. AB (Blackmore et al., 2011; O’Leary, Warland, & Parker, 2012).
blood type or previous miscarriage) that may place a black Having a baby after a reproductive loss may bring on
woman at an increased risk for a miscarriage (Harmon, 2011). an array of emotions which are not always positive. Some
Although reproductive loss continues to affect many women, mothers who have weathered the loss and afterward have a
there still appears to be no specific or common cause associ- healthy baby may feel an enormous sense of guilt and self-
ated with stillbirths; that is, most couples’ pregnancies may doubt. Experiencing emotions such as fear and anxiety is not
start out as “normal” or low-risk pregnancies. uncommon with a subsequent pregnancy. Some mothers may
be preoccupied with fear feeling that others will see them as
having forgotten about their previous pregnancy loss or even
What is a Rainbow Baby? that they have replaced the lost child with their rainbow baby
Following a heavy rain, when the clouds break, often- (Jaffe & Diamond, 2011). In turn, the rainbow baby then be-
times peering through emerges a rainbow. The rainbow has comes the penumbra baby, also known as a shadow baby; the
not expunged the storm, it represents the beauty of nature. baby is born in the shadow of the lost infant rather than as
The term rainbow babies refers to a mother experiencing a replacement (Jaffe & Diamond, 2011). These feelings may
pregnancy after a previous reproductive loss. That is, this make it difficult for the mother to properly bond with her
new pregnancy does not erase the tragic loss of a previous newborn. Additionally, being a penumbra baby may also have
pregnancy (Tabo, 2017). A rainbow is metaphorically viewed a subsequent negative psychological impact on the child.
as a symbol of beauty, delight, promise, and optimism, simi- In general, a mother’s overall emotional status can
lar to the mother who experiences a pregnancy after a previ- greatly affect her ability to nurture and bond with her
ous reproductive loss. Women with a history of reproductive baby. Compounded with unresolved grief over her previ-
loss are at greater risk of another pregnancy loss (Bhattacha- ous pregnancy loss or losses, she may become emotionally
rya, Prescott, Black, & Shetty, 2010). However, these women unavailable to connect and nurture the rainbow baby. To
are still capable of successfully conceiving and delivering a some extent, it is normal for women to have a difficult time
healthy baby (Bhattacharya, Prescott, Black, & Shetty, 2010). bonding with their baby during each new pregnancy (Jaffe
When a couple successfully achieves a pregnancy after & Diamond, 2011). The mother may experience feelings of
the experience of a previous reproductive loss, it is assumed guilt from seeing herself as dishonoring her deceased baby,
by others that the new pregnancy will alleviate the emo- or she may fear moving forward and fully embracing the
tional trauma that may be caused by the initial pregnancy newborn because she will be perceived as no longer grieving
loss. When the couple learns of a new pregnancy, the initial for her lost child. This thought is a misnomer in that most
celebration may fade and be replaced with anxiety and trepi- mothers never forget such a devastating loss. Instead, having
dation. Previous studies note that women with a history of a rainbow baby should be viewed as giving that mother or
pregnancy loss have higher rates of anxiety specific to preg- couple the opportunity to experience triumph over a tragedy
nancy compared to women who have no experience with and as an opportunity to allow the healing process to begin.
pregnancy loss (Armstrong & Hutti, 1998; Côté-Arsenault & As childbirth educators, it too becomes important that we
Morrison-Breedy, 2001; O’Leary, Warland, & Parker, 2012). are aware of the psychological impact of reproductive loss so
Pregnancy may be emotionally overwhelming such as the that we may effectively help these women and couples work
mother-to-be or couple becoming consumed with fears of through want can be a challenging time.
losing the pregnancy and that such a loss may be inevitable
(Jaffe & Diamond, 2011). These mothers-to-be/couples may
struggle to enjoy their pregnancy experience. They may fear Implications for child birth educators
becoming too attached and instead brace themselves for The transition to parenthood is an enormous adjust-
another pregnancy loss. Unfortunately, this new or unre- ment for many new parents. Preparation for a new birth
solved layer of grief, regardless of how much time has passed even after a previous successful delivery presents its own set
or intervention has occurred, may interfere with the initial of challenges as well. The added stressors during a subse-
attachment to the growing fetus (citation?). quent pregnancy that stem from a previous reproductive loss
can make what is typically a blissful occasion into an abysmal
experience. This makes it more imperative that childbirth
Psychological Impact of a Rainbow Baby educators equip themselves with continuous knowledge on
Psychological and emotional effects should be considered this issue so that they may effectively identify and treat these
when working with a mother or couple who has had a rainbow postpartum related difficulties.
baby. A common misconception is that mothers or couples
overcome the psychological effects of reproductive loss with continued on next page

Permission to Love: Celebrating Your Rainbow Baby Armstrong, D., & Hutti, M. (1998). Pregnancy after perinatal loss: The relation-
ship between anxiety and prenatal attachment. Journal of Obstetric, Gynecologic,
continued from previous page and Neonatal Nursing, 27(2), 183-189.
Bhattacharya, S., Prescott, G., Black, M., & Shetty, A. (2010). Recurrence risk of
stillbirth in a second pregnancy. British Journal of Obstetrics and Gynecology, 117,
Some mothers or couples may present with unknow- 1243-1247.
ingly unprocessed grief and trauma related to a previous Blackmore, E., Côté-Arsenault, D., Tang, W., Glover, V., Evans, J. Golding, J., &
O’Conner, T. (2011). Previous prenatal loss as a predictor of perinatal depression
pregnancy loss, whereas others may have had informal (e.g. and anxiety. Journal of British Psychology, 19(5), 378-378.
family) or formal (e.g. professional counseling) support sys- Brookington, I., Macdonald, E., & Wainscott, G. (2006). Anxiety, obsessions,
tems to help deal with their previous reproductive loss and and morbid preoccupations in pregnancy and the puerperium. Achieves Women’s
Mental Health, 9(5), 253-263. DOI: 10.1007/s00737-006-0134-z
their current pregnancy. Providing services to these women
Centers for Disease Control and Prevention (CDC). (2017). Facts about stillbirth.
and couples include initially just helping them sort out and Retrieved fromhttps://www.cdc.gov/ncbddd/stillbirth/facts.html
process their feelings, giving them permission to relinquish Côté-Arsenault, D., & Morrison-Breedy, D. (2001). Women’s voices reflect-
being “strong” in “survivor mode” and actually grieving the ing changed expectations for pregnancy after perinatal loss. Journal of Nursing
loss of the previous pregnancy. Scholarship, 33(3), 239-244.
Working with mothers and couples individually or Harmon, K. (2011, .). U.S. stillbirths still prevalent, often unexplained. Scientific
American. Retrieved from http://www.scientificamerican.com
in small groups can create a therapeutic environment that
Jaffe, J., & Diamond, M. (2011). Reproductive trauma: Psychotherapy with
allows the client or couple feelings of vulnerability in a safe infertility and pregnancy loss clients. Washington, DC: American Psychological
environment, and begin to actually process the grief of Association.
loss and attachment to their unborn child or new infant. Leon, I. (2008). Helping families cope with perinatal loss. Global Library of
Additionally, during this time, the childbirth educator can Women’s Medicine, 6(81-82). DOI 10.3843/GLOWM.10418
work with the mother or couple on allowing themselves Mukherjee, S., Edwards, D., Baird, D., Savitz, D., & Hartmann, K. (2013). Risk
of miscarriage among Black and White women in the U.S.: Prospective cohort
“permission” to love both their deceased baby as well as their study. American Journal of Epidemiology, 177(11), 1271-1278.
rainbow baby at the same time. As a childbirth educator, O’Leary, J., Warland, J., & Parker, L. (2012). Childbirth preparation for families
we can help mothers and couples who have experienced pregnant after loss. International Journal of Childbirth Education, 27(2), 44-50.
previous reproductive loss by sharing our own optimism with Prager, S., Dalton, V. K., & Allen, R. H. (2017). Practice bulletin: Clinical
the client that they will have a positive pregnancy, birthing management guidelines for obstetricians-gynecologists. The American College of
Obstetricians and Gynecologists, 150. Retrieved from https://www.acog.org/Clinical-
experience and that it is okay to welcome their rainbow baby Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-
into their world. Teaching mothers and couples that they do Gynecology/Early-Pregnancy-Loss
not have to deny or reject one child for the other, and that Regan L., & Rai, R. (2000). Epidemiology and the medical causes of miscarriage.
Best Practice Research Clinical Obstetrics Gynaecology, 14(5), 839.
they can embrace the future with their rainbow baby while
Seimyr, L., Edhborg, M., Lundh, W., & Sjögren, B. (2004). In the shadow of
still working through their grief. maternal depressed mood: Experiences of parenthood during the first year after
childbirth. Journal of Psychosomatic Obstetrics & Gynecology, 25(1), pp. 23-34.
Conclusion Tabo, C. (2017). What is a rainbow baby? http://www.thebump.com

Warland, J., O’Leary, J., & McClutchen, H. (2011). Born after infant loss: The
Childbirth educators are in a position to reassure moth- experiences of subsequent children. Midwifery, 27, 628-633.
ers and couples that their feelings of loss are normal, and
more important, that they are okay. Supportive services and
Turenza Smith holds a Master of Social Work and a PhD in
education have been found to have a significant, positive
social work. Dr. Smith is an assistant professor and currently
impact on mothers and couples parenting after experiencing holds the position of Interim Chair and MSW Program Director
a reproductive loss (Warland, O’Leary, McCutcheon, & Wil- at Alabama State University. Dr. Smith has over 15 years of social
liamson, 2011). Working with mothers and couples who have work practice experience in the areas of psychiatric social work,
experienced a reproductive loss can be exquisitely painful but medical social work, child welfare, public health, social work
yet gratifying at the same time. In the case of reproductive administration, and 14 years in academia.
loss, the ultimate goal of the childbirth educator is to help
clients integrate their experience of a previous pregnancy loss Wanda Davidson holds a Master of Social Work and a PhD
with their new pregnancy and anticipated successful birth of in social work. Dr. Davidson previously held the position of as-
their rainbow baby. Helping clients unsaddle the emotional sistant professor of social work at Tennessee State University. She
burden that accompanies the experience of a reproductive currently is an adjunct instructor at the University of Alabama
at Tuscaloosa. Dr. Davidson has more than 15 years of practice
loss allows for the mother/couple to develop a sense of self
experience in child welfare.
and develop a strong bond to their rainbow baby.
Karen Roberson holds a Master of Social Work and a PhD in
References social work. She currently serves as a social work lecturer at
Georgia State University in Atlanta, Ga. Dr. Roberson has over 15
Anderson, I., Nilsson, S., & Adolfsson, A. (2012). How women who have experi- years of practice experience working with families and children.
enced one or more miscarriages manage their feelings and emotions when they
become pregnant again: A qualitative interview study. Scandinavian Journal of She also served 11 years as the Field Education Director of Social
Caring Sciences, 26, 262-270. Work at Alabama State University in Montgomery, AL.
Book Review
The Real Guide to Life as a Couple

by Azri, S.
Praeclarus Press, Amarillo, TX.
2018. 204 pp. $17.95 paperback.
reviewed by Jennifer Cooke, MSN APRN FNP-C
The Real Guide to Life as a Couple is a comprehensive ficult, positively and negatively affecting a relationship. The
must-have handbook for anyone in or seeking a lasting rela- author intentionally and genuinely addresses parenting by
tionship. Lasting relationships are difficult in today’s society emphasizing the importance of adult time, communication,
as they are vulnerable to negative influences and extraneous and romance, as these areas are often neglected during the
factors. Finding effective methods of resolution for relation- parenting journey. Roles and responsibilities in a relationship
ship challenges can be cumbersome as well. Couples desire can be a difficult subject to approach for many couples. Tools
practical and realistic approaches to making a relationship are presented in this book to overcome the social stigmas
work. The information presented in this book addresses the associated with gender roles, and further suggests sensible
many stages of relationships from dating to marriage, to approaches to either manage or delegate the day-to-day
the honeymoon, to raising a family, to couples considering operations of the household.
divorce. The author, Dr. Stephanie Azri, a wife and mother, The fourth and last part of the book is an open and
has counseled many couples in her career which presents as a authentic approach to dating, intimacy and sex, and dis-
very credible source of relationship advice. Written based on cusses the very real phenomenon of relationship hardships.
the experiences, education, and training of a clinical social Dating is often a concept thought of during the beginning
worker, this book delivers in the field of relationship, mar- stages of a relationship, and often fades away when two
riage, and family counseling. individuals grow closer and become more comfortable with
Author Dr. Azri discusses several relationship topics one another. However, Dr. Azri proposes that dating is an
including communication, compromise, family planning, important aspect of lasting relationships and that it “keeps
parenting, dating, sexual intimacy, and conflict. Each topic the spark alive.” Dr. Azri further suggests that couples who
is approached with encouragement, honesty, and a bit of continue dating throughout their relationship are happier,
humor. Furthermore, the author’s guidance is simple, yet have improved communication, are better parents, have a
meaningful, and induces self-reflection and self-awareness. better sex life, and have longer relationships. The author
Dr. Azri first explores the basic psychology of personality promotes the importance of intimacy and sex in a healthy
and compatibility emphasizing nature vs. nurture concepts relationship. The book additionally explores the many exter-
and how couples must overcome and accept the inequalities nal influences such as parenting, pregnancy, work, finances,
of their significant other. Throughout the book, the author and conflict that can interfere with the quality of a couple’s
integrates one of the most essential skills for couples to en- sex life. Lastly, the book travels to the not so uncharted
gage in – communication. Communication is broken down waters of relationship woes. The author often reflects on her
into straightforward components to include active listening, professional experiences with counseling to expose some
importance of timing and location, emotion, sharing, and rather common relationship trials such as domestic violence,
advice on how to express wants, needs, and feedback. Dr. trauma, grief, resentment, and infidelity. Several techniques
Azri continues in the book to explore conflict by examin- and strategies are presented in the final chapter of this book
ing the art of compromise and effective negotiation tools by to offer couples a roadmap to navigate even the most dif-
distinguishing aggressive, assertive, and passive approaches. ficult relationship challenges.
The second part of the book highlights relationship This easy to read book offers simple and relevant guid-
goals, dreams, and values, and the importance of moving ance to any couple regardless of where they are in their
and looking forward to a positive future. Dr. Azri further relationship journey. The reader of this book may find the
looks at additional sources of relationship conflict such as thoughts and ideals presented specifically applicable to
extended family and friends and social media. Dealing with family planning and pregnancy and its impact on a relation-
and accepting extended friends and family can bring about ship. The strategies, principles and techniques will help
unwanted and often unavoidable arguments, resentment, prepare couples for the emotional and stressful roller coaster
and rejection. The author suggests straightforward solutions of parenting and further equip them with an artillery of
such as setting boundaries, open communication, and de- solutions when conflict arises. The supportive nature of this
tachment (if necessary). Social media can be both detrimen- book promotes healthy families by offering self-help tips and
tal and fulfilling to relationships. encouraging readers to seek counseling, therapy, mediation,
In the third part of The Real Guide to Life as a Couple, and other sources for additional assistance.
the author investigates family planning, pregnancy, parent-
ing, and responsibilities. Regardless of the situation, planning Kristen Butler, MSN, RN is an Assistant Professor of Nursing at
for and having a baby is life-changing, time-consuming, Austin Peay State University in Clarksville, TN. She has 14 years
stressful, yet rewarding. Dr. Azri presents necessary topics for of experience as a Registered Nurse and has worked in a variety of
couples to discuss when family planning such as pregnancy settings to include Labor/Delivery, Med/Surg, Clinical Education,
decisions, finances, stability, birthing plans, hormones, and Home Health, and Clinic Administration.
intimacy. Transitioning into the role of a parent can be dif-

Book Review
Mayo Clinic Guide to a Healthy

Pregnancy (2nd, ed.).
by Wick, M. J.
Mayo Foundation for Education and Research,
Rochester, MN. 2018. 520 pp. $13.50
reviewed by Kathy Zimmerman, PhD MSN APRN APHN-BC FNP-BC CCH
Mayo Clinic Guide to a Healthy Pregnancy is an excel- bottle feeding, contraception after delivery, and pain relief.
lent resource for individuals, health professionals, and family However others are more complex such as genetic screening,
members alike. This is a must have reference with practical prenatal testing, cesarean birth, vaginal birth after cesarean
information on all stages of pregnancy and childbirth, guides birth. The author presents all these topics in a manner that is
for each step, and issues that may arise along the way. It is informative, but easy to follow along.
written in a comprehensive and clear manner, covering topics The author has included in Part 5, an easy to follow, A
that are compiled from Mayo Clinic experts in obstetrics. These to Z, reference guide for symptoms that may occur during
topics include preparing for pregnancy, specifics on day to day pregnancy. Topics such as morning sickness, acne, fatigue,
choices during pregnancy, information for fathers and partners, heartburn, ligament changes, breast tenderness, varicose
a breakdown of month by month growth and physical changes, veins, gum and oral changes are covered. The author has also
infant care, and potential complications. What is especially included a section on labor, false versus true labor, and an
helpful are how each of these chapters are organized by topics, easy to read chart to follow along.
covered in 30 chapters, which are divided into 6 parts. The final section, Part 6, includes information on
Preparations for and decision making around pregnancy pregnancy and childbirth complications that may occur. The
is covered in Part 1. Having a baby is a wonderful and exciting author goes into topics such as gestational diabetes blood
experience. There are many things parents can do to prepare clots, infection, and postpartum depression. For mothers
for pregnancy that are covered in this introductory section. To with previous health conditions, the author covers issues of
help with the transition, the author discusses topics such as high blood pressure, diabetes, depression, infection, rheuma-
best timing to start a family, choosing a provider, fertility and toid arthritis, thyroid disease, and uterine fibroids.
contraceptive issues, and optimum health and nutrition. While this book is very thorough and written in a bal-
The bulk of the information is laid out under Part 2 and anced format for health professionals and lay individuals,
includes what to expect each month during pregnancy. While there is one area that is missing from the book. There is a
pregnancy can be unexpected, this book lays out exactly what section on healthy sleep habits for baby, with information
changes typically will occur, providing the mother and family on placing baby on his or her back to avoid SIDS, however
practical information. The author describes information on nothing is mentioned about co-bedding. While this is an ac-
changes for mother and baby, including pictures and images to ceptable practice in many cultures, parents need to be aware
further demonstrate growth and development. This provides of any potential safety concerns.
understanding and reassurance for the rapid adjustments There are many strengths of this book, such as the
to pregnancy occurring in the mother’s body, but also helps reader is presented with a clear description of what will
families be much more informed, especially when communi- happen during pregnancy and after delivery. Also included
cating with their health care providers. Not only is the book is what the changes mean, what to do about changes, and
thorough and concise, but the author takes a holistic approach specific information on when something is considered a
to pregnancy, covering not only physical changes, but mental problem. Throughout the whole book, information is orga-
and emotional symptoms that may arise during pregnancy. nized in a balanced and detailed fashion, is very straightfor-
Part 3 includes detailed information on newborn care, ward, and easy to read. Furthermore, the author presents
postpartum care, and transition to home for parents. It the information in a nonjudgmental manner, especially for
covers common issues such as newborn jaundice, infection, difficult topics such as choices for breastfeeding versus bottle
eating, vaccinations, and screenings. In addition, there are feeding, prenatal screening and genetic testing, and circum-
specific discussion of multiple births and premature delivery. cision. I highly recommend this book as it helps parents be
The postpartum chapter covers basic topics that moth- actively involved in their care, well informed, and participate
ers might experience as their body adjusts after delivery: in decision making for their family. The Mayo Clinic Guide
breast care, bowel and urinary issues, uterine and perineal to a Healthy Pregnancy is a valuable and reliable resource for
healing, and bonding with their baby. One very important anyone involved in helping care for growing families.
topic is discussion of dealing with hormonal changes, emo-
tional response, ‘baby blues’, and postpartum depression. Kathy Zimmerman PhD, MSN, APRN, FNP-BC, APHN-BC, CCH
Part 4 includes in depth information to help fami- is an advanced practice holistic nurse practitioner and a Professor
lies make informed decisions on a variety of topics. Some of Nursing at Austin Peay State University in Clarksville TN. She
of these may seem simple choices such as breast versus teaches on-ground and online BSN, RN-BSN, and MSN students.
Book Review
Battling Over Birth: Black Women and

the Maternal Health Care Crisis
by Oparah, J., Arega, H., Hudson, D., Jones, L., and Oseguera, T.
Praeclarus Press, Amarillo, TX.
2017. 204 pp. $19.95 paperback.
reviewed by Tiffany Yoder, MSN FNP-BC RN
Battling Over Birth: Black Women and the Maternal Health One of the major themes of this chapter was pain and com-
Care Crisis is an informative and interesting book that cap- fort measures. Holistic care that includes physical, spiritual,
tures the health disparity of pregnant black women. The book emotional, and cultural components was described and found
opens and concludes with recommendations made by the to be crucial to this population throughout the labor process.
Black Women Birthing Justice (BWBJ) organization based The last section involved what many deem the last
on research conducted in California regarding black women trimester of pregnancy – the first six weeks of postpartum. It
who have given birth. The remainder of the book is organized contained information about recovery, both physically and
much like pregnancy itself, starting with a section on prenatal emotionally. This section also discussed how breastfeeding
care, moving onto the labor and delivery process and ending was perceived by this population. Significant barriers includ-
with information on the first six postpartum weeks. The book ing history, embarrassment, lack of support and lack of edu-
contains evidence-based information and integrates stories cation were identified. These challenges must be considered
from black women whom the BWBJ have interviewed. when discussing breastfeeding with black women.
The chapter on prenatal care discusses barriers to care Battling Over Birth brings to light thoughts and feelings
including lack of health insurance, relationships with provid- from real women who have experienced childbirth. By using
ers, and lack of culturally competent healthcare profession- the participants’ direct quotes, realistic patient perspectives
als. Education regarding cultural competency is important are provided. This information further supports the recom-
to help improve the care of this population. It also discussed mendations made by the BWBJ. Battling Over Birth contains
midwifery prenatal care. Many of the participants who had recommendations for healthcare, black women, policy mak-
the opportunity to utilize a midwife, had a positive experi- ers, pregnant women, community organizations, and friends
ence. Battling Over Birth then reviewed the importance of the and family of pregnant women. Therefore, this book would
relationships between pregnant women and maternal health be appropriate for any of these populations.
care providers. As expected, there were common themes I would recommend Battling Over Birth to all health-
identified in the interviews that were found to influence this care professionals involved in the care of pregnant women.
relationship in a positive or negative manner. The book also It truly captures the patient perspective and gives realistic
compared births at hospitals, birthing centers, and home. recommendations to improve the care of pregnant women,
Ultimately it was concluded that it is important that patients especially those who are prone to health disparities. Battling
receive education regarding available options, allowing for Over Birth provides information that can improve practice
informative decisions of where to deliver to be based on ac- and the birthing process for black women.
curate information and personal preference.
The next section of labor, birthing and delivery also Tiffany Yoder has been practicing as a Family Nurse Practitioner
contained personal experiences of the interviewees. It helped since 2013. She is an adjunct faculty member for George Mason
present the birthing experience from the patient’s perspective. University in Alexandria, Virginia.
New Educational Tools from ICEA

Two new evidence-based Position Papers are available on the on normal maternal and infant physiology, behaviors surrounding
ICEA website — “Safe Infant Sleep” and “Education of Pregnant feeding and sleep, and on naptime and nighttime safety in order to
Families on Harmful Environmental Substances”. Written by con- make informed decisions about where their babies will sleep.
tent experts Linda J. Smith MPH, IBCLC and Diane Wiessinger, Education of Pregnant Families on Harmful Environmen-
MS, IBCLC, and Donna Walls BSN, RN, ICCE, IBCLC, ANLC tal Substances: The International Childbirth Education Associa-
respectively, these two position papers will enhance any birth tion recognizes the need to provide evidence-based education to
professional’s practice. expectant and new parents on strategies to minimize the harmful
ICEA recognizes your need for tools and are committed to effects of harmful environmental chemicals and toxins to the
provide the highest quality tools. developing fetus, the pregnant woman and the family.
Safe Infant Sleep: ICEA recognizes that most breastfeeding
mothers share sleep with their babies at least some of the time. For more information, visit our website at www.icea.org.
All expectant parents should be given evidence-based information

http://facebook.com/ICEApage @ICEA_org
International Childbirth Education Association

110 Horizon Drive, Suite 210, Raleigh, NC 27615
Phone 919-674-4183 Fax 919-459-2075 www.icea.org

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International Journal of

VOLUME 33 NUMBER 4 OCTOBER 2018

We will be providing you with:

• Free Courses for ICEA CEU credits beginning

• “Stem Cell Insider” newsletter featuring current topics

• Educational video and other materials to use

• Referral beneﬁts for educators

• Other exciting beneﬁts!

For more information about this

The World’s First Cord Blood Bank

©2014 Cryo-Cell International. All rights reserved. COT0306_0114A

The official publication of the

Book Review Editor

Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 3

Brief Writer’s Guidelines for the ICEA Journal

4 | International Journal of Childbirth Education | Volume 33 Number 4 October 2018

Follow ICEA Online!

Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 5

Supporting African American Mothers

6 | International Journal of Childbirth Education | Volume 33 Number 4 October 2018

Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 7

8 | International Journal of Childbirth Education | Volume 33 Number 4 October 2018

References Dr. Samantha Francois is an Assistant Professor in Social Work

Call for Papers for the ICEA Journal

Birth Around the World

Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 9

Views of Breast Feeding

continued on next page

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continued on next page

size of a walnut. It can only hold 22-27 ml at a time. By the

Hadi Danawi, PhD MPH is trained in Public Health with a PhD

Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 13

continued on next page

breastfeeding in African-American women is warranted.

Volume 33 Number 4 October 2018 | International Journal of Childbirth Education | 15

VBAC Education Project

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continued on next page

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continued on next page

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Receive Healthy Mom&Baby Magazine for Prenatal Classes

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2018 ICEA Officers & Board of Directors

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aid in adaptation, while supportive interventions maintain

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continued on next page

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