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Doula Programs: Risk Management Strategies

The 16-hour (or so) bare-bones doula training is insufficient to prepare doulas for coping with the needs of high-risk moms. I recommend developing enhanced doula training that covers medical and social risk topics including:

• Signs of premature labor
• Instruction in infection risks and universal precautions
• Substance abuse risks, behaviors, and appropriate doula responses
• Symptoms of postpartum depression (differentiate “baby blues”)
• Domestic violence awareness
• Child abuse and neglect and the doula’s role
• Perinatal grief and loss support
• Client confidentiality and HIPAA laws
• Cultural competency
• Establishing and maintaining professional boundaries
• Personal safety strategies and self-defense for home visitors
• Community resources and accessing help

 

The Doula Programs blog provides a forum for doula program visionaries and implementers to consider common challenges, ask questions, and learn from each other. Patty Brennan is the author of The Doula Business Guide: Creating a Successful MotherBaby Business.

Birth & Parenting News: Anxiety Disorders in Pregnancy and the Postpartum Period

Are you worrying excessively? Do you have horrible thoughts of harm coming to your child? Are you suffering with panic attacks? Do you have flashbacks or nightmares of traumatic events? Are your loved ones concerned about you? If so, you are not alone. Anxiety during pregnancy and in the postpartum period is very common, but is considered a “disorder” when it causes great distress and interferes with one’s ability to function well. Studies have shown that 5-16% of women suffer with anxiety disorders in the perinatal (around the time of childbirth) period (1 p. 8). In addition, many moms and moms-to-be suffer with symptoms of anxiety but do not quite meet the diagnostic criteria for a “disorder” (1, pg. 8). These women, however, would still benefit greatly from treatment. Some of the anxiety disorders that may emerge or worsen during this time in a woman’s life are: Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD), Panic Disorder, and Posttraumatic Stress Disorder. Anxiety can occur by itself or can coexist with other conditions such as depression. Women of every race, income level, culture and age, as well as fathers and adoptive parents, can suffer from perinatal anxiety disorders. If you are suffering, please tell your doctor. You deserve to get the help you need.

Generalized Anxiety Disorder (GAD)
People with GAD worry excessively about everyday things, including the health and safety of their children, even though the chance of something bad happening is very low. Other symptoms include: difficulties with sleep and concentrating, being easily fatigued, irritability, restlessness, and muscle tension.

Obsessive Compulsive Disorder (OCD)
Obsessions are unwanted, disturbing images, thoughts, or impulses that occur over and over and cause feelings of disgust, fear and doubt. In the perinatal period, obsessions usually revolve around harm befalling the baby either accidentally (i.e. being in a car accident while the baby is in the car) or intentionally (i.e. the mother may fear losing control and harming the baby herself).* The crucial feature of these thoughts is that they are very distressing to the mother and contrary to her personality and character (called “ego-dystonic”); she does not want to act on them and tries desperately to avoid them. Although the chance of a parent with OCD acting on a violent obsession is extremely rare, the anxiety and fear caused by morbid obsessive thoughts like these can be paralyzing and dramatically effect a mother’s ability to care for herself and her child. A parent suffering from OCD may fear being left alone with their baby and, in some cases, completely avoid the child. Ninety percent of people with OCD perform compulsions, or behaviors, to neutralize these thoughts; in reality, these compulsions make the OCD worse.

Panic Disorder
Symptoms of a panic attack may include a racing heart, shortness of breath, dizziness, tightness of the chest, chills, hot flashes, claustrophobia, and the fear of going crazy or losing control. These symptoms appear out of the blue—there is no apparent trigger – and are very distressing. Panic Disorder is characterized by two or more panic attacks where at least one of these attacks is “followed by one month (or more) of persistent concern about having another panic attack or worry about the possible implications of having another panic attack” (2, p. 5).

Posttraumatic Stress Disorder (PTSD)
Some of the symptoms of PTSD include intense anxiety, fear, flashbacks of a traumatic event, recurring nightmares, emotional numbness, feelings of detachment from others and avoidance of external situations associated with the trauma (2, p. 17). The symptoms of PTSD can arise after a traumatic childbirth experience. In addition, pelvic exams, delivery, breastfeeding and other events in the perinatal period can trigger memories of past abuse and lead to PTSD.

What should you do if you are suffering from an anxiety disorder?

• Tell your doctor and get a referral to a Health Care Provider who is trained in perinatal mood and anxiety issues.
• Share your feelings with your partner or a trusted family member or friend.
• Learn as much as you can about your condition. See the “Resources” section below.
• Ask your partner, family members, friends or a postpartum doula for help with the baby.
• Take care of yourself. It is not easy with a new baby, but eating well, exercising, and trying to get at least 4-5 hours of uninterrupted sleep every day can help reduce your symptoms.

What puts you at risk for a perinatal anxiety disorder?

• A personal or family history of an anxiety or mood disorder (for example, depression).
• High levels of stress. In addition to the baby, other stressors my include marital problems, a new house, positive or negative changes to one’s finances or job, loss of a loved one, and personal injury or illness.
• Difficult personal life experiences such as: past miscarriages (1 pg. 9), a high-risk pregnancy (1, pg. 9), a traumatic childbirth experience, or a history of abuse (especially sexual abuse).
• Sensitivity to hormonal fluctuations.
• Lack of support.

Are anxiety disorders treatable?

Yes. According to Pamela Wiegart and Kevin Gyoerkoe, authors of The Pregnancy and Postpartum Anxiety Workbook, the two most effective forms of treatment for anxiety are: (1) Cognitive Behavioral Therapy, a form of psychotherapy that focuses on how your thoughts and behavior affect your mood and (2) medication.

What if I don’t have insurance?

Many therapist and psychiatrists offer their services on a sliding scale for those without insurance. The local coordinators through Postpartum Support International (www.postpartum.net) can help you find services within your means.

Local affordable services include:

• University of Michigan Psychological Clinic, www.psychclinic.org, 734-764-3471
• Eastern Michigan University Psychology Clinic, www.emich.edu/psychology/dept-psychologyclinic.html, 734-487-4987
• Women’s Center of Southeastern Michigan, http://www.womenscentersemi.org, 734-973-6779

Is medication safe for the baby during pregnancy and while nursing?

The two main classes of medications used to treat anxiety are anti-depressants and anti-anxiety medication. In some cases, the benefits of medication may outweigh the risks. Talk to your doctor about the pros and cons.

My loved one is suffering with an anxiety disorder. What can I do to help?

• Listen and do not trivialize her feelings.
• Be patient, supportive, and non-judgmental.
• Encourage her to get help.
• Learn about the illness via the resources below.
• Help her with the child, around the house, etc.

Resources

Books

• The Pregnancy and Postpartum Anxiety Workbook: Practical Skills to Help You Overcome Anxiety, Worry, Panic Attacks, Obsessions, and Compulsions by Pamela Wiegartz and Kevin Gyoerkoe.
• Dropping the Baby and Other Scary Thoughts: Breaking the Cycle of Unwanted Thoughts in Motherhood by Karen Kleiman and Amy Wenzel.
• Postpartum Depression for Dummies by Shoshana Bennett.
• The Anxiety and Phobia Workbook by Edmund Bourne.
• Overcoming Postpartum Depression and Anxiety by Linda Sebastian.

Organizations

• Postpartum Support International (PSI), www.postpartum.net, 800-944-4773. PSI is a nonprofit group dedicated to helping those suffering with perinatal mood and anxiety disorders. In addition to a wealth of information on their website, they offer expert advice via the telephone and online support groups.
• The Postpartum Stress Center, www.postpartumstress.com
• Fathers Support, www.postpartumDADS.org
• Postpartum Depression Blog, www.postpartumprogress.typepad.com
• International OCD Foundation, www.ocfoundation.org
• DONA International, www.dona.org
• Association for Behavioral and Cognitive Therapies, www.abct.org. This website allows you to search for Cognitive Behavioral Therapists in the area.

Suicide Prevention
National Suicide Prevention Hotline at 800-273-8255

Local Support Group

• Postpartum Depression Support Group of the Greater Ann Arbor Area, www.ppd-annarbor.org, 734-418-2683
• See also, Center for the Childbearing Year, online Directory, www.center4cby.com.

Therapy/Support Services in Ann Arbor
The University of Michigan Depression Center, www.depressioncenter.org, 734-764-9190. In addition to helping pregnant women and parents who are suffering with anxiety and depression, the Depression Center also counsels women, before they are pregnant, who are at risk for emotional difficulties in the perinatal period.

References

1. Wiegartz, Pamela and Gyoerke, Kevin. The Pregnancy and Postpartum Anxiety Workbook: Practical Skills to Help You Overcome Anxiety, Worry, Panic Attacks, Obsessions, and Compulsions. Oakland, California: New Harbinger Publications, Inc., 2009.
2. Bourne, Edmund. The Anxiety and Phobia Workbook, Third Edition. Oakland, California: New Harbinger Publications, Inc., 2000.

 

Article written by guest blogger, Kristin Burgard, kristinb@talkamerica.net

Birth & Parenting News: Car Seat Safety

AAP Issues New Guidelines for Car Seat Safety

In a new policy published in the April 2011 issue of Pediatrics, the American Academy of Pediatrics has updated their policy on child safety seats to advise that parents leave their toddlers in rear-facing car seats until they are two years old or until they reach the maximum height and weight guidelines for their car seat. While previous AAP policies stated that children were safer in rear-facing car seats, added commentary regarding a child being a minimum of age one year old and 20 pounds left most parents assuming that it was acceptable to change children’s seat position at this time which resulted in toddlers being more likely to be seriously injured in the event of a collision.

Each Wednesday, our Birth & Parenting News blog highlights the latest news items, research results, consumer alerts, and legislative action alerts of interest to expectant and new parents and the professionals who work them.

Doula Programs: Risk Management Strategies

Transportation  of clients by car is another area of risk for doula programs. To limit the risk:

• Develop a policy regarding transportation of clients. All doula programs need to consider, and discuss with their insurance provider, the implications of doulas using their own vehicles (a) to transport clients or (b) to conduct business such as birth doulas providing prenatal or postpartum home visits, or postpartum doulas running errands for the client. One strategy to limit transportation-related risk for postpartum doulas is for the doula to drive the client’s car for errands or transportation to and from doctor visits. In this instance, doulas can be required to check for proof of registration and insurance. For their part, administrators should check the doula’s driving record and require evidence of a current driver’s license with no restrictions. Finally, doulas must ensure that all passengers are properly restrained, according to the law.
• Develop a policy regarding child car safety seats. Restrict doulas from installing child safety seats in clients’ cars OR certify the doulas in child car safety seat installation.

The Doula Programs blog provides a forum for doula program visionaries and implementers to consider common challenges, ask questions, and learn from each other. Patty Brennan is the author of The Doula Business Guide: Creating a Successful MotherBaby Business.

Birth & Parenting News: Consumer Product Safety Commission

This past week the Consumer Product Safety Commission (CPSC) launched its new database designed to provide a place for consumers to submit reports of harm or risks of harm from products, and to search for safety information on products they own or may be considering buying. The creation of www.SaferProducts.gov was mandated by Congress as part of the Consumer Product Safety Improvement Act. The database makes it easier for consumers to report product safety incidents and will help CPSC identify product hazards more quickly.  CPSC will review all online reports and will have five business days to send reports to the manufacturer. At that time, manufacturers will have 10 business days to respond and provide comments and/or claims. After that, if all requirements are met, the report and the manufacturer’s comments will be posted in the database.

Each Wednesday, our Birth & Parenting News blog highlights the latest news items, research results, consumer alerts, and legislative action alerts of interest to expectant and new parents and the professionals who work them.

Doula Programs: Risk Management Strategies

Here are some additional strategies or considerations for doula program administrators to limit liability risks.

• Doulas are not babysitters. Participating postpartum doulas are prohibited from providing services in a home where no other responsible adult is present at the time services are rendered.
• Place restrictions on age. Set a minimum age of 18 years as a requirement for participating doulas. In my experience, there were a few younger women who desperately wanted to become volunteer doulas and did not meet this requirement, but we welcomed them into trainings and managed to get them involved in other ways until they could qualify.
• Do a criminal background check. Call your local police department to see what is involved in doing a criminal background check for all participating doulas and then build that cost into your budget. It is certainly a reasonable precaution to take when sending doulas into people’s homes.

The Doula Programs blog provides a forum for doula program visionaries and implementers to consider common challenges, ask questions, and learn from each other. Patty Brennan is the author of The Doula Business Guide: Creating a Successful MotherBaby Business.

Birth & Parenting News: Summer Safety

The American Academy of Pediatrics (AAP) has published tips for keeping families safe during the summer months. Topics include guidelines for preventing sunburn and preventing heat stress, in addition to tips for pool and boating safety and for open water swimming.

For babies less than six months of age, prevent sunburn by avoiding sun exposure and dressing them in lightweight long pants, long-sleeved shirts and brimmed hats that shade the neck. Parents can apply a minimal amount of sunscreen with at least 15 SPF to small areas such as the infant’s face and the
back of the hands. To prevent heat stress, practices and games played in the heat should be shortened and should include more frequent water/hydration breaks. Families with backyard pools should install a fence at least four feet high around all four sides of the pool. The fence should not have openings or protrusions that a young child could use to get over, under or through.

Each Wednesday, our Birth & Parenting News blog highlights the latest news items, research results, consumer alerts, and legislative action alerts of interest to expectant and new parents and the professionals who work them.

Doula Programs: Risk Management Strategies

Doula program administrators, with or without liability insurance coverage, may want to consider implementing the following risk reduction strategies.

• Incorporate indemnification language into the Articles of Incorporation to protect the Board of Directors.
  
• Create or adopt a formal professional scope of practice document that clearly defines the doula’s role, and limits to her role, and ensure that all participating doulas adhere to it.
• Prohibit labor support at home and require doulas to meet laboring clients at the hospital or birth center. An exception can be made in the case of a planned homebirth, but only if the midwife is present in the home at all times that the doula is present (i.e., program doulas are not to be used as “labor sitters” by the midwives). It is important to note here that professional doulas often do provide very beneficial in-home reassurance and support to mothers in early labor. For the anxious first-time mother who might head off to the hospital in very early labor, only to be sent home again, the doula’s presence can help keep her calm, confident, and rested at home. However, program directors need to consider whether it is reasonable to accept the risk that a doula might be put in the position of catching a baby at home, and I recommend against accepting this risk. Program administrators may want to consider making an exception for the client who needs transportation assistance to the birth center or hospital. Given the high-risk population many doula programs are targeting, removing“access to care” barriers through transportation assistance may advisedly be a retained risk.

The Doula Programs blog provides a forum for doula program visionaries and implementers to consider common challenges, ask questions, and learn from each other. Patty Brennan is the author of The Doula Business Guide: Creating a Successful MotherBaby Business.

Birth & Parenting News: Summer Safety

Children should never be left alone in a car.

As the summer begins, Safe Kids USA is reminding parents and caregivers about the risks of leaving a child alone in a car. Between 1997 and now, 498 children have died as a result of hyperthermia or heat stroke when unattended in vehicles. On average, 38 children die this way every year, with 49 deaths from heat stroke reported in 2010. Already in 2011, four children have died, and summer has not yet started.  It need not be a very hot day or even a sunny day for this to occur, and deaths have occurred with temperatures in the 70s on cloudy days. Vehicle-related hyperthermia deaths generally occur in one of three ways:

• In 51% of the cases, the driver arrives at his destination and is so intent on the next activity that he gets out of the car, locks it up, and heads directly to the office, inside the house or into a store leaving a baby in the back seat behind.
• In 30% of cases, young, unattended children gain access to an unlocked car or trunk for play and are overcome by heat; they are unable to leave the vehicle; many are gone hours before someone checks the vehicle.
• In 18% of cases, the adult intentionally leaves the child alone in the car while they go to work or
  run an errand; they get distracted and may forget the child altogether.

Each Wednesday, our Birth & Parenting News blog highlights the latest news items, research results, consumer alerts, and legislative action alerts of interest to expectant and new parents and the professionals who work them.

Doula Programs: Do You Need Insurance?

I started the Doulas Care community-based volunteer doula program in 1999. This grassroots effort was a slow one-person start up and grew to become a nonprofit program with four staff members, multiple student interns, and approximately eighty active volunteers, serving approximately 250 families per year. The program was up and running and served eight women in the first two years. As I was getting the 501(c)(3) nonprofit status secured and recruiting our initial board of directors, expansion of the doula program was put on the back burner while board members considered the issue of liability exposure.

The ensuing search for suitable insurance for our doula program proved elusive. It wasn’t merely a matter of cost, or that we couldn’t afford it. It simply didn’t exist! One group did offer insurance to individual, certified doulas. This option was not consistent with our program needs. Our volunteer base was developed on the concept that newly trained doulas seeking to fulfill certification requirements would be eager to provide support to families who otherwise could not afford to pay for doula services. The program was designed, from its inception, to serve both the doulas and the families and was framed, in part, as career development for low-income women. We could not require certification as a prerequisite for insurance when the essence of what we were doing was creating a pathway to professional certification. After exhausting available options, we opted to forego “errors and omissions” insurance and focused instead on risk-reduction strategies. More next week …

The Doula Programs blog provides a forum for doula program visionaries and implementers to consider common challenges, ask questions, and learn from each other. Patty Brennan is the author of The Doula Business Guide: Creating a Successful MotherBaby Business.

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