Insurance reimbursement for childbirth education

With third-party reimbursement for childbirth education, one of the biggest barriers that exists in policy discussions is that not all stakeholders, including the educators themselves, understand what the current system is. The system is intricate and always changing, but on the surface, it boils down to three things: What is covered, who can render services, and how much are they paid.

Part of our existing insurance system is controlled by the federal government. A good example of this would be how the Affordable Care Act mandated that breast pumps and breast-feeding support was a covered benefit. Otherwise, most healthcare regulation decisions are made on the state level. This is where childbirth education falls right now: the coverage varies from state to state, and can change as new statutes are passed.

In Minnesota, childbirth education is considered a mandatory covered service by the Department of Human Services for residents who have coverage through Medical Assistance programs. Strangely, newborn care education is not considered essential, so as a standalone class it is not a covered service, but birth classes that include this information can be billed to insurance. Residents who are on Medical Assistance are either enrolled directly through the state’s Medical Assistance or MinnesotaCare coverage. Some of the plans are managed though the state itself, but most are have PMAPs (Minnesota Prepaid Medical Assistance Project plans) that are administered through Managed Care Organizations.

So then, in Minnesota, not all employer-based insurance plans or plans purchased by individuals have the same coverage parameters. So while some do reimburse providers for in-person group classes, other health plans consider access to online information or sending pregnant patients a book as an acceptable way to deliver childbirth “education”.

Most state’s health departments then decide who can provide services– what kind of credentials they need to have and if they have to bill under a supervising provider. Again, in Minnesota, I have to operate under a “supervising provider” as an LCCE. It usually doesn’t take much digging, but each state is different, so what applies here may be different, but states are currently in charge of the “Who.”

As for the how much…that gets really complicated. Reimbursement rates for Medical Assistance services are set at the state level, and many of the rates haven’t been adjusted for inflation in 10-20 years. Employer-based plans set their own reimbursement rates, and those rates can vary even within the same insurer as determined by what the employer has negotiated. For example, you could have Blue Cross Blue Shield insurance and the contracts would say that if the provider bills the insurer for a procedure at $150 and the contractual obligation would be to only reimburse $110 of that money; Somebody else with a Blue Cross Blue Shield insurance plan with a different employer might have that same service reimbursed at $97 when it was billed for $150. And then you have some other insurers who would take that $150 that was billed and only reimburse $35.

Not just anybody can bill insurance though, even if you are providing care within the state’s parameters. If you are not contracted with an organization as a provider, then anything billed would be out of network and would be subject to reimbursement rates set by the plan for out of network reimbursement. This really only applies to employer-based or individual plans; I’ve yet to find a state that allows billing reimbursement for out of network providers.

Hopefully this brief explanation helps you understand the very basics of third-party reimbursement for childbirth education as it exists today. If childbirth education is covered depends on which state you are in. Who can provide that childbirth education in a way that’s billable is also up to each state. The how much is something spelled out by each plan coverage. It’s not an ideal situation in the slightest; however, anyone who  wants to fix something first needs to understand how it works, otherwise it’s very likely any attempts to fix it will break it.

I am hosting a series of workshops, first for doulas locally, later for birth professionals via webinar. If you’d like to notified of upcoming dates, sign up for the professional development newsletter below.

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Parent Shame and Car Seats

It’s National Child Passenger Safety Week!

Last week, in a fit of irritation, I wrote a little tweetstorm on how irritated I am with the notion of “parent shaming”.

And I really meant all of it. Yesterday, I got called to help a very well-meaning family who knew something was up with their car seat and wanted it to be installed correctly. Once I got there, though, I looked at the seat and realized it was not only an expired seat, but a recalled seat. But it’s so common to buy used car seats, many parents don’t even question it.  Or what about this viral video from last month? Here. Here’s a screenshot:

bad-car-seat

I haven’t watched the full video, nor do I care to. Why? Because every time I look at this I get sick to my stomach. Not only is this an infant seat that’s ONLY supposed to go backwards, but I’m pretty certain it’s close to 10 years old, the straps aren’t even on one of the little boy’s shoulders, and my WORD…what is going on with the seatbelt? It’s over the arm, it’s…it’s just a mess. There is almost no likelihood that this poor sweet little boy would escape a crash without major injuries or worse.

Or what about this video?

bad-car-seat-2

The straps are too loose, they are falling off, and she’s too young to be facing forward. Truthfully, 99.9% of the videos and pictures parents post of their kids in car seats have at least one horrible, obvious flaw. Nothing else you buy is THIS critical to keeping your child alive. Nothing. And yes, for a variety of reasons, car seats are just really hard to use correctly. It also doesn’t help when parents so commonly are exposed to other parents making unsafe choices, such as:

  • Buying used car seats
  • Choosing to use expired car seats
  • Placing car seats on top of carts, tables, chairs….
  • Keeping babies in a car seat when they aren’t in a car
  • Turning a baby to be forward facing when they turn 1
  • Letting a baby nap in a car seat outside of the car
  • Not keeping a baby buckled in when the car seat is being used in a stroller
  • Using coats under car seat straps

Parents don’t want to hear that they’ve been doing something that puts their children in danger. I would never DREAM of going up to a parent when I see any of the above things. No matter how it’s phrased, it’s never taken well. Ever. So we try to educate broadly, and I go along and say a silent prayer every time I see a baby sleeping in a car seat, head falling forward, or a $450 car seat precariously perched on top of a shopping cart.

If you’ve been committing any of these car seat cardinal sins, today should be the day you stop. Car crashes are on the rise as more and more people are driving while distracted. Nothing is more important than keeping your children safe. There’s always a solution to every car seat problem. Have a trained professional, a Child Passenger Safety Technician (like me!), help you out if you need it. But really, don’t brush it off. Please.

Warmly,

Veronica

The Allina Strike: Another Mom’s Warning

Veronica: I’ve been continuing to collect stories from moms who gave birth during the June strike at Allina hospitals. Another strike started today at 7am. Staffing levels are lower than in the last strike. Not all birth workers share this sentiment, but going to a hospital during a strike is risky. Talk to your doctor or midwife, with the caveat that many of them didn’t take the last strike seriously. Contact me if you have questions, concerns, or stories you’d like for me to share here.

Below, a story from Jessica, shared in it’s entirety with permission.

Upon walking through the doors of Abbotts Mother Baby Center in Minneapolis on June 19th, a cold and erry feeling came over me. The feeling of walking through an abandoned building, the uniforms were different; almost like guards in a prison. I never saw a smile– only the faces of replacements looking confused, frazzled and pressured. Wasn’t this suppose to be the happiest and most friendly place welcoming new life? Not here.
After patiently waiting for my name to be called, bags in tow and my husband by my side, we were lead down an empty hall into a room and simpy left alone. My contractions were fierce, I was hurting with tears of pain, not joy. And finally we were joined by a women who couldn’t explain why we couldn’t hear my son’s heartbeat until she was assisted by another 2 women. He was of course healthy as could be! It was then confirmed, we were having a baby on Fathers Day! My husband was thrilled to have a healthy son born on his day!

But we couldn’t get over the fact of how inadequate the replacements were. Once we arrived in our 2nd room, it was time to be hooked up to countless machines and ivs. It took my nurse and 2 other women with 4 times and blood everywhere to correctly place my IV; it was a bloody mess. My husband had to direct the many women who tried to help but thankfully my husband knew where the blankets were, and many other things in the room were that were needed to comfort his wife and mother of his children.

It was only 7 hours after being admitted that I heard the sweet cry of my baby boy, never was he placed on my chest, never was he cleaned from the mucus covering his sweet glowing skin. I still kissed him and the mess didn’t matter. I was never guided to breast feed, I was never escorted to the bathroom to clean myself, luckily my husband had been through this and helped me. My epidural was not effective , so I was able to care for myself immediately. I don’t think we saw a nurse for almost 2.5 hours after delivery, we enjoyed the time alone but knew I was missing something.

As the nurses prepared to do the newborn screening, my son began to choke and I had to direct the nurse to please help my baby breathe, and they immediately started to do the newborn screening- it took almost a half an hour and 3 attempts to get him to bleed enough to complete the pallet. As we sat there helpless listening to the screams of my baby, I was broken inside. Needless to say, we very adamantly pushed to go home after 24 hours; we knew we could care for our baby alone in the comforts of our home as a family of 5. Since then, we have watched our son grow into a beautiful healthy baby.

 

Allina’s Replacement Nurses and Patient Neglect: Another mom’s story

Nurses Union

After I shared Lisa’s story Monday and Tuesday, another mom contacted me who had given birth during the strike. This time, the circumstances were a little different; Ashley had a planned cesarean. She was still suffered from incompetent care, and she wasn’t given food, water, or medication for long stretches of time for the duration of her 4 night stay.

When you read her story, please keep the following things in mind:

A few things are starting to become clear: While staffing during the strike might have been adequate in other departments and other hospitals, the night nurses at Abbott from 7PM to 7AM did not take care of the patients. Food, medication, and water were withheld from at least 2 moms for very long stretches of time. Only very vocal family members saved these moms from total neglect.

Penny Wheeler is a former OBGYN. Again, she claims up and down that the replacement nurses took good care of patients, but no decent OBGYN would find this to be safe care. How can anyone justify the care that these moms received? I’ve spent the last decade of my life advocating for good maternity care, and nothing has angered me as much as hearing this care happened within my own city.

As before, if you have questions about your care options after Monday, contact me. If you have a story about your care that you want heard, contact me. My phone number is 651-200-3343 and I can be reached at veronica@babylovemn.com

Ashley’s story is below. It was edited for clarity, and I have been given explicit permission to post it.

I had a scheduled C-section on June 22nd, 2016 due to my son being breech. When I arrived at Abbott, I noticed that there were hundreds of people walking around protesting only to learn these were the nurses I had gotten to know over my entire pregnancy journey.

I was scheduled for surgery at 12pm, and up until I was brought into the OR everything had been going great. Then things went downhill.  The nurse who was assisting with the surgery was holding the clamp opening up my incision pulled so hard that she fell backwards off of the stool she was standing on. This ripped my incision open larger than needed and made for an extremely crooked scar. I was not allowed to hold my son for a good 45 minutes once he was taken out, but not because there was any complication. I begged and pleaded to get some skin to skin contact with him as I knew it is very important in the breastfeeding process. I was told skin to skin was unsanitary for me while being in the operating room.

Once I had been all stitched up, I was put into recovery while they made sure my uterus was shrinking and I wasn’t going to lose too much blood. At this time, they noticed my son was grunting and took him to special care to be evaluated for fluid in his lungs.

Two hours later I was brought up to my postpartum room and was introduced to my first nurse. She was amazing, and I would take her again any day. She promptly gave my meds and kept my water full, but she wouldn’t allow me to eat anything. She informed me about everything going on and kept me cleaned up well. I asked when I could go see my son and she said as soon as my catheter was removed. I was told the next nurse would do it immediately after shift change at 7pm– at that time, it was around 6pm.

When 7pm came, I paged for my nurse. I was in excruciating pain and I was bleeding so much that I had bled through the pad I had on and the blankets on my bed had become saturated. I paged my nurse at least 3 times, but nobody ever answered my calls. My dad came to visit. He found me sitting in a bloody mess,  bawling my eyes out. I was desperate for help that I was not receiving. My dad was outraged and tracked down any nurse he could to help me. At 9PM I was finally given my pain medication. I asked again about having them take out my catheter; by 10pm it was finally removed and I could go see my son.

While my son was being kept in the nursery, the staff had done an x-ray and his lungs looked clear. I had received a call from special care at 8pm saying my son had still not been fed and he was delivered at 1:18pm. He hadn’t been fed anything at all since he was born, and his blood sugar dropped to 35. I asked to breastfeed him, but I was told that was not allowed. I was told I could pump to feed him, but because I’d had a cesarean, I wasn’t allowed to breastfeed him. I was heartbroken. The only options I was given for feeding him was donor milk or formula.

I got to him around 10pm and stayed until 11pm. I went up to my room to rest and let my body recover. I was told 3am was his next feeding time, and I was welcome to come bottle feed him–but I still wasn’t allowed to breastfeed. At 3am when I came down my son had an IV in his hand. Neither his dad nor I ever gave informed consent for this to be placed. Then the nurses told me they had to give him sugar water because his blood sugar was still too low. They didn’t mention to me that his blood sugar was low when I had been there 4 hours prior. Then they also informed me they started a preventative antibiotic while I was away to stop his grunting, and he was going to have to stay in special care for at least another 48 hours. I cried as they told me if he pulls out this IV would need to put it in his head. I felt scared, sad and angry that not only they had done these things to my baby without me knowledge or consent, but that they could threaten more procedures. Infection had been ruled out prior to this IV, so I knew my son was fine without then.

On day 2 of my stay again my morning nurse did a fantastic job. My night nurse completely neglected me; she never filled my water or told me where I could go to fill it. She didn’t bring me my pain meds until 6am– right before the end of her shift. This occurred all 4 nights I was there. By 7am I was begging my good nurse to help me get the pain managed again. And it would continue to relapse at shift change every time.

My last night I was finally able to have my son with me in my room. The morning nurse was there to help me breastfeed him finally for the first time. He latched great and stayed on 30 minutes each side she was so supportive of me the entire time wanting to breastfeed my son. She promised the second I got him I could feed him myself and kept her promise.

A week and a half after I was discharged, I developed a staph infection in my incision. Originally, they told me I was mistaken. I insisted on a culture. They finally did it and sent me home that I would get results later. Next day they called me and told me I had a serious staph infection;  they sent antibiotics to my pharmacy that I needed to get immediately. If nothing got better in 3 days I was to go to urgent care. Thankfully, the infection cleared.

I encourage anyone due during strike to do your research before going through with your delivery. I also want to apologize to any other mothers who had a terrible experience during their deliveries. The delivery of my son turned into the biggest nightmare I could have never imagined. I expected it to all be so happy and didn’t imagine I’d be so depressed throughout my hospital stay. Thankfully my son and I are both extremely happy and healthy since being home.

More Allina Strike Concerns

Monday’s post on the Allina strike has hit 4,000 views—in 48 hours. People are reading it, people are sharing it, which is great, but you guys? I’m not being hyperbolic when I say this– it’s going to be worse than I thought. I met Lisa in person, who was super brave to share her story, today. She’s been amazed at the response, that anyone cares what her experience was. And yes, she gave me permission to share all of this. But the more I learned as we spoke, the more disgusted I am with Allina’s CEO and administration to allow another strike to go on.

Once the strike started and after her Cesarean, not only was Lisa (and at least one other mom) left in recovery for HOURS– at least 2, maybe 3—without a single staff person checking in (AFTER SURGERY), once Lisa and her baby were finally taken to the postpartum wing, the room she was in didn’t have any diapers, and all attempts that Lisa and her husband made to get a nurse to help with anything were refused. They would not bring medication. They never asked what she was doing to feed her baby.  She was at least experienced enough with breastfeeding that she knew what she was doing, but if she needed formula, I don’t know if anyone would have been there to bring her any. The replacement overnight nurses did not check to see if her son was being fed. LISA WAS NEVER FED, save for some crackers her husband managed to find, until she reached out the next morning and after her midwife raised hell to get Lisa any care in any way, shape, or form.

So, let’s get this straight: I have seen union propaganda. I have been very diligent in getting as much detail as I can on all sides of this issue. I am not sharing this as union propaganda. I am sharing this because I am TERRIFIED to learn what hundreds of other moms and babies were subjected to during the strike. I’m sure Lisa’s experience was what everyone else had to go through. In 4,000 page views, nobody has told me anything was inaccurate. I’ve had people reach out and confirm that Lisa’s experience was a fair representation of what it was like and will be like during another nurse strike.

Someone needs to tell me why this is ok: A mom who gave birth at Abbot Northwestern during the June strike gave birth via major abdominal surgery, was left for hours immediately following with no care, was brought into an actual room with no diapers, nobody checked her vitals or her son’s vitals after major surgery. Allina’s replacement nurses did not care if she was fed. They did not care if the baby was fed. It wasn’t until an outside party stepped in that Lisa and her son had any care whatsoever. Most people who give birth at Allina don’t have the access to their OBs that would have allowed them to have an advocate that would have raised hell and gotten them care.

I’m sharing this because somehow, someone needs to speak up. This isn’t about not having a birth go a specific way. This is about a hospital system refusing to make sure that their patients are cared for in the slightest. Allina’s powers that be need to tell me why they are OK with letting their patients get not just sub-standard care, but likely absolutely no care, no food, and without their basic medical needs met. Allina’s CEO kept saying the staffing levels were adequate. She was either misinformed or outright lying.

As women, we are often told that as long as are babies are here and alive, we should shut up and be thankful. I’m here and I’m going to rock the boat for Lisa and for that other mom in the recovery room with her and for the hundreds of moms and babies that I have no doubt weren’t provided basic care. I have a blog. I have this platform. I can share Lisa’s story and hope it gives others the courage to speak up. Otherwise, I’m mad, I’m sad, and I’m scared.

If you need or want to reach me, the office phone is 651-200-3343 and I can be contacted by email at veronica@babylovemn.com

The Allina strike will put birthing families in grave danger

I have been blogging for almost exactly 5 years in this space, and maternity care outcomes and transparency hold a special place in my heart. I don’t know if anyone gets as excited as I do when new info comes out. After a lot of thought over the weekend, I am posting this. Buckle in.

The Allina nurse strike saga continues. In June, the nurses went on a 7 day strike. Back then, I had concerns about the safety of giving birth with replacement nurses. Now that a strike date of September 5th at 7am has been set, and after careful consideration, I can’t say this without enough emphasis: DO NOT HAVE YOUR BABY AT AN ALLINA HOSPITAL DURING THE STRIKE. CHANGE PROVIDERS AND/OR PLACE OF BIRTH NOW!!!!!

I may not make any friends with the system’s physicians or administration, but the evidence is more than circumstantial to back up my warnings. While I understand the political forces at stake with public opinion of unions in general, staffing ratios and staff safety are always issues at Allina. And in fact, the National Labor Relations Board ruled that the Minnesota Nurses Association’s complaints about unfair labor practices were with merit.

Historically, Allina’s hospitals have had some of the highest cesarean rates in the Twin Cities Metro Area. Recently, a change was made and births are no longer done at Unity Hospital, but in 2014, the c-section rate for Abbott Northwestern was 30.2%, it was 28.3% at Mercy Hospital, and 30.4% at United Hospital; all of these are above the state average of 26.9%. In 2014, 11,207 births occurred at Abbott, United, Mercy, and Unity–an average of 217 per week. With such high volume, Staffing problems will hit maternity services hard. Lactation services are sure to be hit hard as well, as union IBCLC RNs will also be on strike, so moms will have a very hard time getting appropriate breastfeeding help.

The last strike, which was limited to 7 days, cost Allina $20 million. On social media pages, nurses from other parts of the country are posting information they’ve received from staffing agencies recruiting workers to fill in for the striking nurses. Replacement nurses are being offered $6,900 per week and are not required to be licensed to practice in Minnesota. Additionally, because of such a high cost to replace nurses and because of the very large number of striking nurses (4,800), there is absolutely no way that Allina’s hospitals will have adequate staffing– in fact, only 1,400 nurses were brought in during the strike in June. A hospital system with a whopping 71% reduction in nursing staff is without a doubt incapable of providing safe care. While this creates a dangerous situation for all of the hospital units, because safe staffing ratios are so high– 1:1 nurse to patient ratios during labor and birth, and 1:3 nurse to patient ratios postpartum, there’s no doubt that having less than 1/3 the normal number of nurses will put mothers and babies in grave danger.

Very specifically, replacement nurses can’t provide appropriate care in the “Mother Baby Centers” of Allina hospital because:

  • Nurses will be much slower at charting in a system that they aren’t familiar with. Even if the nurses are familiar with EPIC, the most common EHR in our area, each organization has their own unique configuration. In births, charting is extensive– many, many things need to be documented in real time, taking away the nurses’ ability to provide patient care.
  • Maternity Care practices in our area are very different from those in other parts of the country. We tend to have better outcomes than in other parts of the US–meaning the replacement nurses will probably be used to maternity care practices that are considered outdated or unsafe. So, for instance, while Allina hospitals have Nitrous Oxide as an analgesic option for birth, it’s still rarely used outside of our metro area. Because the replacement nurses won’t have the training needed to provide Nitrous, parents will very likely find that options they expected to be available aren’t.
  • Patients with high-risk pregnancies are very likely to have replacement nurses that lack the higher training needed to keep medically fragile conditions under control.
  • Staff morale in hospitals during strikes always takes a major hit, distracting from the real need-providing patient care.
  • Even if the nurses were perfectly trained to work as Labor and delivery and postpartum nurses, even if they knew exactly how to use the Electronic Health Record System– In no way, shape, or form will there be nearly enough nurses to provide safe care.

When I previously wrote about my concerns, I wasn’t sure what birthing mothers would end up experiencing. However, last week, I made contact with one mother who gave me permission to share her story. Her name is Lisa, and her story follows:

I planned birth at Abbott due to VBAC.  I was aware of the strike and very concerned that I would go into labor during that time, but I was planning to birth with my midwife and with my doula and I was reassured that I have nothing to worry about. In fact I’m going to say what no one said to me when I was worried about the strike: RUN! I know everyone might not agree with that, but I speak from personal experience. I moved back from Alabama so that I could receive the care we’re accustomed to here in MN, and I still ended up with nurses from states where I would never give birth.  My due date was 6/19.  Same day as the strike. Water broke 6/16.  Labor never started so I went in 6/18 at 4am for Pitocin.

24 hours later [early in the morning of June 19th, the day of the strike], I’m laboring hard on Pitocin. I have a wonderful supportive Allina nurse. The best nurse I’ve ever had, but there’s a tension in the room so thick that you could cut it with a knife. We all know she has to go home at 7am, when her shift ends and the strike begins. In just 3 more hours. It was awkward. There was an elephant in the room. I considered asking her if she would stay with me but that seemed awkward and inappropriate.

So 7am came and she said “I’m sorry, I have to go now. ”

After that I had a stream of nurses. “I’m you nurse now. ..no I’m your nurse now. No I’m your nurse again.” I was in the shower and they kept interrupting me. I had a doula and a very supportive husband. I just wanted some privacy at this point, I wasn’t asking for extra support.

At another point I had nurses just standing around me with their arms crossed. Just watching me. Like they had never seen a woman labor before. Like I was a fucking zoo animal!!!!

At another point, one nurse was giving another nurse a tour of the room. “Here’s the warming station…” and then the two of them stand in front of the computer and discuss how the medical system works. I just hear whispering and taping on the keyboard. I’m butt ass naked, standing at the foot of my bed, huffing nitrous every 2 minutes for 90 seconds. I can barely speak. I’ve been at this for 30 hours. I wave my hand at them “They need to go. They’re distracting me.” I’m begging/irritated. My midwife then shooed them away.

This still pisses me off. I shouldn’t have to protect my own birth space like this. My midwife was there and my doula and my husband. But no one said anything. I had to ask them to leave.

It’s no surprise that soon after this I lost my ability to handle my Pitocin induced contractions. I asked for an epidural. Then my contractions went to 18 minutes apart and I ended up with a cesarean, again. Cesarean was 6/19 at 6pm.

They surgery itself had some parts that were less than what I would expect from Abbott and my post surgery care was grossly negligent.

I actually had to page my midwife on call during the overnight hours.  When the baby was born (unplanned cesarean ) we were told he could stay with us but would need to have his temp closely monitored due to prolonged rupture of membranes.  But they never checked his temperature the entire night.  Nor did they check my bleeding on the night shift.  It literally felt like everyone had left the hospital,  apocalypse. When she [the midwife] called me back I told her that I wanted to transfer with my baby to another hospital because no one was taking care of us. I paged her just after 7 am.  I knew I was supposed to have a new nurse and still no one had come to check on me or the baby.   I told her I was scared because we weren’t being monitored  and wanted us to be transferred to another hospital,  by ambulance if necessary.  She said “hold tight,  I’ll see what I can do and I’ll call you back.”

It’s my belief that when she hung up with me she called up there to the hospital and raised hell, because within a few minutes I has my day nurse and the charge nurse there.  They helped me clean up the blood that was dried from my waist down, changed my sheets and got me some food.  And filled out the white board.  There was definitely a turnaround of my care at that point.  My midwife called me back about 8am on June 20 and asked if I still wanted a transfer,  and  told me she could make it happen.  At that point I said we had a new nurse and I  felt safe again.  I told her we would stay.

Hiring a doula won’t be enough. Every single birthing family  with babies due in the next month needs to change plans on where to give birth, which likely will result in also changing providers, and they need to do it NOW. Changing is easy– I’ve outlined the process before. If you’re late in the game, you may need to change to a Family Med Provider who does OB care or an OB group. If you need help sorting your options, I’m happy to help. Call or email me– 651-200-3343 or veronica@babylovemn.com.

And Allina union nurses? I have your back. Allina’s C-suite? You are putting people at risk with your ongoing actions, and you need to be ashamed of yourselves.

Veronica

The Baby-Friendly Hospital initiative is perfectly safe

Last week, the American Academy of Pediatrics published a clinical report that took a look at safety practices of bed-sharing and rooming in. This wasn’t a policy paper, but instead more of a “this is what a group of Pediatricians think” sort of thing. Headlines have been all over the map on this one, though. Some wise nurse and professionals looked at the publication and took away the advice that hospitals need to have good staffing levels and well-trained competent nurses to make sure patients are safe. Sorry to sound flip, but DUH. I guess there are plenty of places that put profits before patient safety (ahem), but in 10 years of attending births, I’ve only seen poor care of a baby after birth in 2-3 cases.

And then, Elisa Strauss of Slate has her opinion: The paper proves that a Baby-Friendly designation makes a hospital inherently unsafe.

Are you kidding me?

In reality, the paper does mention that aspects of the practices outlined by the Baby Friendly Hospital Initiative need additional guidance for safety– but nothing shows that these hospitals are inherently unsafe. Strauss has a history of writing about studies in a very odd way– in January she tore apart the idea of having a doula based on the most inane logic possible. If you want to see someone hell-bent on espousing experience-based practices, she’s your writer.

How dies she even come to her conclusions?

First, she writes that, “Their [the researchers] first area of concern is the initiative’s requirement for skin-to-skin contact between mother and child directly after birth until the completion of the first feeding, and to encourage skin-to-skin contact throughout the hospital stay. The problem is not the skin-to-skin contact itself, which has documented benefits, but the fact that mother and child are often left unsupervised during this time.” Immediately postpartum, nurse coverage should be 1 to 1– a nurse should have no other patients than the baby and new mother. Yes, complications can develop quickly right after birth, and medical supervision in needed. However, the problem isn’t the skin to skin contact– it’s hospitals that profit from lean staffing levels. Further, Strauss doesn’t present any solutions– does she think these babies should be taken away from the new parents and placed in a nursery with dozens of other babies with only 1 or two nurses to take care of these babies? Or should the babies be left in the warmer in the room for a couple of hours following birth? Or…..what?

The next paragraph is a doozy. Strauss writes,

Other concerns in the JAMA paper include the encouragement for rooming-in, even when the mother is exhausted or sedated. They believe this can lead to unsafe conditions for the newborn, and that parents, thinking that such sleep-arrangements were hospital-approved, may continue sleeping in such a manner once they return home. Also, they question whether supplementation with formula should really be banned, as there is no hard evidence linking early formula use to a decreased likelihood of breastfeeding further down the line. In fact, one study suggests that early formula use might help increase breastfeeding rates by reducing stress among new moms while they wait for their milk to come in.

Where to start?

NO HOSPITAL in their right minds would EVER encourage rooming in when a mother is sedated. The hospitals I have worked at rightly and explicitly disallow rooming in if a mother is unconscious and nobody else is there to attend to the baby’s needs. I want to see proof that this is a practice any place actually follows. I’m also not sure what she means by “these sleeping arrangements”. In reality, current SIDS reduction practices actually encourage parents to have babies sleep within 15 feet of the parents– in the same room. As far as formula supplementation being banned– it’s not. Nothing about Baby Friendly designation bans formula use. It calls for hospitals to pay for the formula (rather than get an unlimited free supply from the formula companies) and it calls for guidance when mothers do supplement. That’s all. This oft-repeated myth is a great tool for formula companies who want to create public panic, but it’s simply a lie. And WHY do otherwise intelligent writers perpetuate the whole nonsense that until a mother’s “milk comes in”, there’s nothing to feed a baby. It’s called colostrum, and it works very well to feed human babies and all other mammals, thankyouverymuch.

Finally, according to Strauss,

They end the paper by arguing that the Office of the Surgeon General should reconsider its call for an acceleration of the implementation of the Baby-Friendly Hospital Initiative in the United States. “If government and accreditation agencies wish to encourage and support breastfeeding, their focus should shift from monitoring Baby-Friendly practices and breastfeeding exclusivity to monitoring breastfeeding initiation rates coupled with evidence of lactation support both during and after the hospital stay. More attention should also be placed on ensuring compliance with established safe sleep programs, emphasizing the need to integrate safe sleep practices with breastfeeding.

The language she quoted does not exist ANYWHERE in the cited publication, and at no point do the authors even come close to encouraging the discontinuation of the 10 steps outlined as Baby-Friendly. Further, she doesn’t even include a citation for this quote, and it could be completely made up for all we know.

In reality, the authors of the AAP paper praise the 10 steps, saying, “The Ten Steps include practices that also improve patient safety and outcomes by supporting a more physiologic transition immediately after delivery; maintaining close contact between the mother and her newborn, which decreases the risk of infection and sepsis; increasing the opportunity for the development of a protective immunologic environment; decreasing stress responses by the mother and her infant; and enhancing sleep patterns in the mother.”

For better or for worse, there will always be a backlash against the movement of hospitals towards the implementation of the 10 steps of the Baby-Friendly hospital designation. However, it would serve all of us better to see this discussion happen in a place without twisting a clinical report to serve one’s preconceived editorial slant.

About that Alabama birth settlement…

Last week, a mom in Alabama was awarded $16 million by a jury to compensate her for damage; they found the hospital “violated the standard of care for labor and delivery and participated in reckless misrepresentation of fact.” Evidently, the hospital had a pattern of what the jury described as “Bait and switch”. Of note was that they hospital’s advertising touted waterbirth until At least July of 2015, even though water birth had been banned since January of 2013.

Waterbirth bans happen. In April of 2014 in response to one of the dumbest, most illogical opinions ever published in the American Journal of Obstetrics and Gynecology, Allina hospitals banned waterbirths. At the time, I blogged about the controversy, writing,

Rebecca Dekker over at Evidence Based Birth does a really good job talking about the evidence to support (or not support) the practice of allowing women to labor in a tub and to give birth in the tub. I’m not going to reinvent the wheel, so go read it on her website. The upshot? This isn’t an easy thing to study due to logistics and ethical standards, but it has been studied. It’s been studied enough that the practice is considered safe throughout much of Europe. And guess what? Their water works the same there as it does here.

So, here’s the problem: According to an archived copy of The MotherBaby Center’s (really just Abbot Northwestern, an Allina Hospital) website from June 6th, 2014, waterbirth was still an option.

Waterbirth

Despite the fact that there was ample media coverage of the waterbirth ban, this page is, essentially, the very same bait and switch that the Alabama hospital was sued over. Waterbirth is being actively marketed, but it is not available.

This is not OK. It isn’t OK in Alabama, and it isn’t OK here.

While it’s true that Alabama ranks as one of the worst states in which to give birth in the US, with very poor outcomes for both moms and babies, cases like what this mom experienced happen all the time. As a doula, I have witnessed obstetric violence. I have been in the room as OBs told moms that if they didn’t comply, their babies would die. I have seen moms get episiotomies even though they explicitly stated that they did not consent. Some of these cases happened at hospitals that otherwise had good cesarean rates. Many of these actually happened while a patient was under the care of Nurse Midwives. Backlash from the medical community in response to last week’s verdict was severe; some doctors claimed that this verdict was not actually a victory for birthing families, but that hospitals would respond by caring even less about what her patients wanted and refusing even more obstetric choices. However, it’s important to point out that it took one mom who knew her options and knew her rights to stand up.

As expectant parents, it’s on your shoulders to take responsibility for making informed choices. Looking at a website and marketing is not making an informed choice. Staying blissfully unaware of the ins and outs of the maternity care system IS NOT assuming any responsibility for the outcome of your pregnancy and birth. You are the ones who need to ask questions. Put as much time researching your options as you spend researching cribs. Find out the difference between the different kinds of doctors and midwives that provide care. Look at freestanding birth centers. Tour hospitals and for heaven’s sake– ASK QUESTIONS. If they say they have waterbirth, ask to know the average times they use it a month. They know. If you must, tell them that you want to make sure what they market is really available.  And on the flip side, every single time something like the above happens, we need to make sure lots of people point it out and stay critical of it. Hold both marketing and maternity services to the highest standards. If nobody says anything, nothing will change.

In the MSP and surrounding communities, the voices of patients can and have produced profound change. And as much as I want to paint birth as a magical, shiny, unicorn-filled time, reality doesn’t always match that. Let’s talk about when it sucks, and when the places and people we trust create trauma, we need to raise our voices.

If you’ve seen a bait and switch in maternity care, I’d like to hear about it.

Warmly,

Veroniva

The sudden slide into depression

semi colonI’ve been pretty open about my daily life as someone who lives with anxiety. I do have enough readers and I do know that what I say has helped others reach out and feel less alone. What I haven’t been as eager to be open about is that, as long as I can remember, I’ve also had at least one depressive episode per year. It’s nothing so extreme that suicide is contemplated, but it’s definitely more than just feeling sad.

The anxiety has been a struggle this year. A big struggle. At some point last year I switched from Zoloft to Celexa. The Celexa never really did much. In retrospect, this was a terrible decision, but as I felt the creep of anxiety increasing, I was desperate to stave it off. This spring, I ended up switching to Prozac and Buspar (seriously one of the stupidest names ever). That’s when the sideways slide into depression really began.

The thing about depression is that I don’t notice it’s hit until the dark thoughts begin. Maybe this is normal, but since we don’t talk about the reality of mental health openly very often, I don’t have anything else to go off of. Someone pointed out today that we should talk about mental health the way we talk about physical health– like asthma (which I have) or allergies (which I also have); it’s a chronic condition. Most of the time these things are under control. Sometimes, the medications that I take to manage the asthma, allergies, or anxiety aren’t enough, though.

Starting in April, and through May, I was trying to help my grandmother recover from a very serious illness that needed weeks of hospital and rehabilitation center care. I mostly got through it ok, but I was without one of my teachers due to maternity leave, and some of the things about owning a business really got very seriously neglected to the point where I wasn’t capable of doing more that just showing up to teach.

It’s manageable to own a business with anxiety; the act of doing things to promote and grow and run the business become fantastic ways to soothe the nerves. If I’m doing something, I’m less anxious. It is, however, impossible to run a business once a full-blown depressive episode hits. Returning phone calls? It seemed like too much work. Reach out to providers and partners in the community? Nope, I’ll stay balled up in bed instead. Check out what others are doing to get a feel for the market? Thanks, but the mean voices in my head telling me I’m not good enough have enough fuel for their fire. And as I did less I felt more shame, inadequacy, and doubt about my ability to run a business.

Depression lies. The narrative in my head got darker as summer began. I grew desperate. I did meet with my therapist, but that didn’t help. Finally, in late June, everything came crashing down. I never got to the point of suicide being an issue, but the screening forms for anxiety and depression were startling; since I work so much with mental health through the nonprofit, seeing the scores on paper was scary.

I was so desperate to feel better. The anguish of the sadness and hopelessness grew. I’m lucky that I have wonderful friends and family did everything they could to keep me afloat. But still…

I don’t remember much from the last week of June and the first week of August. I remember feeling an overwhelming desire to check myself into a mental health unit and be hospitalized, but I also rationally knew that beds are very hard to find, and going through the hell of finding a place to be didn’t sound appealing. Again, if it was an asthma flare up, the steps would be obvious; if I got to the point of not being able to breathe, I’d go to the ED. There would be plenty of beds I could stay in while I got the meds I needed to be able to breathe. This simply is not an option during depression or anxiety flare ups.

This is what’s so bleeping frustrating about our system: while the barriers to care have slightly improved, as has been studied over and over, it’s still hard for anyone to get access to mental health for people with more minor challenges; for someone is crisis, a helpline isn’t enough. The mental health infrastructure just does not exist. We essentially have a two-lane road made of a mishmash of bricks, asphalt, concrete, and gravel that really needs to be upgraded to an eight-lane highway. Politicians like to talk a lot about “improving mental health”, but money isn’t going into building the clinics and hospitals and coverage and creating easy access to the mental health care providers that families need when they reach a point of desperation.

I am getting better. I am better. I went back on my old-old meds, and they finally kicked in July 10th. Yes I remember that day because I needed to make sure I placed my marker back into the passage of time rather than just float through the days and months as I had before.  The fog is still lifting, but I am finally getting back into the groove of life, or parenting, of running BabyLove and the non-profit. I’m getting there. I had so many friends and family, especially my husband, who held out their hands so that I had something to hold onto until I had the strength to hold on myself. I have anxiety and depression, but that’s not all who I am, and if you’re in the same place I am, it is not all who you are, either. My value, your value, is still there. We’re still here. Let’s stay here and help each other get through this thing called life.

Finally, if you are reading this an need help, you can find local and national resources over on NAMI Minnesota’s website. More work is needed to fund these community mental health response teams, though. We need more funding, more training in our state and in the US to make sure it’s as easy to get the right care for severe depression, anxiety, or other mental health concerns as it would be to get help for an asthma attack.

Warmly,

Veronica

Free Car Seats at BabyLove

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Even before I opened BabyLove, I worked at a local hospital, and one of the things I would do is teach many of the classes we held for people who were on UCare or MHP. They both had car seat programs where members on PMAPs through the State of MN could get car seats.

Fast forward to now.

I haven’t ever advertised it, but I am a contracted provider for people on HealthPartners PMAPs and MN Care to provide both car seat education and a free car seat in my office by appointment.

What, free car seat? Yep!

Women on a HealthPartners PMAP or MN Care plan who are at least 6 months pregnant and children on HealthPartners PMAP or MN Care plan from ages 0 to 8 are eligible to get one car seat during their lifetime as a member benefit. To get a car seat, either the pregnant person or the parent of an eligible child (I’ve never had a child call for himself, but I guess it could happen) calls me to schedule an appointment. The easiest availability is during the day, but I do have some limited evening appointments available. An appointment takes about 45 minutes. During the appointment, they are taught how to correctly install and use their car seat, both by video and hands-on demonstration. Unfortunately, I do not actually install the seat. When we’re done, they leave with the car seat or seats in hand.

Easy peasy!

So tell your friends, family, strangers…..if they have a HealthPartners PMAP or MN Care plan and fall into one of the two groups above….we can get them a seat! Just call me, Veronica, at 651-200-3343 to schedule an appointment.

That’s all for today, folks!

Warmly,

Veronica