Free doula support? It's coming!

Last week a major announcement reached Canadian doulas. Sun Life, the #1 insurance provider in Canada, approved the use of doulas as a reimbursable service to clients. This is a huge step forward in the red tape to get doulas covered through third party reimbursement.

What does this mean for you?

If you are currently covered through a Health Spending Account with Sun Life, you can apply to have my doula support services covered, either partially or fully. As the process and coverage can vary between employers, this will be dealt with by Sun Life on an individual basis. The only doulas who have been approved for this coverage are DONA-approved, so if you are thinking of going with a doula other than myself, please check to confirm their certification and current membership with DONA by going to dona.org.

What if I'm covered by a different plan or company?

At this point, members of DONA's third party reimbursement committee have been successful with Sun Life. However, they will be working with the other large insurance providers across Canada, and with any luck, other providers will soon provide coverage as well.

Can I apply retroactively for previous doula services?

It's doubtful, but I would recommend sending in any invoices for previously paid doula services in to your insurance company - you never know! The more claims that are processed (or even just sent it) to extended health plans, the more likely these companies are to agree to third party reimbursement in the near future. But do make sure that your doula is a DONA-approved birth or postpartum doula first.

Twenty years ago, midwives became a regulated profession in the province of Ontario, offering women the chance to birth out of hospital, with continuity of care, and informed choices. When we hear that professional doula services are beginning to offer third party reimbursement, it seems like a similar path is taking shape. A doula should be available to every woman and every birth, regardless of income or social status. While we still have a long way to go, this is definitely a step in the right direction!

 

 

Early Labour - What is it? How does a doula help?

Of all the potential benefits to having a doula support you through your labour and baby's birth, one of my favourite reasons can be summed up in two words: early labour. It's an idea that seems easy to understand, but I like unpacking it for my clients, to really give a full idea of how I can help, and why that will become so important for them later on.

Labour and birth are divided into three stages: the first stage, during which your uterus contracts and your cervix dilates, is made up of a few sections (this is where it can get a little bit confusing). Early labour occurs during the first part of the first stage, when the rushes (contractions) are just beginning, and you may or may not feel discomfort or pain. The latter parts of the first stage are active labour, transition, and complete, but they are topics for another day.

What's important to remember, from a doula's support perspective, is that early labour is the only time when you will likely not be offered hands-on support or guidance. Hospitals will admit women when they reach active labour, which is confirmed by a vaginal exam that shows 3-4cm dilation, and midwives will come to a home birth at the same time. While this system is great for offering support at the time that active labour gets into full swing, it means that a labouring woman is on her own for, on average, 6-12 hours before she can benefit from the help of someone who is comfortable and skilled in providing comfort measures and knowledge of labour.

I point this out to clients because I believe that those hours of early labour are an important time: your body is learning how to work with the contractions, and the hormones that will provide relief and progress are beginning to work on your body. It is an excellent time to rest, though the excitement of seeing your baby very soon can make it difficult for some moms. 

As a doula, I arrive to provide hands-on support throughout early labour. In fact, I have yet to attend a birth where I wasn't needed until active labour, which suggests the real need that most labouring moms have for support during this crucial time. I think that when women feel supported, comfortable, and in control during these hours, they manage well as labour progresses to its more intense moments. I can only say this anecdotally, of course, but studies looking into the effects of continuous support by a doula reach similar conclusions. 

I love that I get to be with my clients, often one-on-one, during this time. Whether it's using massage, or watching a funny movie together, it's easy to relax into the labour when you have both physical support, and the knowledge that a doula brings to reassure you that everything is going well. Starting your labour out right means passing through early labour as comfortable and relaxed as you can manage, and it's a wonderful time to feel the effects of a doula's presence. 

 

 

On Midwives, Doulas, and "the System"

Yesterday I linked to an article originally posted to the Positive Birth Movement website, and written by a former NHS midwife. The National Health Service, the UK's universal health care system, has long been considered a model of midwifery care to imitate the world over, because of its approach to childbirth. As you might guess, the UK never lost its connection to women assisting other women during labour, and as the medicalization of childbirth occured, midwives remained an important part of maternity care.

The author of the piece, however, was disenchanted with the system that she had become a part of. I won't paraphase the entire thing, but it certainly gives the impression, as she points out, that midwives are becoming more akin to our own understanding of labour and delivery nurses than autonomous care providers for low risk women. 

This got me thinking about our own midwifery model, so recently revitalized in Ontario. Demand far outpaces the number of available midwives to attend births in the province; at one point there were estimates that one in three women requesting a midwife would not find one. The US has a different system for midwives, that also seems more akin to nursing at times, as many professional midwives train first as nurses. Here, midwifery is a complete university degree, separate from nursing, and even from the standard hospital as teaching centre, which makes it quite unique. 

We can't know how our system might be different if we hadn't lost touch with our midwifery model during the 20th century. But it's interesting to see how rebuilding that level of care from the ground up has led to a standard of care that encompasses all aspects of pregnancy, labour, birth, and the postpartum period for mothers, and a low intervention rate for babies. And with the impending opening of Toronto's first Birth Centre, I think we have a lot to look forward to as we grow into a model of care for birthing women that embraces the normalcy of the childbearing year as a life event.

The author of the original piece ultimately decided to abandon her role as a midwife in favour of becoming a doula and holistic childbirth educator, feeling that these roles were closer to what she had envisioned her job to be. It seems like the track we are on here in Toronto, as well as the province, is a system that respects the hospital standard of care for emergencies, but that is giving women the confidence to birth their children as they choose, whether that is in their homes, a birth centre, or a hospital, under the guidance of midwives who are there to support and guide, rather than to direct the progress of a birth.

What has been your experience with the midwifery model of care? Where and under whose care would you feel most comfortable giving birth? 

And Baby Makes Four? Having a Doula for your Second Birth

I'm often in conversation with moms. On the playground, at the library, or at a music class, and when my status as a doula is mentioned, I get such a varied response on women's experiences with having a doula. Some swear that they couldn't have done without one, and will again for another labour, while others say they had one for the 'unknown' aspects of birth, but feel capable of going at it alone for any subsequent children. I'm impressed by the moms who are confident enough in themselves to fearlessly consider their next birth. Whether it's because they managed to have the birth they envisioned, or that there was no unnecessary intervention to change their opinion, having a strong sense of positivity surrounding your second (or third) birth can have a huge impact on your overall experience.

However, today I feel in the mood to champion the case of having a doula at your birth, even if it's not your first time having a baby. Relatives are found of telling families pregnant with their second child that this next baby will be the antithesis of the first one, that "no two children are ever the same." And we acknowledge the truth of their words most often. Parents whose first child was extra sensitive and often needing to be held find that their second child is strong-willed and independent. Those whose first babies were good natured and easy to soothe find that their second baby is the one that always needs another song, or an specific routine to calm them.

It turns out that, like children, no two births are ever the same. Women find early in their pregnancies that the symptoms of carrying a second child can be very different from their first, and that even the way they carry the baby feels new. And given the fact that a mom planning for a second baby most likely has a busy toddler in tow, it stands to reason that a doula's expertise may help lessen the load that a woman has to shoulder as she becomes a new(again) mother to a newborn.

As a doula, I see births regularly, and have yet to see two that were alike. Even if you feel like a seasoned pro by the time your due date with your second baby rolls around, consider how a doula can enhance your birth experience a second time around.

We can:

- provide prenatal support tailored to your needs, including breastfeeding children of different ages

- offer age-appropriate teaching tools for your toddler or child to welcome their new sibling

- network with other local birth professionals and resources you may need, including postpartum support or childcare

- focus entirely on your needs throughout your labour and birth

- assist your partner in supporting you through a new birth experience

- support early breastfeeding and bonding

- increase postpartum visits, and include childcare within the scope of postnatal support, giving you time to nurture yourself and your new baby

Parents are quick to point out the differences between having one child, and having two. Fewer photos, less one-on-one time, the harried schedule of a newborn and a child - it seems so easy to say that you've been there and done that. But I've also heard many moms say that they wish they had been offered more help the second time around. The excitement of having your first child is shared by your entire family and your circle of friends, neighbours, and coworkers. However, when you find yourself in the thick of new parenthood a second time around, often within three years of the first time, the lack of support can be a frustrating entry into the world of two (or more) children. Of course the excitement is still there; what isn't, sometimes, is the trays of home-cooked meals, and the offers to hold the baby while you shower and take a nap.

It's true - you have been there, and you've got the experience and all the baby gear to prove it. But investing in a doula for the birth of your next child is an easy way to steer this new direction of birth into a positive trend of parenting multiple children. The selfless attitude that has put your first child's needs before your own can sometimes make nurturing yourself seems like an indulgence. The simple truth is that moms who feel nurtured and taken care of themselves are often the best carers of their own children. When you've got a little one running around and another on the way, a doula can be a great way of meeting your unique needs and ensuring that your second birth and early postnatal weeks are calm and nurturing for your entire family.

To Swaddle or Not to Swaddle? That is the Question.

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If there is one issue that seems to divide many doulas, midwives, lactation consultants, and paediatricians, it the question of swaddling. In its most basic form, swaddle is a technique of snuggly wrapping a baby in a light blanket. The purpose of swaddling, says its proponents, is to help babies sleep better and longer.

There are so many advocates of swaddling, most notably these days Dr Harvey Karp, author of Happiest Baby on the Block. Of his now famous '5 S' techniques, swaddling is generally the first one most parents use to calm a fussy infant. What has been very beneficial about Dr Karp's book and subsequent fame is the confidence it has given parents to swaddle their babies correctly. Studies have linked correct swaddling to lower SIDS rate, when the baby is placed on his or her back. It's very important that swaddled babies are never left on their stomachs, and that as soon as your baby is able to turn from back to front, you no longer swaddle her, as it risks suffocation.

But for those early days, when your baby is adjusting to life outside of the womb, there is quite a body of evidence to back up Dr Karp and others' belief that swaddling can soothe your baby. As a doula, I'm not entirely sold on its premise of replicating the womb - we know that babies, even large ones at the end of gestation, are able to move within the womb. Furthermore, the cushioning of amniotic fluid is very different from the muslin or flannel blankets we use for swaddling. However, we can see even anecdotally that most babies are comforted when placed in a well-done swaddle.

So who's against swaddling?

The earliest professionals against swaddling were doctors who began seeing a rise of hip dysplasia, a relatively uncommon condition, in children who were swaddled. This was more than forty years ago, and thanks to public awareness on how to swaddle babies correctly, this issue has largely gone away. The important difference from earlier forms of swaddling is to allow your baby enough room for his legs to kick and move within the blanket. Another way of mitigating this problem is to put a second diaper over the first, which puts your baby's hip at a better angle to prevent the rare condition of dysplasia.

The group that remains against swaddling today are mainly breastfeeding advocates, who point to a disconnect between nursing your baby, and swaddling. This is not to say that one can't be a advocate for breastfeeding and swaddling - but those who advise against swaddling base their argument like this: swaddling causes your baby to sleep longer, and deeper, than she otherwise might if left unswaddled. This may be beneficial for sleep-deprived parents, but it risks both you and her missing what we call 'early hunger cues,' the signs that she is ready to nurse that come before crying. Once she reaches a state of hunger that is strong enough to wake her up, she may cry to the point of not being able to latch on correctly. This can be extremely frustrating for both of you, and even distressing if it lasts more than a few minutes. A lactation consultant I know also points to the problem of such long, uninterrupted sleep for mothers: even if the idea of sleeping for four hours sounds extremely appealing, a nursing mother generally cannot go that long without feeding, or risks the pain of engorgement and a potential blocked duct. You need to nurse as much as your baby needs to!

Where does this leave us? From my role as a postnatal doula AND a breastfeeding advocate, I would say that there shouldn't be an imperative to swaddle your baby, if you feel rested enough and that your baby is comforted by being held, suckling, or any other combination of techniques. If you find that your baby isn't sleeping for stretches of at least forty five minutes without waking herself up, either by scratching herself, because of her startle reflex, or simply because she dislikes being put down, swaddling may be a help. If your milk hasn't yet come in, I wouldn't recommend it, as it's a time that your baby will want to be at the breast, cluster feeding in order to ramp up your milk supply. Likewise, there are times when similar cluster feeds will happen, and no amount of swaddling will pacify your baby. This generally occurs at two weeks after birth, and again at six weeks.

If you do choose to swaddle, there are many products on the market that offer different ways of wrapping your baby. From simple muslin cloths to Velco straps, you  can find the one that works best for you and your baby. Remember though, to be mindful of those early hunger cues, and wake your baby up to feed if he's slept soundly for a couple of hours. Undressing him and doing skin-to-skin is the best way of waking a sleepy baby.

The final word on swaddling goes to Ina May Gaskin, whose advice is always practical and imbued with her usual common sense approach: "I use swaddling mainly to help a jittery or fussy baby take her mother's breast without frustration. Swaddling is not a good idea if your baby is gaining slowly as it prevents the skin-to-skin contact that will help your baby stimulate a greater milk supply." (Ina May's Guide to Breastfeeing)

So while there's no hard and fast rule when it comes to swaddling, I hope that the benefits and issues surrounding the topic can help you decide what to do with your own baby. Perhaps we'll leave it by saying this: swaddle if necessary, but not necessarily swaddling.