Why Do I Care About Birth?

Jul29

Some time ago I wrote a post on the Citizens for Midwifery blog about medical control as acceptable, in which I pondered the question of why do we care about birth, if many birthing women themselves don’t really seem to care? Why do we make it any of our business what other women choose to do with their births? And, is it any of our business anyway?

Well, I’ve been doing some thinking and I made and shared a list of why I care on the CfM blog. However, I wanted to go ahead and share my reasons on this blog as well. This is why I care about about other women’s births:

Because women are suffering (birth trauma is real–see organizations like Solace for Mothers–and postpartum mood disorders are very common).
Because babies are suffering–late pre-term births are increasingly common due to induction, many babies experience at least some post-birth separation from their mothers (which is not their biological expectation), and many babies spend time in the NICU. Infant mortality rates, especially for minority babies, are higher than in other industrialized countries.
Because breastfeeding is suffering and thus public health is suffering (see my previous article on the birth-breastfeeding continuum)
Because the physical costs of our current birth model are high (morality and morbidity rates are higher than necessary due to high volume of cesareans and many physicians and hospitals do not practice evidence-based care–continuing to deny laboring women food and drink and continuing to use Cytotec for inductions for example).
Because the financial costs of our current birth model to society are high–birth is a multi-billion dollar a year industry. Some facts from CfM:
- Over four million births in the US each year (26.4 births per 1000 women aged 15-44 years in 2004).
- Second most common reason for hospitalization of women.
- Care for mothers and babies combined rank 4^th for hospital expenses.
- Hospital costs for deliveries mounted to more than $30 billion in 2004. More than 30% of births by cesarean section. ranking seventh highest total on the “national bill” for procedures (over $17 billion per year).
- Of all births, 99% take place in hospitals, 90% are attended by obstetricians.
- Over 6 million obstetric procedures are performed – the most common category of surgical procedures.

The percentage of births paid for by Medicaid varies from state to state but can be as high as 50% or more in some states. Coverage by all insurers (Federal government, Medicaid, private, HMOs, etc.) varies; many will not reimburse for OOH births, and when midwives are covered, the reimbursement rate is only a percentage of the rate for physicians. We all pay for births, including unnecessary interventions and preventable complications and injuries, through our taxes, health insurance withholding, and individual policies.

Because women’s birth memories last a lifetime (see Simkin, Not just another day in a woman’s life).
Because women deserve better.
Because I know in my heart that birth matters for women, for babies, for families, for culture, for society, and for the world.

The Future

Jul26

I enjoyed reading an article called “The Future of Midwifery” by Judith Rooks and Kitty Ernst in the December 1999 edition of the IJCE (another find from the previously referenced big binder of back issues). The conclusion of the article was as follows:

It is said that the best way to predict the future is to create it. Creative forces come from our souls, our beliefs, our values, our moral and spiritual strength, and from the scientific evidence available to us at any given time. If we are to meet the challenges ahead, each of us must weigh authoritative pronouncements and popular opinions against the available scientific evidence, temper it with our own beliefs and values, and chart a course drawing on our collective moral and spiritual strengths. Change is often shaped not only by what we do but by what we do not do. The future of midwifery and our children’s care in childbirth is in our hands today. To be silent is to speak. To do nothing is to take action. (emphasis mine)

Sometimes it seems as if I am saying the same things over and over and trying to reach people who may or may not want to be reached. I found the above quote a good reminder that continuing to pursue change in birth practices is a worthwhile endeavor.

Opening for Birth

Jul24

Some time ago, I bought several large binders of back issues of The International Journal of Childbirth Education (ICEA‘s publication). The December 2001 edition of the IJCE contains an article titled “The Pelvis Revisited” by Elizabeth Noble. An interesting article overall, I particularly enjoyed the language of the section titled Opening for Birth:

“Birth is what women do. Women are privileged to stand in such power! Birth stretches a woman’s limits in every sense. To allow such stretching of one’s limits is the challenge of pregnancy, birth, and parenting. The challenge is to be fully present and to allow the process because of inner trust. How can women find their power, claim it, and stand firm in it throughout? The vertical position comes again into prominence. Women must ‘stand up’ for what they want and ‘on their own two feet’ by refusing to take their birth ‘lying down’! Being upright is essential for pelvic power–psychological strength, pelvic mobility, gravity’s assistance, pelvic pump efficiency, and the hygienic downflow of bodily fluids.”

In the September 1999 issue, the article “Belly-Dancing Through Pregnancy: A Way to Give Birth and Not Be Delivered” by Gaby Mardshana Oeftering caught my eye. In it, she also addresses the needs to build inner trust and to open to birth through physical movement and an active approach to birthing:

“Women expecting their second or third child don’t necessarily need this [traditional prenatal classes]. They are looking for a way to relax, find their inner selves, and get better acquainted with their bodies, their babies, and the process of birthing. When allowed to move during childbirth, many women instinctively start moving their pelvis in hip circles which are typical of belly-dance…All soft and gentle belly-dance movements are beneficial to pregnant women; for example, hip circles, the various hip-eights, and hip rocking. The rule is: all horizontal movements relax the uterus; vertical movements excite it. Physically speaking, all these movements strengthen and mobilize the pelvis and the legs and train the pelvic floor. They also activate deep abdominal breathing…the hip movements demand a lot of attentiveness and body awareness. On a mental level, this leads to better consciousness of tension and relaxation—a body feeling that is needed during birthing.”

Recently, I feel myself intrigued by the possibilities of working with these women—those who are on their second or third pregnancies and who are seeking to “go beyond” traditional birth class information (that often assumes first baby status). I know that I, personally, have wanted new, fresh, inspirational birth information during each of my pregnancies—labor and birth 101, stages of fetal development, or even labor support and comfort measures isn’t “enough” for me anymore (and wasn’t after my first baby). The desire to honor the pregnancy experience, prepare for the birth experience, and to work with psychological and emotional elements of childbearing are still very much present though! I envision doing a series of “pregnancy retreat” type of things or other types of workshops that “go beyond” and help second, third, or fourth time mothers to spend some dedicated,special attention to each pregnancy and birth experience in a personally enriching and rewarding way 🙂

An Encouraging Thought…

Jul19

Some time ago I read the book Teaching Natural Birth. In it, the author shares this thought about the importance of teaching families about birth:

“We are not ‘hobbying’ or ‘playing house.’ We do this not because we like people or like babies, but because there are earthshaking issues involved in the way our culture is giving birth and raising its children…We are playing for keeps and the stakes are high. We are professionals. We matter. Always and indescribably.”

I do not view my birthwork as a “hobby.” I view it as my career/profession. I have noticed a tendency of people outside the “birth world” to look upon it as a hobby however. Reading this quote was a nice reminder that this work is important!

Birth & Control

Jul12

Labor is a microcosm of life. It brings pain and pleasure, sadness and joy. Labor will put you in touch with both your strength and your dependency and offer you an opportunity to learn more about yourself. Sometimes we are happy with ourselves, other times we are not. Labor is not a time to judge ourselves but a period for reflecting on our movement through life at a given moment. It is not possible to control labor, it is only possible to follow the process and to meet whatever it may offer. Labor is also teamwork. It is a mother and baby learning together how to push and how to be born, how to yield and separate from the union of pregnancy. You are not in control nor are you out of control during labor. The best way to approach labor is with an attitude of learning rather than controlling –Gayle Peterson, An Easier Childbirth

One of the things I explore in birth classes is feelings about wanting to be “in control” or “staying in control” during birth. I ask couples to consider what “losing control” would mean to them and what the benefits of “losing control” might be.

I really enjoy this section from Childbirth with Insight by Elizabeth Noble about control and birth:

[with regard to prepared childbirth films and classes] …are instructive rather than enlightening. They confirm a particular teaching method by advocating roles and techniques. Such films obscure the fundamental holistic experience of birth. Couples are not aware that the power of giving birth involves individual surrender to its uncontrollable nature. It is understandable that expectant parents become anxious about their abilities to maintain the kind of control that is expected of them, given that no such control of natural forces is possible–or desirable.

The actual experience of contractions, like other intense bodily sensations, is extremely difficult to describe…The more completely an expectant mother can experience labor as a unit of body and mind, the more easily she can flow with the process of birth…the more a woman tries to be in control, the more she fears the inevitable loss of control…

Women will sometimes mention “fighting” the contractions or struggling with them. Or, sometimes trying to “escape” the contractions. Both of these approaches are efforts to stay “in control.” It is very difficult—if not impossible—to describe in birth classes what labor is “really like.” Birth is a lived experience, not a rehearsed one! (Though, I really believe that practicing different skills and doing some labor rehearsals in class are really valuable at building confidence, which in turn hopefully leads to a confident, adaptable birth experience.) I struggle with wanting to give people in my couples plenty of “tools” they can use in labor, while also communicating the vitalness of “surrendering” and “flowing” with birth. There is no “right way” to give birth and I find that couples sometimes want to learn definitives from me—right ways—while really the best advice I can give them is to go with the flow and respond to their instincts and inherent body wisdom. (Of course, for this, they need to be in a birth environment that is conducive to the freedom necessary to do so…)

Here is another quote I enjoy about the value of surrender in birth:

“I am starting to see that a woman’s strength in birth is also in the letting go and allowing herself to tumble fearlessly with the current, never losing sight of the belief that, when the energy of the tide is through, she will find herself upright again on the shore.” –Maria (at the blog A Mom is Born)

While I have never labored or birthed in water, or been a particular fan of swimming or being in water, water metaphors about birth always feel really right to me from my own lived experience.

And here is another post I wrote called “fears about birth and losing control“

Poem: Thoughts on Risk

Jul8

Two years ago, I read Sheila Kitzinger’s book Homebirth. In doing so, I was struck anew how much I love her writing (I quote her often!). It is so lyrical and vibrant and really gets to the heart. I also deeply identify with it. I want to share a poem (not by her) that was in the book in the section about assessing risk and statistics and homebirth and is it really safe, etc. I feel like sharing it today (something that is difficult for me about pregnancy after loss is feeling more “at risk” about pregnancy than I have ever felt before—you know the quote, “birth is as safe as life gets” often said so blithely, has a different impact when you’ve been part of the statistics instead of “escaping” them. I still think the quote is true, but it is NOT a “light” quote!) :

Thoughts on “risk”
by Judith Dickson Luce (in Homebirth by Sheila Kitzinger)

word so small
born a verb
an “action word”

as I learned in 4th grade
I risk
you risk
she risks
even a noun something
I take
you take
she takes

in philosophy a description of what life is
with its own rewards:
I love and risk loss and pain
I try and risk failure
I trust and risk betrayal
I live and risk death
but we’ve moved so far beyond philosophy
to insurance–for anything and everything
to machines
to technology and control
(no daring)

and computers spit out the risk we are “at”
before we breathe
before we take a first step
that might lead us to fall
and the computers and the statisticians tell us
it is healthier and safer
and wiser not to take risks
since we are “at risk”
and they can reduce risk
and with it our capacity
for living
and touching
and caring
it’s safer that way
neater and more efficient
and definitely more sterile
and what more can we ask of life?
—–
Commentary by Tom Luce: “It’s very risky to be born since very few people who are born avoid dying (though many avoid living). If you are born there is a high statistical risk you might die.” 😉

Birth Feelings

Jul5

Those who push themselves to climb the last hill, cross the finish line, or conquer a challenging dance routine often report feelings of euphoria and increased self-esteem…women who experience natural birth often describe similar feelings of exaltation and increased self-esteem. These feelings of accomplishment, confidence, and strength have the potential to transform women’s lives. In many cultures, the runner who completes the long race is admired, but it is not acknowledged that the laboring woman may experience the same life-altering feelings… —Giving Birth with Confidence (by Lamaze International)

This is so true and so often overlooked or diminished in our modern birth culture. Comments such as, “you don’t need to be a martyr” or, “would you get a tooth pulled without medication?” or, “there are no medals for natural childbirth,” or, “in the end, all that matters is a healthy baby!” fail to acknowledge the transformative power birth holds in women’s lives. I think these comments (and the many others like them) often come from one of two places: the first being a place where birth did NOT hold transformative power in that speaker’s life (and, this is something I have to acknowlege as real—birth can be transformative, but it isn’t always, AND it can be a powerful influence in a negative sense as well [i.e. a woman who really did suffer during birth and/or was abused and/or experienced any variety of traumatic things, whether or not we, the listener, “know” that some of those things could have been avoided with different choices, etc., etc.]).

The second place, I believe is one that many medical care providers come from in that they do not want to look at the reality of the importance of birth because then they would have to confront the reality of how they may have interfered with or “ruined” birth for so many women. Perhaps that isn’t true or is a “bad attitude” or judgment on my part coming through, but that is how it looks to me from the outside. It is easier to dismiss natural birth advocates as “zealots” and mothers who wish to birth unmedicated as “martyrs” than to critically examine the institution’s birth practices and policies.

Related to the initial quote, here is a previous post about Birth and marathons…

As a side note, I really like the book I quoted—Giving Birth with Confidence—as a good “basic” birth book for pregnant women. I’m glad it is usually available in “conventional” bookstores as many other birth book treasures are not!

A Fantasy

Jul2

Several years ago, I requested permission to reprint an essay from La Leche League International’s book Learning a Loving Way of Life. The essay is a birth/breastfeeding parody and I realized I’d never shared it here (please do not reprint without permission!).

A Fantasy

By Melanie Axel-Lute

Time: The not-too-distant future.

Scene: A Doctor’s office.

Doctor: Yes, Judy, the test is positive—you are going to have a baby. Now I’ll just give your instructions for the artificial womb.

Judy: Well, doctor, I have been planning to be pregnant.

Doctor: (surprised) Oh! I do have a few patients who say they’d like to try that. It’s very difficult nowadays, though, so many pressures on the modern woman. Of course, I’m all for it. It is the best thing for the fetus, though the new artificial wombs are very good. Now—have you done any preparatory exercises?

Judy: I didn’t think about that.

Doctor: You’ll find it very hard then, especially at first. I usually have my patients do several months of sit-ups and leg-lifts.

Many women say they’d like to try being pregnant, but they have to give it up in a few weeks. They have morning sickness and are very tired. I always recommend that anyone with nausea switch to the artificial womb.

Being pregnant takes a lot out of a woman. You’ll need your strength for the baby. And you don’t seem very big through the pelvis. You may not be big enough to be pregnant. I’ll have to test your amniotic fluid to see if it’s adequate.

It’s very hard to judge the weight of the fetus when it’s in a human womb, too. Some women worry whether it’s gaining enough weight. I always like to start intrauterine feedings at about two months.

Now, how long had you planned to be pregnant?

Judy: I planned on letting the baby be born naturally.

Doctor: (shocked) Oh, my! That’s really not necessary, you know. Most of my patients go for about three months—that’s the critical period—although a few stick it out for six. More than that is definitely unnecessary.

Have you thought about what people will say? Most people don’t mind seeing a woman pregnant with a tiny fetus, but when it gets to be more than six months—well! It’s just very unusual.

Besides, have you thought about how tied down you’ll be? You’ll have to take that fetus everywhere. Women really need to get out alone once in a while, you know. I feel that most women who prolong pregnancy like that do so for very selfish reasons.

Judy: I want to go ahead with it anyway.

Doctor: (patronizing) Well, I guess I just have to let you try it for a while and see how it goes…

This essay was reprinted with permission from the book Learning a Loving Way of Life, published by La Leche League in 1987. The essay reprinted was originally written in 1978. LLLI is the world’s foremost authority on breastfeeding. For a wealth of breastfeeding information, support, resources, or to purchase a copy of the book referenced, visit: www.llli.org.

Manual Clot Extraction Following Birth (Sequestered Clots)

Jun29

There is a new blogger at Science and Sensibility—a science writer (and pediatrician) named Tricia who is going to be writing about patient safety and other interesting topics. She wrote an article for the online medical journal Pulse about her traumatic post-birth experience that involved (among other things) a large number of clots and a painful manual extraction.

What an intense story it was. I had a manual clot extraction following my first son’s birth and my uterus literally HURT while reading her story and remembering that experience. However, unlike Tricia, I was at a birth center and had a very gentle, caring doctor who was wincing as she did the extraction saying, “I’m sorry, I’m sorry. I know this is hurting you.” Even so, it was an excruciatingly painful experience—the most painful physical experience I’ve ever had. Uteruses are simply not MEANT to have hands in them. And, birth is about things coming out, not going in! I was left with lingering questions about why the doctor did a manual extraction instead of having me squat to see if the clots would come out on their own. Perhaps it was a more serious situation that I realized at the time and she was just playing it cool. I can find almost no information online about this type of an experience, just a small mention in one of my midwifery texts about “sequestered clots,” which is I guess what I experienced.

Reading about this other blogger’s experiences really brought back this painful experience for me. I have noticed a tendency amongst childbirth educators and doulas to sometimes only focus on the good and empowering parts of births and to overlook or not mention the “traumatic” parts. Personally, I felt so good OVERALL about my birth experiences, that it seemed like a “betrayal” of sorts to talk too much about the parts that were not as good. While I experience giving birth as the most powerful, transcendent, empowering, and just super awesome cool, experience of my life, when I take a couple of steps back into memory I also realize that each of my births involved a certain element that was significantly traumatic as well. With my first it was the manual extraction and then my postpartum recovery from what I feel like was a very mis-diagnosed/poorly treated labial tear. With my second, it was recovery from a very similar tear right next to the old one (but with the visually traumatic addition of bruises). I really felt like I had “failed” in some way to have not protected myself from tearing again in such an unusual and very awful way. Someday I would like to write a blog post or article about this—I find that labial/clitoral tears are a significantly overlooked subject in the birth and midwifery literature. Indeed, I hadn’t even it was possible to have a non-perineal tear. If they are mentioned, it is in some dismissive way about “skid marks” or “labial split” or “a little burning when you urinate,” not in terms of the fairly significant genital mutilation I experienced.

I also had an intense amount of clots following my third birth (second trimester miscarriage at home)–-“only” the size of grapefruits though, not “frying pans” as in Tricia’s story-–and when I finally went into the ER about it they acted like I was making a big deal out of nothing (“people have miscarriages all the time. They’re very common.”) They were not “sequestered” though, they were coming out (and coming out, and coming out). Despite these experiences, I was never classified as “hemorrhaging”—the ER doctor even said (with a shake of her head like I was an idiot), “you’re not hemorrhaging.” And, indeed, I did not have any postpartum symptoms of hemorrhage—no anemia or anything like that (though yes, loud heart-pounding-in-my-ears after this third birth). In addition to the more obvious trauma of having my baby die, the experience of very truly feeling close to death—of no longer being able to distinguish whether I was fainting or dying—is the thing I can barely talk about from this birth experience.

Sheila Kitzinger on a Woman’s Right to Her Own Experience

Jun28

I have written before that every woman has the right to define her own experience—a phrase I first remember hearing when used by an ICAN volunteer. I was cleaning out a pile of stuff by my computer this weekend and found I’d marked a related quote in Education and Counseling for Childbirth by Sheila Kitzinger, so it obviously caught my eye before hearing it from ICAN, but hearing it is what fixed it into my own personal philosophy of birthwork. With regard to what good childbirth educators need to know/how they should approach teaching:

…nothing can replace the experience of having joyfully born one’s own babies in full awareness and of having had to face and cope with some of the psychological and social problems which confront most women in childbearing and child rearing. But simply having given birth happily oneself is inadequate as a basis for good teaching. Too often then a woman has a very one-sided picture of labour, and merely superimposes on other women ideals of how labour ought to be.

Labour is a highly personal experience, and every woman has a right to her own experience and to be honest about the emotions she feels. Joy tends to be catching, and when a teacher has enjoyed her own births this is valuable because she infuses her own sense of wonder and keen pleasure into her relations with those she teachers. But she must go on from there, learn how difficult labour can be for some women, and develop an understanding of all the stresses that may be involved.

I’ve noticed that women come into birthwork for a variety of different reasons (okay, that is a very obvious statement!) and two of the big ones seem to be either that she had a wonderful birth herself and wants to “share the light” or, she had a disappointing birth herself and wants to help prevent other women from having the same experience. I came from the first camp—my first birth experience was tremendously empowering and I couldn’t wait to share the joy with others. My second was even more triumphant and powerful and really lit my fire to finish my certification process and to start teaching in earnest. I feel like I have always been compassionate to that fact that not all women DO feel a sense of triumph and joy in birth, even if they do everything “right,” and I read plenty of books and articles on “unexpected outcomes” and about birth trauma. Additionally, as I’ve noted before, I also feel like my birth-miscarriage experience with my third baby more fully opened the complete range of experiences of the childbearing year to me and gave me a deeper sense of compassion and heart for all women.