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Midwife means “loves women”…

Blessingway gift from my first midwife

I know the traditional root of the word midwife is “with woman” (some sources say “wise woman”), but I’d like to offer another. When I was pregnant with my second son, I had a wonderful midwife and we spent many hours together talking about birth and midwifery. During one conversation she said to me, “you can’t be a midwife unless you love women.” This struck me profoundly—a midwife must love women. This phrase has come back up for me several times in the last couple of months as I reflect on my relationship with my current midwife and give thought to midwifery care and birth care in general. I actually believe that not all midwives do, in fact, love women and indeed, my observation is that midwives from specific religious traditions, may actually hold a perspective of women that is almost the opposite of loving them 😦

In any subset of birth work—including breastfeeding consultation—I’ve noticed there are two primary motivators for the women doing this work. For some, it is about the babies and for others, it is about the women. I have noticed this as a volunteer breastfeeding counselor also—women who do this work will say, “I just love babies…” or, they will say, “I love helping mothers.” Please note that I’m not actually saying that one motivation is “better” than another (though, I personally prefer one), just that I’ve noticed this trend. And, obviously, the two are also inextricably intertwined. But, some women do come into birth work primarily to improve the world for babies and some come into it to change the world for mothers (which, I believe, changes the world for babies!). Obviously, you’ve guessed that I’m in the latter category. I believe that we cannot help babies without helping mothers first and that by helping mothers, we cannot help but also be helping babies—but, for me, the mother comes first. And, from the perspective of both a pregnant woman and a birth activist, I think we need midwives whose definition of midwifery is loves women.

In  the Autumn 2010 issue of Midwifery Today, I read an interview with a midwife named Gigliola from Paupa New Guinea and in the article I marked this quote:

“Gigliola has a strong reverence for the power of mothers, for women who are willing to give up their lives for their children, willing to work hard through long labors, feeding their babies from their bodies, staying up nights with them, loving and loving for long years. Then as graciously as they can, watch their ‘successes’ walk off to lead their own lives. The path of motherhood is as rigorous a spiritual path as any on our planet. Gigliola holds motherhood as a sacred calling, deserving of great respect…’Tell them it is about the mothers,’ she said. ‘The mothers are amazing.’” [emphasis mine]

I agree.

Euthagenesis

I just finished reading another book about the history of childbirth. This one was called Get Me Out: A History of Childbirth. I half expected it to be a repeat of Birth Day, which I finished reading earlier this month, or at least similar to Birth: A Surprising History of How We are Born (the covers are even similar). I was pleased to discover that this book stood on its own as an interesting and absorbing tale—the emphasis was really on the recent history of childbirth, up to and including sperm banking and cryo-preserving eggs. I will share a full review soon, but I first wanted to share one of the new things I learned from the book. In the chapter on Freebirthing, the author shares the story of Pat Carter, a woman in the 1950’s who had seven unassisted births and wrote a “manifesto” about unassisted birth called Come Gently, Sweet Lucina (the book I had heard of, the rest of the historical information, I had not). She called her theory of birth euthagenesis (“good origin”). It didn’t really catch on and the author of Get Me Out states that euthagenesis is one of the “few un-Google-able terms.” So, I instantly wanted to write a post and make it googleable 😉 Of course, I did google it prior to posting and lo and behold I did get a single result, Rixa Freeze’s dissertation Born Free: Unassisted Childbirth in North America. So, darn, I didn’t get to put it on the map first after all! Rixa is so awesome that I can forgive her for that though 😉

Climate of Confidence, Climate of Doubt

Recently I finished reading (and reviewing) the new book Our Bodies, Ourselves: Pregnancy & Birth. In the opening chapter, they identify a concept that I have *felt* for some time, but hadn’t really put a finger on. The authors refer to it as a “climate of confidence” and a “climate of doubt.” I love this way of articulating the messages swirling around pregnant women in our society.

A Climate of Doubt comes from “The media’s preference for portraying emergency situations, and doctors saving babies, sends a message that birth is fraught with danger. Other factors, including the way doctors are trained, financial incentives in the health care system, and a rushed, risk-averse society, also contribute to the popular perception that childbirth is an unbearably painful, risky process to be ‘managed’ in a hospital with the use of many tests, drugs, and procedures. In such an environment, the high-tech medical care that is essential for a small proportion of mothers and babies has become the norm for almost everyone…[a] ‘climate of doubt’ that increases women’s anxiety and fear.”

A Climate of Confidence “reinforces women’s strengths and abilities and minimizes fear. Some of the factors that nourish a climate of confidence include high-quality prenatal care; healthy food and time to rest and exercise; a safe work and home environment; childbearing leave; clear, accurate information about pregnancy and birth; encouragement, love and support from those close to you; and skilled and compassionate health care providers.”

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I encourage my birth class clients to consider ways in which they can create a climate of confidence in their lives as they prepare for their births and their babies.

Will I need an episiotomy?

The short answer is no, you do not “need” an episiotomy. Women rarely (if EVER) actually “need” an episiotomy. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening as the baby’s head is being born. This procedure is rarely necessary and you should ask your care provider how often they perform episiotomies. A good answer is, “almost never” or “I’ve done 3 or 4 in my career.” Answers that are NOT good and that should encourage you to question further are, “only if you need it” or, “many first time moms need one” or, “a clean cut is easier to repair than a nasty, jagged tear!” or, “don’t worry about it. I’ll make the decision when the time comes.” These are not good answers, because there has no study has ever shown any benefit to routine use of episiotomy! There is no scientific evidence supporting the practice.

A commonly used analogy to explain why a cut is NOT better than a tear is to imagine a piece of fabric–when you try to tear it, it resists. But, when you make a small cut in the top of the fabric and then then try to tear it, it easily rips all the way down. The same is true of your skin! (and your muscles–an episiotomy cuts through your muscle as well as your skin. Many naturally occurring tears are very small and occur only on the surface of your skin).

Here is some more explanation from an issue of Midwifery Today e-news issue number 8:23:

“Ironically, one of the biggest contributors to perineal tearing is episiotomy, which has long been heralded as the great preventer of tearing. One recent study, which only assessed the effects of episiotomy on third and fourth degree tearing, found a definite correlation between episiotomy and tearing. The risk of severe tearing was found to be nearly four times higher with episiotomy than without. Another study involving thousands of women found that the number one risk factor for perineal tearing was episiotomy.”

Though it often is presented as a choice–i.e. “would you rather tear or be cut?” I offer that there is a third option….Neither! A perineal wound is NOT an inevitable part of giving birth (even with your first baby). Though it is not abnormal to tear, it is also perfectly possible to not tear or need stitches. One way to work with your body to avoid tearing is to give birth on your hands and knees, kneeling, or squatting. Another way is to stop pushing when you feel a burning sensation or “ring of fire” and let the baby’s head naturally ease out. Your uterus will push the baby out without sustained, breath holding, high exertion pushing from you–you can rest and let your uterus do the work! When you are doing forceful or directed pushing you are more likely to tear than if you follow your own body’s pushing urges and signals. Some people also advocate perineal massage prior to birth to help the tissues stretch. While it does not hurt to become more familiar with this part of your body and how your muscles feel when they are relaxed or tense, perineal massage has not been shown to have very much effect on your chance of tearing during birth.

Why “Woman-Centered” Childbirth?

I refer to my approach to childbirth education as “woman-centered.” Why? I believe woman-centered birth supports normal birth. The two are inextricably linked. According to the Association of Labor Assistants and Childbirth Educators, “woman-centered childbirth recognizes the primary role of the mother, and allows labor to progress according to the mother’s natural rhythms.” As an ALACE trained educator, I stress the importance of respecting the mother’s instincts and choices about how to give birth, including positions for labor and birth,  comfort measures, and choice of caregivers and support. My goal is to help women reclaim trust in their bodies inherent abilities to give birth in a safe and unhindered manner.

This does not mean there is not a role for the father in birth or that I do not value the role of fathers. A father most definitely goes through a “birth” of his own–into fatherhood–and the psychological growth he experiences is significant. He also experiences fears and changes as he prepares to meet his baby and is of significant importance during labor and birth in his irreplaceable role of loving and supporting the mother of his baby. My beliefs about birth are underscored by the feeling that the mother is of central importance in the process of birth and that respecting birth as a woman-centered and woman-directed passage is the healthiest, safest, and best way for babies (and therefore, families!) to be born.

More about normal birth

I recently read on the Passion for Birth blog that the Maternity Care Working Party in the UK has a new consensus statement called Making Normal Birth a Reality. It is difficult to arrive at a concise definition of normal birth (which I define as “physiological birth”). They describe it as a women whose labor “starts spontaneously, progresses spontaneously without drugs, and who give birth spontaneously.” There is a lot of room in each of these for some interventions (such as electronic fetal monitoring) that many activists would argue impede the progress of normal, physiological, naturally progressing birth. However, it is nice to see the emphasis on spontaneity and also to see what other countries are doing/saying about protecting and promoting normal birth.

Evidence Based Care

Simply put, evidence based care is care that is based on the best available evidence (research, studies, accurate, up-to-date published materials) and upon the individual woman’s unique situation. Any interventions are applied judiciously and with consideration of true medical indication and also the needs of the woman. Evidence based care is different than “routines” or “policies” which may or may not have a basis in evidence.

Citizens for Midwifery has an excellent fact sheet summarizing the evidence behind the Mother Friendly Childbirth Initiative’s 10 Steps.

 In her excellent new book, Pushed, Jennifer Block shares the following about evidence based care:

“…The goal is to have a healthy baby. ‘This phrase is used over and over and over to shut down women’s requests,’ she [Erica Lyon] says. ‘The context needs to be that the goal is a healthy mom. Because mothers never make decisions without thinking about that healthy baby. And to suggest otherwise is insulting and degrading and disrespectful’…What’s best for women is best for babies. and what’s best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the kind of experience that most women have. In the age of evidence based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial considerations, by a provider’s licensing regulations and malpractice insurer. The evidence often has nothing to do with it.” (emphasis mine)

In the next couple of posts I will address some specific examples of evidence based care.