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.

Book Review: Giving Birth with Confidence

Jul6

Since I recently wrote a post inspired by a quote from The Official Lamaze Guide: Giving Birth with Confidence, I figured it was high time that I share the review I wrote of the book! The review was originally written in 2007 for CfM News.

The Official Lamaze Guide: Giving Birth with Confidence. By Judith Lothian & Charlotte DeVries. Published in 2005 by Meadowbrook Press (307p), $12.00. ISBN: 088166474X

Reviewed by Molly Remer, MSW, CCCE

Very few pregnancy books deliver the message that we think pregnant women need to hear most: Birth is a normal and natural part of life….We believe deeply that birth is a process you can trust just as millions of women before you have. This belief isn’t sentimental; it’s based on our thorough understanding of the physiologic birth process and research that confirms interfering in that process is harmful unless there is clear evidence that interference provides benefits.

So begins an opening section of the book The Official Lamaze Guide: Giving Birth with Confidence. The degree to which the book accomplishes its simple message can be summarized with a simple review: Excellent! The Lamaze Guide is digestible and reasonable for busy people to manage at less than 300 pages of text and it contains a simple, profound, and elegant message that women in the U.S. desperately need to hear.

The book begins with defining normal birth as “…a normal birth is one that unfolds naturally, free of unnecessary interventions.” It then briefly explains the history of birth and how and why normal birth is not actually the norm in our culture. The authors then clearly address the following areas in one chapter each: early pregnancy; choosing a caregiver and birth site; middle & late pregnancy; preparing for labor and birth; the simple story of birth; keeping birth normal; finding comfort in labor; creating a birth plan and a baby plan; communication and negotiation; greeting your newborn; and early parenting. The authors are clearly very supportive of midwifery and the Midwives Model of Care (though it is not referenced by name) as well as of the benefits of a doula in the birthing room.

The book is framed in the context of Lamaze International’s powerful foundation, the Six Healthy Birth Practices:

The book is also guided by Lamaze’s comprehensive and lovely philosophy of birth:

Birth is normal, natural and healthy.
The experience of birth profoundly affects women and their families.
Women’s inner wisdom guides them through birth.
Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.
Women have the right to give birth free from routine medical interventions.
Birth can safely take place in homes, birth centers and hospitals.
Childbirth education empowers women to make informed choices in health care, to assume responsibility for their health and to trust their inner wisdom.

After effectively bolstering the confidence of women in birth, The Lamaze Guide concludes with several useful appendices. The first is the excellent tool “Effective Care in Pregnancy & Childbirth: A Synopsis.” Though this information is easily available on the internet (see www.childbirthconnection.org), I find that many parents do not come across it on their own. How powerful to have it included for easy reference of indisputable evidence based practices. The Mother-Friendly Childbirth Initiative is included in another appendix as well as the always excellent text of The Rights of Childbearing Women. I was delighted to see all of these powerful documents in one place—and, in the hands of consumers who need to be aware of them.

This book is a refreshing presence on the shelves of my local bookstore (yes, there is only one retail book shop in my community and The Lamaze Guide is the only “alternative” birth book stocked in the store!). As I read the book, I kept nodding along and wishing it was in the hands of each pregnant woman in my community. Lamaze has a “name recognition” that gives this book the potential to have a wider and broader impact than other alternative birthing books which, though brilliant contributions, may only end up in the hands of “the choir.” The Lamaze Guide is written in such a matter-of-fact and comforting tone that I cannot see it being off putting to the average consumer as having “hippie” language or “extreme” ideas. The blueprint for normal birth that the book lays out is extreme compared to the standard practices at most hospitals, but the way in which the information is presented opens doors of communication, understanding, and exploration as well as providing the evidence basis to back normal birth. I would not hesitate to lend this book out as it will not scare anyone away with “weird” ideas. With the other books in my personal library, I have to carefully consider my audience before choosing which book has the right style and blend of information—not this one! It is good for everyone with its open, simple message. It is a good addition to lending libraries, personal libraries, to give as a gift, or to recommend to others. The Lamaze Guide is straightforward and clearly written with an unabashedly honest and truthful message of what normal birth is and how it can either be supported or undermined.

My only critique of the book is that in contains no real acknowledgment of the several other well known and effective organizations that train and certify birth educators (other than Lamaze International itself). Conspicuously absent from the resources pages are any of these other organizations.

In conclusion, The Lamaze Guide is a source of information that women need to have and a message that women need to hear. I think Giving Birth with Confidence accomplishes its purpose skillfully and has the potential to be a transformative influence. I hope women read it, absorb it, and begin to Celebrate Birth!

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.

My Message?

Jun15

The Orgasmic Birth fan page on Facebook was having a giveaway and to enter the contest the following question was posed:

You are given the chance to speak to the world about childbirth. What is your message?

What a great question! This was my response (as I re-read it, I see I answered as if I was only speaking to one person and not the world. Darn it. I want to speak to the world!):

Birth can be a beautiful, powerful, joyful celebration and a transformative experience. Women’s bodies have a deep knowing of how to give birth and I encourage you to choose a birth setting the supports the unfolding of this knowledge. Women can safely and joyfully give birth in any setting, but freedom, privacy, individualized care, and respect make a HUGE amount of difference in how readily you will be able to have the birth you imagine–so, choose carefully. You do have options. This baby will only be born once, so don’t wait for “next time” to have the birth that you and your baby both deserve.

The needs of mothers and babies during birth are intimately entwined–what is good for mother is also good for babies. Do not ever be misled into thinking that you have to choose between a “good birth” or a “healthy baby”–good, satisfying births are exactly the kind that are most likely to produce that healthy baby!

One Woman Awake

Jun12

Several years ago, I received a card from the National Association of Mothers’ Centers with the following poem printed on the front:

One Woman Awake
Awakens another,
The second awakens her next door neighbor.
And three awake can rouse the town,
And turn the whole place upside down.
And many awake
Can raise such a fuss
That it finally awakens the rest of us.
One woman up,
With dawn in her eyes,
Multiplies.

——

It has been hanging on the wall behind my computer since 2007 and it still gives me chills to read it. Of course, it can be applied to many elements of women’s lives, but I look at it through the lens of birth advocacy. I always say that what I want to do with my life is simply to transform the birth culture in the U.S. A lofty goal maybe, but if many awakened women raise enough of a fuss, it could happen!

Pain Pie Exercise for Birth Classes

Jun9

I address the issue of pain in several ways during my classes. I have struggled with doing this—by mentioning pain do I plant the seed that their births will be painful? etc. I’ve eventually come to a place where I feel like it is important to mention pain directly and to look at it head-on. Many people have the perception that birth is THE most painful thing ever and essentially the most painful thing anyone could ever imagine. So, I feel like by not talking about pain in class, I would be ignoring the elephant in the room of THE (cultural) pinnacle of pain. While I have no doubt that birth can be very painful for some women, I deeply feel that our current birth culture and manner of treating birthing women makes birth painful for more of them.

A very useful tool in exploring sources of pain is the “Pain Pie” idea from Teaching Pregnancy & Birth: A Childbirth Educator’s Perspective by Marcy White (published by ICEA). With this tool, you create a red circle with the word pain on it and a separate set of white wedges (pie pieces) each containing a supportive element, such as “movement” or “relaxation techniques.” Each piece of pie covers up a portion of the red “pain”—as elements of the pie are removed, the pain piece gets bigger and bigger (an alternative presentation is to add pieces, so that the pain gets smaller).

I mention that too often women in our society are left feeling as if they “couldn’t do it” or that their bodies failed them, but in reality their coping pieces of the pie were stripped away from them (sometimes forcibly). I also talk about how sources of distress to the mother during labor: lack of emotional support, disrespect, ignoring of needs, repeatedly offering medications when none are desired, and restriction of movement, often have little to nothing to do with pain, but instead to what is happening around her (environment and caregivers).

Interview with Elizabeth Stein, CNM

Jun7

Recently I had the opportunity to interview certified-nurse midwife, Elizabeth Stein, CNM, MSN, MPH. Elizabeth practices in New York and has experience with high-risk populations. Visit her at her website: Ask Your Midwife.

1. Please tell me a little bit about your services as a midwife:

My private practice provides obstetrical care, which includes prenatal care, labor and delivery, postpartum and breast feeding. After delivery, women are seen 6 weeks postpartum. Alternatively, women who had a cesarean delivery are seen for an incision site check at 10-14 days post partum and once again at 6 weeks.

GYN care includes an annual GYN exam, which includes a Pap smear, STD testing and treatment, breast exam, urine test and blood work. I also address common GYN complaints, such as family planning/birth control, basic infertility, and pre/ postmenopausal care. I provide primary care and stress the importance of being proactive.

2. How long have you practiced?

I have been a certified nurse midwife 25 years and have delivered more than 2600 babies.

3. What inspired you to become a CNM?

I was an EMT before I was a nurse. On one occasion, I was working in the emergency room when the director told me to go upstairs to L & D to learn how to do a delivery, since that would be helpful while working in the ER. The female doctor I worked with was so beautiful, calm and relaxed, yet very attentive. She calmly and gently delivered the baby. Instantly, I knew this was what I should be doing!

4. What are the top questions you are asked by expectant mothers?

Is my baby ok? Is it a girl or boy? Where will I deliver? When can I have a sonogram? When is my next appointment? How much weight should I gain? Do I have to take prenatal vitamins? How will I know if the water breaks? How will I know when labor starts?

5. What are your thoughts on current bioethical issues in maternity care? (particularly elective cesarean section)

Elective cesarean delivery (maternal request)

TOL/VBAC (trial of labor-vaginal birth after cesarean) versus repeat cesarean delivery

Home births

Circumcisions

Cord blood collection (fetal stem cells)

Chorionic villus sampling (CVS) and amniocentesis

Oocyte and embryo storage (prepregnancy)

6. Any tips for women planning a natural hospital birth?

The hardest yet most rewarding day of your life! Natural means vaginal versus abdominal (surgical).

Baby’s going to come, when the baby’s going to come (doesn’t read the sonogram report or prenatal chart). Baby is in charge.

Stay home as long as possible (exceptions: rupture of membranes, group b strep positive, vaginal bleeding, other medical or obstetrical reason to come right in)

Your birth plan is a wish list, not a guarantee!

Don’t start labor exhausted! Rest!

Eat and drink (you may vomit later)

Know who will deliver you

Know when to go to labor and delivery

Beware of unrealistic expectations. Go with the flow of your body. Be flexible and open minded.

Know how you may labor…..in bed, on the ball, walking, on the fetal monitor, in the shower

You may have to bail out……and have a cesarean delivery….it’s not a failure, just another route of delivery

It’s your baby……everyone wants the baby in the first 5 minutes! Bonding is ongoing and forever

Breast feeding is not as easy as it sounds but everyone will help you

Nobody is judging you! Once you are a mom, you wear the badge MOM.

Whatever pregnancy and birth experiences it took to make you MOM should remain a memory and should not haunt you.

Enjoy your baby!