Tag Archive | maternity care

Sheila Kitzinger

‘Sheila taught me, from an early age, that the personal was political – not just by what she said but by what she did. As I was growing up I learnt from her campaigns for freedom and choice in childbirth that passionate and committed individuals can create social change. She never hesitated to speak truth to power. –Prof. Celia Kitzinger, Sheila’s oldest daughter

via Sheila Kitzinger 1929-2015 | Pinter & Martin Publishers.

Yesterday morning, I learned that childbirth education trailblazer, maternity activist, and phenomenally influential author, Sheila Kitzinger has died. By the end of the evening, her name was coming up as “trending” on Facebook, which is the first time I’ve ever noticed anything flagged for me as trending that wasn’t mainstream celebrity-related, holiday, sporting-event, OR horrible tragedy, disaster, or scandal related. So, Sheila continues to break new ground in maternity care activism!

My own work with birth and my philosophy of birth education and activism has been deeply shaped by this marvelous woman. She is one of my all-time favorite childbirth authors and may be the most quoted person on my blog! In fact, as I was scrolling through old posts to find some to share in memorial, I had to quit looking after the fourth page of search results because there were simply too many. Here are some of the ones I did find:

I agree with anthropologist Sheila Kitzinger who said that, “In any society, the way a woman gives birth and the kind of care given to her and the baby points as sharply as an arrowhead to the key values of the culture.” Our current birth culture does not value women and children. Though my focus is usually on the women, it also doesn’t much value men or fathers either. I also agree with Kitzinger’s assessment that, “Woman-to-woman help through the rites of passage that are important in every birth has significance not only for the individuals directly involved, but for the whole community. The task in which the women are engaged is political. It forms the warp and weft of society.”

via A Blessing…and more… | Talk Birth.

Same quotes used in two other posts:

These concepts—and the lack of a similar one in American culture—reminds me of a quote from Sheila Kitzinger that I use when talking about postpartum: “In any society, the way a woman gives birth and the kind of care given to her and the baby points as sharply as an arrowhead to the key values of the culture.”

via Some reminders for postpartum mamas & those who love them | Talk Birth.

And, Rites of Passage… Celebrating Real Women’s Wisdom | Talk Birth.

Touching on the political aspects of birth culture:

“In acknowledging woman-to-woman help it is important to recognize that power, within the family and elsewhere, can be used vindictively, and that it is not only powerful men who abuse women; women with power may also abuse other women.” –Sheila Kitzinger

via Birth Quotes of the Week | Talk Birth.

Personally influential to my own labors:

During my first labor, I experienced what Sheila Kitzinger calls the “rest and be thankful stage” after reaching full dilation and before I pushed out my baby. The “rest and be thankful stage” is the lull in labor that some women experience after full dilation and before feeling the physiological urge to push. While commonly described in Kitzinger’s writings and in some other sources, mention of this stage is absent from many birth resources and many women have not heard of it.

via The Rest and Be Thankful Stage | Talk Birth.

And, my own personal postpartum care: Ceremonial Bath and Sealing Ceremony | Talk Birth.

Her books shaped birth HERstory:

Women’s (Birth) History Month | Talk Birth.

And, my own birth education philosophy (as well as my core value in working with women):

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.

via Sheila Kitzinger on a Woman’s Right to Her Own Experience | Talk Birth.

And, she celebrated birth:

I hope all of the women I know who are giving birth in the upcoming season discover that, as Sheila Kitzinger said, “Birth isn’t something we suffer, but something we actively do and exult in.” (from promo for One World Birth)

via Invisible Nets | Talk Birth.

Thanks for everything, Sheila! You’re amazing!

“Childbirth takes place at the intersection of time; in all cultures it links past, present and future. In traditional cultures birth unites the world of ‘now’ with the world of the ancestors, and is part of the great tree of life extending in time and eternity.” –Sheila Kitzinger

via Tuesday Tidbits: Tree Mother | Talk Birth.


Tuesday Tidbits: Cesarean Awareness Month Round-Up


April is Cesarean Awareness Month and a lot of great resources have been catching my eye! First, there is a free webinar about the “Natural Cesarean” coming up on April 11th.

If you’re a first-time parent, make sure to check out 10 Tips for Avoiding a First-Time Cesarean from Giving Birth with Confidence. This blog also has a response to the question of Are “Big Babies” Cause for Cesarean? 

And, of course, also check out ICAN’s blog for an ongoing collection of Cesarean Awareness Month related posts as well as helpful cesarean awareness information on a year-round basis.

Science & Sensibility offers a great round-up of resources for clients and classes with regard to cesarean births, cesarean rates, and cesarean prevention: April is Cesarean Awareness Month! Resources for You and Your Classes

One a related note, Science and Sensibility also has a two-part series of posts analyzing the role of doulas in reducing cesareans for mothers using Medicaid:

Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part One

More fundamentally, however, we argue that doula benefits cannot be captured solely through an economic model.  Neither should doulas be promoted as a primary means to reduce cesarean rates.  Both strategies (economic benefits and cesarean reduction) for promoting doulas have significant barrier.

Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part Two

However, greater attention needs to be paid to issues of privilege and oppression within the doula community at large.  Advocates need to consider how the prioritization of the cesarean rate as a primary research or policy issue reflects a certain level of unexamined privilege. For those facing spotty access to health care, cultural and linguistic incompetence in care settings, the detrimental effects of the prison industrial complex and the child welfare system on families, and the effects of poverty, racism, and/or homophobia in general, there are other, perhaps equally pressing concerns surrounding childbirth than over-medicalization. Certainly, unnecessary cesareans and over-medicalization are detrimental to everyone, but we need to understand how the effects of these problems play out differently for differently situated people and not limit advocacy to these issues.

When I consider coercion into unneeded cesareans, I think of my own post addressing the flawed notion of Maternal-Fetal Conflict and from these earlier thoughts, I created the little graphic for Citizens for Midwifery seen above.

I think it is fitting to remember that mother and baby dyads are NOT independent of each other. With a mamatoto—or, motherbaby—mother and baby are a single psychobiological organism whose needs are in harmony (what’s good for one is good for the other).

As Willa concluded in her CfM News article, “…we must reject the language that portrays a mother as hostile to her baby, just because she disagrees with her doctor.”

via Maternal-Fetal Conflict? | Talk Birth.

I was honored recently to make a series of sculptures for mom recovering from a traumatic cesarean and hoping for a VBAC in the future. I hope to make a more detailed post in the future describing these figures and what they’re trying to communicate!

March 2013 070

I dug into the archives and found some older posts either about cesareans or relating to cesarean prevention:

Book Review: Understanding the Dangers of Cesarean Birth

Cesarean Awareness Month

Cesarean Trivia

Cesarean Birth in a Culture of Fear Handout

Guest Post: Abuse of pregnant women in the medical setting

Becoming an Informed Birth Consumer (updated edition)

The Illusion of Choice

ICAN Conference Thoughts

Helping a Woman Give Birth?

Consumer Blame

Two things came to my attention today that made me think about how ironic it is that the medical system “lets” or doesn’t “let” women do so many things with regard to pregnancy and birth care and yet if something goes wrong, the locus of control shifts suddenly and it is now her fault for the situation. I see this often with things like “failure to progress”—“she’s just not dilating”—and even with fetal heart decelerations (“the baby just isn’t cooperating”). With induction—“her body just isn’t going to go into labor on its own”—and with pain relief—“she’s just not able to cope anymore” (yes, but is she also restrained on her back and denied food and drink?!). There are other ugly terms associated with women’s health that blame the “victim” as well such as “incompetent cervix” and “irritable uterus” and even “miscarriage” (and its even uglier associate, “spontaneous abortion.” And then for women with recurrent pregnancy losses we have the lovely, woman honoring term, “habitual aborter.” EXCUSE me?!). And then today, via The Unnecesarean, I read about a doctor inducing “labor” and then performing a cesarean on a non-pregnant woman.

Okay wow. So much could be said about that, but the kicker for me is that the woman was blamed—“The bottom line is the woman convinced everybody she was pregnant.” Huh?! So random surgery is totally acceptable if the person is “convincing” enough? What happened to diagnosing something first? Or, for taking responsibility for an inaccurate diagnosis?

The final thing that happened is that I got a completely unexpected refund check for over $400 today from my own local medical care system. While I’m not complaining about $400 that I thought I’d seen the last of, I had to shake my head in disbelief at the reason for the refund—“you overpaid”—excuse me, but I think the real reason is, “you overcharged me.” I checked back through my bills and I paid what I was billed (which, now that I think about, did seem like a heck of a lot for services NOT-rendered. If I had been in less of a state of grief and shock perhaps I would have questioned it more!), but now it has become “my fault” (in a sense) by switching the language to my overpaying vs. them overcharging.

What interesting dynamics these are…

Benefits of Active Birth

From Janet Balaskas’ classic book, Active Birth:

“When birth is active–

  • There is less need for drugs.
  • Discomfort and pain are less.
  • The uterus functions better, so artificial stimulants are not usually necessary.
  • Labors are shorter.
  • The supply of oxygen to the baby is improved.
  • There is less need for forceps or vacuum extraction.
  • The secretion of hormones that regulate the whole process is not disrupted.”

Make sure to talk to your care provider about your plan for an active birth. You may have to introduce your attendant to the concept and be assertive about your right to have an active, normal birth.

Overused & Underused Procedures

My previous post about a good experience and a healthy baby as well as reading a relevant section in the wonderful new Our Bodies, Ourselves: Pregnancy & Birth book I’m reviewing made me want to post about this topic. There are a multitude of common procedures that are overused in hospitals and that when used routinely actually harm mothers and babies. I also thought about the multitude of evidence based, helpful procedures that are underused in many birth environments despite research indicating that they contribute to better outcomes for both mother and baby. (The use of the terms “overused” and “underused” and the examples below are taken from the OBOS book.)

Overused Procedures–these techniques are often used routinely (instead of appropriately based on true level of need in which case they can be truly helpful and sometimes even save lives) despite clear evidence that overuse is harmful:

  • Induction of labor
  • Episiotomy
  • Epidurals
  • Cesarean sections

Underused Procedures that have been shown to improve birth outcomes as well as to improve women’s satisfaction with their birth experiences include:

  • Continuous one-on-one support from a skilled caregiver during labor (a doula is a professional labor support provider who offers this one-to-one support).
  • Changing positions during labor (especially positions using gravity).
  • Laboring out of bed.
  • Walking during labor.
  • Comfort measures such as water, massage, and birth balls.

To increase your likelihood of satisfaction with your birth experience and of having a normal birth as well as a healthy mother and baby, choose a birth setting and care provider that supports and USES these underused procedures and only rarely, and appropriately, uses the overused procedures listed above.

Birth Experience or Healthy Baby?

As you may have read in many blogs in the birth world, ACOG issued a press release this month opposing the choice of homebirth for women. One of the quotes towards the end of the release, “Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby,” is a sentiment that I see expressed fairly frequently and I’d like to explore it a little. I do not think these two things are mutually exclusive by any means. I say, why not BOTH? A “good experience”/process of giving birth AND healthy baby–these two things can, should, and do go together. Many of the elements that make up a good experience are also things that are best for the baby–as I said, the two concepts are not mutually exclusive, instead they reinforce and contribute to each other! Most of the time, taking good care of a mother in birth (i.e. contributing to her “good birth experience”) is the very best thing you can do to take care of her baby. Babies do not need to be “rescued” from their mother’s bodies–healthy mothers help lead to healthy babies! Women and babies BOTH deserve a good birth experience.

I also question whether ANY mother actually considers this a choice, or makes this choice. Erica Lyon, quoted in the book Pushed, speaks eloquently on this topic:

“…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)

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.

Evidence Based Care Fact Sheet (& Mother Friendly Care)

In Sept. 2007, Citizens for Midwifery published a useful new fact sheet summarizing the evidence basis for the 10 Steps for Mother-Friendly Care. The fact sheet is two sided and packed with information. The Coalition for Improving Maternity Services (CIMS) has a mission “to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.” To this end, they created the evidence based
Mother-Friendly Childbirth Initiative (MFCI). This Initiative “provides guidelines for identifying and designating “mother-friendly” birth sites including hospitals, birth centers and home-birth services.” There are ten steps for mother-friendly care and ample evidence supporting each step.

CIMS also has a very useful consumer handout–“Having a Baby: 10 Questions to Ask“–that helps expectant couples ask questions of their health care providers to determine if the care they are receiving is the evidence based, mother friendly care all pregnant women deserve.

The 10 Steps are:

“A mother-friendly hospital, birth center, or home birth service:

  1. Offers all birthing mothers:
    • Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
    • Unrestricted access to continuous emotional and physical support from a skilled woman-for example, a doula or labor-support professional:
    • Access to professional midwifery care.
  2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
  3. Provides culturally competent care — that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
  4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
  5. Has clearly defined policies and procedures for:
    • collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
    • linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.
  6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
    • shaving;
    • enemas;
    • IVs (intravenous drip);
    • withholding nourishment;
    • early rupture of membranes;
    • electronic fetal monitoring;

    Other interventions are limited as follows:

    • Has an induction rate of 10% or less;
    • Has an episiotomy rate of 20% or less, with a goal of 5% or less;
    • Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
    • Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
  7. Educates staff in non-drug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
  8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
  9. Discourages non-religious circumcision of the newborn.
  10. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding…”

What about fetal monitoring?

Another area in which common practice or hospital policy often diverges from evidence based pratice. Women in hospitals commonly experience electronic fetal monitoring as a matter of course, particularly an “admission strip” on the baby and then at least 15 minutes of monitoring throughout labor. ACOG itself has recommended that routine continuous fetal monitoring be dropped from the standard of care for low-risk pregnant women and instead recommends intermittent fetal heart tone listening (which can be done with a hand held doppler instead of a fetal monitoring belt). Still, at least 85% of women giving birth in the US have electronic fetal monitoring even thought their practitioners own trade union (ACOG) does not specifically recommend it. Additionally, “electronic fetal monitoring without access to fetal scalp sampling” is on A Guide to Effective Care in Pregnancy and Childbirth table of forms of care likely to be ineffective or harmful. This exhaustive research summary of evidence based care practices for pregnant women also nots that there is insufficient data to support or to disprove the use of short periods of electronic fetal monitoring upon admission to the hospital.

Continuous electronic fetal monitoring with scalp sampling vs. intermittent ascultation (listening) during labor is included on the table of tradeoffs between benefits and harm. the book suggests that women and caregivers weigh the effects of those practices according to circumstances, priorities, and preferences  (this is the same table under which epidural analgesia is classified).