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Archive for the ‘birth advocacy’ Category

Tuesday’s Perinatal Health Conference featured keynote speakers Dr. Michael Lu & Dr. James Collins, who presented us with evidence for the root causes of the huge disparity between birth outcomes in black and white American women.

As you can see here, there is a huge percentage point differential between pre-term birth rates of black women than other racial groups – in fact it is nearly half again as much as white women. This chart shows that black American infant mortality rates are more than double white American rates. America’s scores on maternal-fetal health are poor across the board – we are 26th among industrialized countries, but we tend to not see the breakdowns by population when the numbers get released.

When I see graphs like this, I tend to think about how poor health care access, institutionalized racism, poverty and hunger lead to pre-term birth & low birth weight infants. You probably think about that too, but it turns out we are wrong. We should be thinking about something much harder to measure.

On Tuesday I saw with my own eyes data indicating white women with only a high school education have better birth outcomes than black women with a college education. I found this disturbing and a little hard to believe. It was even more disturbed when I saw the chart that indicated women immigrants from Africa and the Caribbean had birth outcomes as good as the white population here but that their daughters, in exactly one generation of living in the United States, carried the same risks as black women whose mothers were born here.

One generation of growing up black and female in America takes a bigger health toll than the pregnant body can bear. Our speakers shared the findings from recently conducted research connecting instances of interpersonal racism and preterm labor. This suggests that the allostatic load of black girls and women in America is so high that their bodies are suffering the consequences of racism. The flight or fight response is the body’s gift in times of danger, but it is not meant to be on at all times. When it is stuck in the on position, the body loses immune function, becomes prey to heart disease, high blood pressure and insulin-resistance – all risk factors for early delivery.

I will write more tomorrow about the effect this early programming has on the fetal development. If you want to look up epigenetics, you will be ahead of the class.

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Trauma

(As always birth stories are told with time mysterious delays and details changed).

The birth looked lovely. We were in a mother friendly hospital with very nurturing midwives. The mother labored well. Her husband held her hand. Her sister pulled her hair off her neck and teared up. I was busy with cool cloths, juice and words of comfort. It was her second baby. The labor was quick and relatively easy. Her baby was born in perfect condition.

We were in a play. Everyone acted just as they should – and still, there was something not right. My client was unkind to her spouse, dismissive towards her sister, and distrustful of the staff, arguing her case for things that they were trying to give her. She was getting everything she wanted, but she was not able to access it. Communication lines were failing. The midwife was lovely, but too soft spoken under the circumstances. I was translating in both directions. They didn’t know each other – that happens sometimes with on-call schedules.

Everything went so well but felt so wrong. It wasn’t the pain. I’ve been with many women in labor so I’ve seen pain. This was trauma. It may have been a previous birth or it may have been abuse – I don’t think from the current relationship – or it may have been both.

She was more peaceful and herself in deep labor. Her anxiety abated but swept back over her after the first moments of her baby’s birth. They were healthy. The dad held the baby and took pictures. They’d be sent home in a few days. I went home painfully aware of statistics.

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If you have heard of Henci Goer, it is probably because you have reading A Thinking Woman’s Guide to a Better Birth. Her other major work is Obstetric Myths Versus Research Realities, which is quite dense book, not exactly light fare pregnancy reading. I read this work as part of my childbirth educator certification. What I sensed intuitively, she has documented thoroughly: many of the most common practices in American obstetrics have little medical basis.

Working as a doula at hospitals here in Connecticut, I see in practise things that I know serve no purpose, that have no benefit and even can do more harm than good. I see different practitioners at the same hospital stating their preferences as though they were set medical truth which must not be questioned (No, you may not get in the hot tub if your water is broken. Yes, of course you can get in the hot tub if your water is broken. No, you may not get in the hot tub until you are 4 cm dilated. Yes, you may get in the hot tub, until you are 4 cm dilated.)
As a professional, I find this to be frustrating. As a laboring mother myself, I found it maddening. After Henry was born, I was very much in need of stitching; he had been transverse & the last moments of labor were just dreadful and messy. At some point after I had nursed him a bit and cooed him to sleep, the baby was whisked away to the nursery & I shooed Matt after him, as was always our plan. My own medical needs taking precedence at the moment. I hardly noticed his absence, wrapped up in my own pain and then transferring over to the maternity floor. By the time I’d gotten re-patched, cleaned and had my first dose of codeine, he was back. We nursed again and fell into a deep sleep.
Twenty two months later, I birthed Theo without a scratch. A hearty 9lb 3 ounce baby, after just a few hours of labor. They took him to the nursery after our feeding, to be watched for a whole hour (or was it 2?) – I was hardly tired, felt fine and literally watched the clock. I rang my bell begging for my baby to come back. I sent Matt in to be with him, but it all felt so stupid. We did not need the separation. It’s not ideal, though sometimes helpful or necessary, but in our situation, well, it was just dumb. If he had been on my chest, we would have slept. Instead, I stewed and got upset. I was told, of by huge baby with big old huge APGARS to match, that if “something” was going to happen, it would be within the first few hours. Oh, yes! They played the horrid “dead baby” card that I hate so much. I hate it because, sadly, sadly, babies do die. To me, the manipulative use of the “dead baby” card is a form of disrespect towards families who have suffered loss. Also, I see it as some form of terrorism for new mothers – who 48 hours from when you say that, you are going to ship off home with a 1-800 number, a few newborn pampers and a car seat check…with the seed planted, that “anything could happen.”
Damn it, people, we are all scared enough. Aren’t we?

So, where was I? Yes, Henci Goer, whose thoughts are much more organized than mine, led a seminar about the Illusion of Choice in Childbirth. It was a fascinating, interactive two hours at Yale – many midwives and midwifery students were there as well as local doulas. We went back and forth on what value information has in the obstetric setting of American hospitals. Knowing that separation from his mother was neither valuable nor helpful, did not keep my baby near me at Hartford Hospital, which is one of UNICEF’s 80 Baby Friendly Hospitals in the United States (Which seems to mean, I got a Whole Foods gift bag, instead of formula on my way out the door)

Birth doulas and childbirth educators have been working under the assumption, that if women have better information, they will have (and make) better (“better”) choices. It just doesn’t turn out to be that simple. Should I inform clients and students of options not reasonably available to them? There are no providers who will attend vaginal breech births here in CT. None, to my knowledge. So, hadn’t I better help them understand the procedures of a surgical birth and what the recovery will be like? When realities show me that choices are limited in scope, and in my ability to chose in a truly autonomous way

Yes, we birth junkies have our little illusion. I’ll tell you all about “natural” childbirth, and then you can go into the hospital and make your informed choice. Perhaps my own bias weighs too heaviliy there at times; perhaps I screen it out better on some issues than on others. We all have our non-negotiables. Maybe I have given you all the information in the world about the high risk of surgical birth associated with scheduled inductions, but it matters not one whit, your doctors are going to induce you, or fire you.

Hospitals have an alarmingly similar illusion – only it tends to translate into reality because in a hospital setting there are some big time power differentials at play. Their game is called informed consent. Its practice in the obstetrics department of hospitals is very nearly a laughing matter & usually goes something like this “it is time to break your water so your labor can move along, okay?” See, information and consent. The information is sparse, the consent is implicit. Informed refusal is hardly ever mentioned. Should you refuse that induction, you will have to find another care provider, late in your pregnancy. You could choose that, but your choice is now being made under duress, isn’t it? How free is your choice in that case?

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The baby was just 34 weeks. Her water had been broken for several days. He was a hearty little soul, quite fiesty – but tiny at just over 4lbs. To the NICU he went to be watched and cared for. Yesterday mom was discharged, and baby stayed, because we have no rooming in at the NICUs in our city hospitals. Nor is there any step-down NICU, for the babies being watched for potential problems, rather than being treated for problems. It was bittersweet. We were all so happy to see him doing so well. It was hard for them to leave their baby there. Yes, they may visit as much and as often as they like, but that is a far cry from coming home with a baby in your arms, a far cry from rooming in at the hospital. This baby is fine. His only requirements for discharge are taking all his feedings by breast of bottle (which he is doing), breathing on his own (which is he doing) and maintaining his body temperature (which he is not yet doing.) The crunchy doula in me wonders if he’d be just as well of rooming in with mom, sleeping at the breast, skin to skin under a blanket. The worried mother in me wants him and his mother to have the security of incubators and NICU nurses. Every part of me wonders, why can’t they have a little bit of both?

Next week I am going to join other caregivers in this area for a discussion with Henci Goer on the illusion of choice in childbirth. Tell me about it. No one plans for their water to break at 33 1/2 weeks. After that, choices are limited.

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The baby was just 34 weeks. Her water had been broken for several days. He was a hearty little soul, quite fiesty – but tiny at just over 4lbs. To the NICU he went to be watched and cared for. Yesterday mom was discharged, and baby stayed, because we have no rooming in at the NICUs in our city hospitals. Nor is there any step-down NICU, for the babies being watched for potential problems, rather than being treated for problems. It was bittersweet. We were all so happy to see him doing so well. It was hard for them to leave their baby there. Yes, they may visit as much and as often as they like, but that is a far cry from coming home with a baby in your arms, a far cry from rooming in at the hospital. This baby is fine. His only requirements for discharge are taking all his feedings by breast of bottle (which he is doing), breathing on his own (which is he doing) and maintaining his body temperature (which he is not yet doing.) The crunchy doula in me wonders if he’d be just as well of rooming in with mom, sleeping at the breast, skin to skin under a blanket. The worried mother in me wants him and his mother to have the security of incubators and NICU nurses. Every part of me wonders, why can’t they have a little bit of both?

Next week I am going to join other caregivers in this area for a discussion with Henci Goer on the illusion of choice in childbirth. Tell me about it. No one plans for their water to break at 33 1/2 weeks. After that, choices are limited.

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The more births I go to, the more I realize that other people exist. They really do exist, just as they are, and what’s more they are very often other. Which is to say, I find them not at all like me.

This is most interesting when I am at a birth in the role of a doula. As a doula, I am there exclusively to serve the laboring woman. I have no other task. The medical staff are there to monitor the health of the mother and fetus. They are there to intervene in a medically emergent situation, or even just an urgent situation, or in some cases when things go particularly quickly and well, just in the knick of time to catch the baby. If a woman’s partner is their, most often a husband, he is having his own experience of the birth – sometimes becoming a father for the first time. In that room, he is there as her partner and as father to be. He cannot possibly put all his wants and needs aside for this block of time – they are too melded into the experience. Sometimes other family members are there. Most often they purpose is to be among the very first to welcome this child into the world. They may or may not be off some service or comfort to the laboring mom. There is a lot of variation in that area, to be sure!! In any case, as the doula, I am usually the only person in the room exclusively their for the laboring woman.

There is little a doula can do to help, which is why I focus on serving. Those of you who have birthed know that the work belongs to the laboring mother alone. We cannot pass around the contractions and each do a few & then later pass around the pushes like it is eenie, meenie, miney, mo. I may be able to rub your back, your feet, or talk you through a contraction, but ultimately you are still in labor – a fact which becomes more and more apparent with each contraction & push. I think my work is purposeful, that it brings comfort, that it is worth respecting and listening to the laboring woman, but I also belief the birth is powerful, we can no more control it with water therapy and essential oils than we can with IVs and epidurals. Birth is big, so I attempt only to serve the woman I am with and leave the rest to internet debates and forums.

One of the most serving things I have to do is to remember that it isn’t about me. The birth I am in is only about the laboring woman. Sometimes I don’t feel any inner conflict about this at all. Sometimes it is easy to give up my time; at other times, not so much (I do get paid, but being on-all means a birth could come on a super convenient day or a really inconvenient night – like 13 days into staying up too late to watch the Olympics). Sometimes I am all energy & other times I am in the middle of my cycle and feel totally anemic. There are times when everything a woman chooses is just what I would in her situation. There are also times when the television is on the entire birth & I think Why is that on? Oh, because this is not my birth.

Some women birth completely in the nude – which bothers me not at all unless they are cold but hate the idea of clothing or blankets and it is July and she is in a hot tub on the second floor of a stuffy apartment. Then I think, why are we doing this? Why aren’t we in an air-conditioned hospital? Oh, because this is not my birth.

Some women are super modest & don’t want anyone seeing “anything”. So even though she may be 5 foot 2 – which means her head and her vagina are not all that far away from each other and she needs some encouragement to push with her epidural, I ask her permission to look and see if she is pushing effectively. Even though I can see just fine permission or no. Why? because this is not my birth.

I may think it is the very best idea in the world for one woman to get an epidural and take a nap and let it run off in the morning when she is 1ocm. Or I may think it is the best idea in the world for another to not get an epidural because her water is broken and it might slow things down and then we are looking at a long birth with pit in the bag & she is only 4 cm. I may think that if you get an epidural at 3am it would be a good idea to sleep. Or I may think if the pain is more than you are coping with well that a hot tub would be just the thing. Or I may think that the baby is posterior and want to run a series of position changes to shake him loose. But this is not my birth, which is to say that if she doesn’t to do what I think is a good idea, I just have to get over myself and move along to another idea that will serve her. Because, it is not about me.

And I confess to you hear and now blogosphere, that sometimes it is hard to get over myself. Sometimes I don’t want to sublimate my will, & ditch what would be my choice in a situation. Sometimes I just want to be the kid in the class who blurts out the answer before the teacher has finished formulating the question, but I do not, because that does not serve the laboring woman. She must find her own way. I must support her in that. It may be hard. It may be easy. She may be a pleasure to work with. She may be difficult and demanding, but it is not about me.

And so I hope you will understand that when I hear stories about doulas judging women for not breastfeeding, about them leaving when a woman chooses to get an epidural, about them being combative with the medical staff (who do after all have their own job to do & must work inside their scope of practice), well I just about lose it all together. So, one behalf of this doula, trying to stay real and sane and well within my scope of practice, I’d like to say, I’m sorry to any woman whose doula left her, bullied her or judged her. You deserve better. You deserve to be at the center of your own birth and have the people around you value you. And to any nurse, CNM or OB who got the wrath of the entire natural birth community tossed your way just because you walked in wearing scrubs, I’d like to reach across the aisle and say, Hi, I am a doula, but I’m not insane. I’m not scared of you. Please don’t be scared of me. Let’s do this together & do it well.

I had the rare pleasure of working in perfect harmony with the staff at a local community hospital. It was my first time there. There was respect and acknowledgment of my unique position from every single person I encountered – including the security guard at the ER who remembered I was coming, remembered my clients name and escorted me up to L&D on his way off his shift and home. In turn, I learned the names of every nurse who came in the room, had a friendly and professional chat with the Obstetrician and received a warm goodbye from the entire nursing staff. I told them I couldn’t wait to go to another birth in their corner of the birthing world. They were incredibly respectful to the laboring mom, who didn’t want to nap at 3am with her epidural. But that’s okay, because we all knew it wasn’t about us.

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This was not the blog post I was writing in my head about my home birth clients. I know I have been extraordinarily lucky to be witness to and participant in so many wonderful, supported births. They have each looked different, but I have felt the mother supported in her choices, in her laboring, in the way she chooses to birth. I have not happened upon any sad outcomes to date in my work life.

The woman who became a mother this morning had a truly beautiful labor at home. At different points along the way it was difficulty, tiring, draining, but she was supported – by me, by her boyfriend and her mother (downstairs making toast and tea), and by two midwives. I felt they were rather hands off for my tastes, but mother and baby were well. At a certain point it became clear that a c-section was necessary. Her contractions had stopped. She was fully dilated with a breech baby in her vagina, right there. One could touch his testicles (I did not. That is out of my scope of practice). I thought of Kneeling Woman, her inner conflict with midwifery & the way it is being practiced in the shadows. Birthing at home is not a hill to die on. There are risks in birth. We ought not to always have trust your body chatter and ignore the obvious – that baby needs out of the vagina, preferably before he notices he is stuck and not after he is in distress.

I felt the fetal monitoring was perfect. He was clearly well & so was she, except tired. So tired, her body protectively & effectively stopped her labor. There was no hard head pressing on her cervix to give her an overwhelming her urge to push & it would take both strong contractions and an urge to push to deliver a baby. When the time came to make the decision to transfer she was fully present with the decision and able to make it for herself. She was fine medically (baby in vagina not actually an illness – no bleeding, no fever, no chills.) She was able to shower and brush her teeth. Her boyfriend packed her bag. I picked a coming home outfit for the baby from a drawer full of hand me downs. It was simple and complicated all in one breath.

Suddenly, it became clear that her midwives were not going to transfer her. I was shocked. I have never heard of this happening. Midwifery is not illegal here; it is just not licensed. They were afraid to go to the hospital, even though there was really nothing wrong, there would be no bad outcome today. She would not be receiving the benefit of their support on the way to the hospital, nor would they be there to give a medical update to the on-call doctors who were about to perform an unplanned surgery on someone who just got wheeled through the ER. Oh and by the way, try not to mention our names. So, it was a self-transfer. We drove one way, the drove another. The admitting process was a bit painful. We expected it, but it overall was manageable. The dad in waiting got some practice standing up for his family. My lovely client just focused inward and occasionally looked my way for reassurance. I told her it was okay to tune out the chatter, the dismay of home birth, oh, we’ll see if you are really in labor, you can’t have a vaginal delivery here….she knew it all, she knew it was coming & had prepared herself for surgical birth to the best of her ability in those moments. The rest was just salt in the wound – she’d been laboring for close on 36 hours.

The hospital staff were disgusted with the midwives for not showing up – one more cog in the wheel of communication. Although, to be fair, no doubt they were disgusted and disappointed that they could not chastise the midwives as well as the parents. Still I heartily agreed. They ought to have come. And as an extra measure of good faith on my part, I will truly say, there were some staff members who were extremely kind to her, to her man, and some even to me – a moment’s humanity, a pause to appreciate this birthday. That this mother should be the casualty of some crazy mommy war spin off between hospital and home birth, well, it sickens me. Did The Business of Being Born movie do more harm then good? I like to think not. In general, I think open discussion and bringing things into the light is the way to go. What happened this morning rocked the ground under me a bit – those midwives leaving – those hospital staffers judging.

It was decided that because she did, in fact, have a baby in her vagina, that there was no time to wait for an epidural to work – she’d have to have a liter of fluids, it could take half an hour and they couldn’t risk any last contractions pushing the baby out (skeptical voice inside my head: yes, that’d be awful, if he was like, accidentally born without incident) because breech birth is out of their scope of practices. OBs are no longer trained in it. I just want you to know that I get that. They don’t do it- which was in fact what led this couple to contract with home birth midwives. They were not there to share her medical information, to advocate for the epidural – I have no medical role and this couple was just tired and needed their baby soon.

The bitter news came, it would general anesthesia. She’d be asleep and dad would not witness this birth. They separated us all. He into one waiting room, me a hallway and a door away in another “non-family” area. Yes, we were put in time out. Ha. Hours before we had shared a bed with this incredibly beautiful birthing woman. I stayed connected to them in the next hour with tears, prayer and meditation – things that don’t mind so much about walls, hallways and hospital policies.

This new father came out to see me after his son was born, numb from joy, tear-streaked and relieved. We snuck into post-op together so I could meet this beautiful boy. He was lovely and fine. She was tired, groggy and had had extra blood loss & so very, very pale. She was cooing to him, holding him, loving him.

The midwives have called me twice. They wanted to check did everything go okay. Was the baby okay – did they give out our names to the hospital, by the way?
I am struck absolutely dumb. I can’t find the words to speak. My exit strategy is sleep. I’ve gotten a few battle scars from the world of birth. I won’t be forgetting these any time soon.

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