Why you shouldn't "try" to have an unmedicated birth

You will hear many women say they are going to "try" to have an unmedicated birth. To me, "trying" connotes sheer effort and endurance. What I hear women say when they say "try" is that they are just going to see how long they can stand the pain. My dictionary defines "to try" as "to make an attempt or effort". What happens when you try something? Either you can succeed or fail.

There's a lot of derisive talk out there about birth plans and women who "plan" an unmedicated birth - or really plan anything about their birth at all. There is a lot of fingerwaving about how birth is unpredictable and you can't PLAN anything. After seeing a lot of births, I have to say I agree. My dictionary says to plan is to "decide on and arrange in advance" - you can't really do that with your birth. What happens when you plan something? Maybe your plans work out, and maybe they don't.

What I wish more women would say, and take ownership of, is that they are preparing for an unmedicated birth. My dictionary says " to prepare" is "to make ready or able to do or deal with something".This sounds just about right! Someone who is prepared does not fail or have plans not work out - they meet what comes with their goal in mind. They have made themselves ready to handle birth and any twists and turns they might meet on the way.

I encourage women to think of birth as a marathon - it is long, challenging, sometimes painful, sometimes exciting, and can be very rewarding. Many people regard having run a marathon as difficult, but very rewarding and a huge achievement. However, if you knew someone who told you that on Saturday they were going to "try" to run a marathon, you'd probably look at them a little askance. You'd start asking questions: "Have you practiced? Did you read up about marathoning and long-distance running? Do you know anything about the route?"

What would you think if they said, "I'm just going to start running and see how long I can stand it. There will be people along the way to tell me where to go." You might have some more questions for them. "Don't you think that at some point you're going to get exhausted and want to quit? If you haven't prepared, how will you have the resources to keep going? Wouldn't you like to know something about the course - where the steep hills are, where to save your energy, where to expect things will be tough?"

If this person then tried to run a marathon, and dropped out at mile 10, or had a miserable time, and then told their friends how horrible marathons were and how stupid someone would have to be to go through that awful experience just to prove they were "tough"...wouldn't you be skeptical about their opinion? And yet that's where we're at in a lot of ways. Many women see unmedicated birth as some kind of test that you pass via sheer endurance and "feminist masochism", as one doctor in "The Business of Being Born" puts it. There's often a vague, generalized perception that drug-free is "better", but without much clear understanding of the actual risks of drugs. If you "try" to have the unmedicated birth and "fail", then you have a lot invested in trying to convince people that this "test" is silly and has no bearing on your strength, motherhood, or womanhood (a position I agree with completely). I think many of the birth horror stories and dismissive "just take the epidural, honey, you're gonna need it" comments that pregnant women here come from that place.

On the other hand, if you approach natural birth with the mindset that this is a rare and challenging event that you would like to fully experience, with interventions available whose risks you'd prefer to avoid, you can prepare for it. You can take classes, read, and find good coaches and support systems. You can remain flexible and open to changes in the situation. Let's ditch this whole "trying" thing and switch to "preparing".

What is breastfeeding?

In my foundational maternal child health class last week, we had a great presentation from one of the leaders of breastfeeding research and promotion. She went through a list of everything that breastfeeding provides:

- Breastfeeding is the baby's first immunization. It continues to protect the baby, through antibodies produced by the mother, as long as the baby/child is breastfed. Breastfed babies get fewer ear infections, less diarrhea, on and on and on.

- Breastfeeding is oral rehydration. Oral rehydration is the simple but lifesaving technique for saving children (and adults) when they have diarrhea - a very common killer. When someone has diarrhea, you make a solution of salts and sugars in water (not just water - you want to maintain electrolyte balance) and have them drink it. It's even more successful when you add a little bit of protein. That's breastmilk. In developing countries, babies and children with diarrhea have a readymade oral rehydration solution in breastmilk.

- Growth and development. She discussed all the ways breastfeeding promotes healthy growth and normal neurological development. Perhaps the most interesting part of this, for me, was the possible contribution of breastfeeding to "epigenetics". Epigenetics is a new field that looks to explain, for example, why identical twins have different health outcomes, even when those health outcomes are strongly linked to genetics. Epigenetics is how environmental factors act upon ("epi" = upon) the genes you're born with. For example, breastfeeding colonizes the gut with a particular kind of flora; how the gut is colonized in infancy may affect how genes are expressed there for the rest of your life. Really interesting!

- Reduced cancer and chronic disease. Again, this may be linked to epigenetics. In terms of chronic disease, obesity and formula feeding have sometimes been linked as well, with the theory that bottle-fed babies are, by nature, overfed. Bottle nipples flow very quickly - in fact, babies don't have to do much sucking at all to get the liquid out and can end up eating a lot more than they're actually hungry for, whereas breastfed babies must actually work for their meal. There's also a tendency to want the baby to "finish" the bottle. Could it be that bottlefed babies always get just a little more than they need - and set that habit for life? It's a theory worth exploring.

- Maternal health and survival. Women who breastfeed return to (and maintain) their prepregnancy weight faster than women who don't. Women who breastfeed also have a lower risk of breast cancer and diabetes later in life. There is a dose-response relationship - the more breastfeeding time, the less risk.

- Birth spacing and fertility. I would not myself depend on lactational amenhorrhea (not getting your period while you're EXCLUSIVELY breastfeeding) for birth control, but in some parts of the world that's all there is. If you can encourage a mom to exclusively breastfeed, she will probably not become pregnant again as quickly and will have a better chance of surviving her next pregnancy (and her children will benefit, as close birth spacing has an adverse affect on them as well).

- Family savings. Breastmilk is free, although it is important to note that breastFEEDING does have a cost, in time and in a small amount of increased calories needed, to the mother. But the health costs associated with not breastfeeding can overwhelm those costs anyway.

The thing I loved about her presentation was that she finished up with "Oh, and also, breastfeeding provides nutrition." Oh wait, right! Along with all these benefits - it's also the baby's food! How often do public health professionals, or the public at large, think of breastfeeding as just what the baby eats? There's so much more!

I know a lot of my classmates got excited about breastfeeding out of that presentation. I've seen a lot of breastfeeding education, but I had never seen it presented so effectively as something that affects almost every area of maternal and child health. And I haven't covered even a third of what she talked about in terms of the benefits - what's above are mostly examples. If anyone out there is interested I can forward you some of the slides.

Wow, a reasoned friendly discussion!

The article this week in the NY Times about home birth of course occasioned pages and pages of comments. The "my baby would have died at home, you need to put your baby's life before your 'birth experience'" and the "I had an unassisted birth and everything was totally fine" - essentially anonymous, mostly anecdotal, and mostly depressing because I feel like the discussion is in no way advanced.

And then I came across this blog entry. Wow - a woman writes about her plan for natural birth, and other women respond sharing their stories and discussing their opinions in a respectful and balanced way. I enjoyed it in that it was literally a joy to read. I hadn't realized how flamewar so many other discussions get until I read one obviously conducted by reasonable adults.

orgasmic birth

I just came from a showing of Orgasmic Birth. The auditorium was full of midwives, doulas, mothers, and more, and Debra Pascali-Bonaro who conceived and directed the film was also there to do a Q & A. I have met her on just a few occasions but I will say without hesitation that she is one of the most wonderful, warm, genuine people I have ever met. If you ever have a chance to do a training with her or see her speak, do it!

I really enjoyed the film, although my enthusiasm did wane at a few moments. Home birth and natural birth have a very hippie-dippy, celebrate-the-moon-goddess reputation. I am not maligning people who do celebrate the moon goddess, but people who don't often do not respond well when invited into birth on those terms. For a movie that I think has such potential to help the "mainstream" see birth as something other than terrifying, there were certainly moments in the film that got into territory I think the mainstream would have a lot of trouble identifying with. That said, we have to ask if those people are going to be willing to see a movie called "Orgasmic Birth" anyway.

There were many moments in the film that I loved. The woman giving birth on her deck. The sexual abuse survivor who talked about reclaiming her body through birth. Seeing a couple who ended up going down the intervention road, which I think shows people just how profoundly different a managed hospital birth is. Not everyone had an orgasmic birth; the movie talks not about every woman having an orgasmic birth, but every woman having the space for one to occur (along with just having the space to birth normally and peacefully). The funniest, and maybe most inspiring moment, is the woman who does actually have an orgasmic birth who is literally cross-eyed with pleasure! It got a big roar from the crowd.

Just being around so many people who care about birth and are working towards the same ends was so energizing. I spent a while after the movie just talking with people, thanking Debra for coming, meeting people who are active in birth in the area. I would love to attend a home birth some day and am going to try to put out feelers for that. It's not easy to break into home birth doula-ing but I'd like to try.

The Q & A was very interesting - of course in a crowd like this, some of the Qs are more stories than questions, but they are often so interesting in their own right. One of the things that was discussed was fear. Biking home on my post-movie high, I started thinking about that. So many women enter the birthing process terrified of birth. The woman I worked with last weekend was one of them. So fearful, so upset, without any information on what was normal and healthy.

I started thinking of comparisons we could draw to the birthing process. When someone is so afraid of birth that they choose an elective c-section, what kind of analogy could we draw? How about people who are so anxious about flying that they can't fly, or have to take heavy sedatives. We don't celebrate their "choice" not to fly; we feel sorry for people who are that anxious because we realize that they're frightened of something that's really not that dangerous, and as a result they limit their life experiences. We realize that while something bad could happen, the risk is very small. As friends, we reassure them, and professionals offer therapy to help them overcome their fear. We don't say, "Well, I guess they're empowered by their choice not to fly," because it isn't a real choice - it's something driven out of fear. But we've made fear of birth so normal that we don't even notice or try to treat it, except for the rare class such as Birthing from Within or Hypnobirthing, that draw these fears out into the sunlight and give women tools to handle them with.

The saddest thing about this analogy is that while we'll do all this work to help someone overcome fear of something so banal as sitting on an airplane with not enough legroom and terrible food, we won't do it to help women experience what can be a life-changing experience. Some of the births you get to see in this movie are just that. It is incredible.

The same analogy doesn't exactly hold true for women who are so afraid of pain that they hope to get their epidural so early they don't feel a single contraction, but I think it's a symptom of the same problem. It's a big problem, a huge problem, and I don't know how to counteract it. But I do know how I'm trying to address it in my own small way, which is to show movies like Business of Being Born and Orgasmic Birth to all my friends. If fear is the disease, then knowledge is the antidote and I want to spread it around.

Back into doula-ing

I haven't been updating this like I want to! I know no one reads a blog that's only updated once every two months (although if you use a feed aggregator - I use Google Reader - then you might see entries from me pop up from time to time). I'm going to try to update at least once a week for the rest of the semester, and see how that goes.

I think that will be helped greatly by the fact that I have started working as a doula again! It's been too long since I was at births. I am volunteering for a hospital-based doula program, which is fabulous - that's how I started working as a doula. I know it so well and enjoy it so much. I believe being a hospital-based public health-focused doula calls on some different skills from those of a private doula. In many situations, you're playing a mix of traditional doula, social worker, and friend - the kind of friend a lot of birthing women do not have.

Last night was my "mentor birth" with a doula who has already been volunteering there for a while, so I could learn the ropes. We just went in there hoping to find someone to work with, and did. My mentor doula partner could only stay for about six hours; it was great to have her there before I started flying solo in a new hospital. Every labor and delivery floor has its layout, quirks, and personality for you to learn.

The labor I attended gave me a lot of food for thought, especially being my first one after an extended break from doula-ing. As I closed my eyes for my catnaps throughout the night, I thought about what I wanted to post today. I wanted to share some meditations about two things I wish all women might do at their births:

First, not to engage in the doctor's "nudging" conversations. "Nudging" conversations go like this:

DOCTOR: [right after a cervical exam] We-ell, you're at 5 now, which is good. We might want to think about breaking your water soon to get things moving a little bit.

WOMAN: [usually this is the first she's ever heard of this concept] What's that?

DOCTOR: It's when we just take a little hook and break your water. It helps bring the baby down and it can speed things up.

WOMAN: Will it hurt?

DOCTOR: No, you don't have any nerve endings in your bag of water. I'll just take this hook [shows hook] and just slide it up there. You'll just feel fluid. It just helps speed things up a little, it can help you get this over with quicker. What do you think about that, could I do that for you?

WOMAN: [overwhelmed by all the information] So, it's going to help?

DOCTOR: That's what we're hoping, there's no guarantees but it can help move things along, you're just at a place where we want to make sure your labor keeps progressing and we don't want things to slow down. I'll just slide it right up there and break your water, it won't hurt.

WOMAN: Yeah, I guess.

DOCTOR: Okay? Can we do that now? It's totally up to you.

WOMAN: No, that's fine, I guess we can do that now.

DOCTOR: Okay, wonderful! I'm just going to sit on the edge of the bed right here...

And so forth. The mom is given the sense of control over the decision, and lots of information, but not the information (risks and benefits) that she might really need, and her "control" option is often emphasized late in the game when she's already seemingly decided in favor. If this sounds like a conversation that you might have with a small child that you're trying to convince to do something, you're not far off the mark. Many women I work with come in with almost zero information about childbirth. They haven't taken classes; they don't know what a cervix is. Doctors know this; I'm not saying they like to have uninformed patients, because I want to believe the best of OBs (I really do), but they are not above (even subconsciously) using the information deficit to their advantage. Even if I can offer the mom and her partner some extra information on risks and benefits, the conversation is usually over before I could have a quiet talk with them alone.

However, this doesn't just apply to the childbirth unedated; even people who are very prepared can succumb easily to the nudge. You're exhausted and a little scared and you just want things to be over with. Whether or not they're going to move your labor in the direction you want, it's easy to find yourself agreeing to something before you've had a chance to pause.

However, there are ways to be un-nudgeable and give yourself space and time to think and talk over your options. One great way is just to say "I'm not sure, let me think about it" to everything. Ask all the questions you want as they explain, but keep saying "I'm not sure" until they've given their final spiel about how it's up to you and left. They might throw some scary stuff in there - heart rate dipping, labor slowing, etc. Hear all that, and then let them leave and think and talk it over. If it's a true emergency, you won't be given any choice; if you're being offered an option, it's because it truly is an option!

The second is the role of fear. I loved this post about fear and childbirth. I have worked with women who are just terrified of birth. No one has ever helped them work through the fear that our society instills about birth so they can embrace it. It's incredibly sad to see what should be a happy experience be a horrified ordeal. Every woman should receive positive childbirth ed.

Some of these women do end up embracing some of the more frightening aspects of technology (elective c-section anyone?). Others, though, become the least nudgeable women I've ever seen. They are paralyzed with fear of doing anything; they consent to nothing. It's one way to have a natural labor, but it's a pretty miserable way! It's also a very difficult way to achieve any kind of progress because they are so tense and frightened, they can't relax enough to dilate. It often leads to c-section and a very challenging experience all around. I feel really deeply for those women.

So those are my meditations for the day, on nudging and fear. Not a very coherent theme, but I wanted to get those down. And one last observation, extremely simple and to the point: inductions can be so difficult and should be avoided at all costs.

If I could wave my magic wand and change one thing, it would be hard to choose, but it might be the willingness of OBs to induce. Reasons not to induce, in my book: tired of being pregnant, "large baby" (uh-huh), past dates (by four days), convenience, etc. etc.