Dear American Hospitals

Dear American hospitals,

They can do it in the Philippines - why can't we? As a world leader in health care, shouldn't all U.S. hospitals be baby friendly?

Yours sincerely,
etc. etc.

"That baby would never have fit"

At Better Birth, the story of a pelvis that seemed too small. The second I read this story I thought of a very different one.

Back when I worked in Denver, I was paged into a birth for a young woman having her first baby. She really wanted to have an unmedicated birth. She was a very sweet woman, and very petite. She and her family asked a lot of questions about whether she could squat for the delivery - they were really interested in alternatives. Unfortunately, she had a slow labor and her membranes were already ruptured. In the hospital, this is more or less a "don't pass go, don't collect $200" card straight to Pitocin. With the Pitocin, her already long and tiring labor become too difficult to manage without medication and she asked for an epidural. She was finally able to sleep and had several cervical checks from a pleasant new doctor, a somewhat older man re-doing his residency after moving from Italy. He looked skeptical after each one. "I just don't think this baby is going to fit," he said.

When she finally dilated to 10 and he said very lukewarmly that we could "give pushing a try". With his fingers still up by her cervix, he encouraged her to push with a contraction. Totally numbed by the epidural and unable to feel a natural pushing urge, we coached her to push during a contraction and she did her best. He shook his head. "It's not budging. We'll need to do a c-section." In my memory, he let her try only once, although he may have given her a couple contractions - it was very brief. She was so tired, and he was so firm that there was no way the baby could come out, but I still think back and wonder if there's something more I could have said or done to encourage waiting. To my memory, there was no fetal distress and no reason to proceed quickly to surgery, although I don't have the birth record I kept with me right now to confirm. But what I do remember is his absolute belief that the baby could not come out vaginally, and how it seemed self-fulfilling.

Now, I didn't feel what he felt. Maybe the head was really wedged oddly and he could tell there was no way to manipulate it and no way for it to fit through. But read above, again, for the story where care providers believed there was no way for the baby to fit and yet proceeded as if there was. Think about how things could have been different if the woman I worked with did not have Pitocin or the epidural, and could follow her instincts or be coached to help expand her pelvis. For the rest of her life she'll believe her pelvis is too small to give birth vaginally...unless of course she sees a video like this.

I have seen doctors tell women post-cesarean that the babies "never could have fit" even in situations where they couldn't really know that. The most recent one was especially strange - the woman had a c-section for a number of reasons including failure to progress (so she never got to push), she was not a small person, and the baby was not that big. And yet the OB told her "that baby would never have fit". One of the things they pointed to was the size of the head, but of course the head can mold during pushing and this baby's head was totally unmolded because of the surgery. Is this a doctor's idea of making women feel better about their c-sections? It's just totally strange.

More on the medical profession

Dr. Pauline Chen asks in the New York Times, "Do patients trust their doctors too much?" She discusses how patients rating their doctors tend to rate almost exclusively based on the doctor's attitude. Are they nice, attentive to questions, not too rushed? There is little comment on the actual quality of medical care. She sees this as trust - that patients trust that all doctors are providing them equally good medical care. I would frame it differently - that patients have no way to compare and assess medical care, the way they can the work of other professionals like roofers. Does the roof look good? Are the materials quality? People feel well-equipped to assess these questions. But to take stock of your doctor's care - did she prescribe an expensive new drug or the cheaper and just as good generic? Did she order tests you needed, or skip them? People don't know and don't feel equipped to find out.

I have met many women who trusted their OBs because they were "nice". Sometimes I have gently tried to question something, only to hear "He's very nice and I trust him completely." I think you should choose trust your care providers, but not because they are nice, but because you have equipped yourself to assess their care skills and how well they can assist you in having the safe, healthy birth experience you want. How do you equip yourself? First, you have to decide what birth experience you do want and then, you have to do a lot of research and ask a lot of questions to find out who that provider in your community is. Talking to other women who had similar hopes for their births, asking doulas and other people in the birth community for recommendations, and interviewing more than one provider are all key. Just deciding that your "nice" gynecologist will be the one who delivers your baby is unlikely to match you up with the exact care you want, especially if you are hoping for a low-intervention birth. If you ask the tough questions when interviewing and forge a respectful partnership with your provider, you will be able to truly trust her or him, and not need to worry about fighting for your wishes during labor.

One more note

Here is a link to the original complaint filed by the plaintiff in the abusive OB case.

When doctors take it out on patients

Via Feministing comes the story of a woman who is suing the OB who cared for her in labor over abusing her verbally and refusing pain medication, saying "Pain is the best teacher". I believe that when he saw her, he could have legitimately considered her too far progressed for any pain meds (every doctor seems to have a very different rule of thumb about how late is too late), but you don't have to be a jerk about it. More troubling is the allegations that he deliberately gave her a vaginal exam in the middle of a contraction (already painful and during a contraction even more so), stitched her up with a too-large needle, and had her start pushing when she was not fully dilated, telling her to "Shut up and push". And of course there's the "you'll hemorrhage and die" card.

These incidents are not as rare as we would like to think. I've seen very disrespectful treatment myself and heard far, far worse stories from other doulas. There are doulas who refuse to practice in hospitals anymore because they can't stand to see treatment like this. In the doula listserve I'm on, doulas often write in with these stories asking for advice - what can we do to change this treatment? How can we encourage patients to complain, without having them dwell on the negative aspects of their birth experience? It's the rare family who will actually bring suit.

My own personal and unscientifically formed perspective is that this treatment seems to be more common when it's not the patient's regular care provider (in the suit above, her OB was out of town) or is someone in the practice the patient hasn't seen very often. I wonder what all the reasons are that this could be...

Home On the Breast (a breastfeeding song)

At a singalong, my mother ran into a guy who had written a breastfeeding song. Given my interest, she asked him to send along the lyrics. I enjoyed it - I especially love the chorus - so here it is:

Home On The Breast (sung to the tune of Home On The Range)
written by Steve Baggish as "channelled" by 8 month old son, Eli

Oh give me some food,
I don't mean to sound rude,
But I'm hungry and cranky and tired.
You've got what I want,
You're a fine restaurant,
And there's no reservations required!

CHORUS:
Home, home on the breast,
Where the love and the milk are expressed,
On the left or the right,
In the day or the night,
That's the place I like hanging out best.

I must think somehow
You're a magical cow,
You've been there since the time of my birth.
So give me one sip,
Or just one little nip,
And I'll milk you for all that you're worth! (CHORUS)

Someday I'll grow up,
And I'll drink with a cup,
And I'll eat with a fork and a knife.
But please don't be sad,
I'll be just like my dad,
And love breasts for the rest of my life! (CHORUS)

Why don't women trust hospitals?

Gloria Lemay writes a response to a Canadian obstetrician who asks "When did we become the enemy?" I took an Advanced Doula training course online with Gloria and think she has some valuable perspectives to share. I like that she calls out the attitudes he demonstrates in his own op-ed to show the reasons that women who want normal birth do not trust the hospital. I particularly noticed his statement, "I have attended about 7,000 pregnant women and have a good idea how the complicated collection of things that must come together in just the right way for there to be a good outcome actually come together." This is how so much of the generic hospital attitude is towards birth: everything has to be just right - just perfect - for you to have a baby normally. You must have just the right strength of contractions, just the right amount apart, or you'll get Pitocin to make them right. You must have just the right amount of progress - not too slow, now! - to avoid Pitocin or artificial membrane rupture. Prolonged pushing? A little concern about the heart rate? Oxygen monitor, oxygen, fetal scalp electrode, vacuum extraction, etcetera. Ask a doctor whether you can avoid interventions - IV, continuous monitoring, and so forth - and he or she will often say, "As long as everything is proceeding normally." But normal is defined so narrowly that almost no one gets to fall in this range. (And then women who get these interventions say, "My birth wasn't normal - something was wrong with the heart rate - I had to get oxygen - birth is so dangerous.") This isn't to say I don't think nothing can go wrong at birth or that interventions are never necessary, but an OB who already thinks that birth is so complicated and will need lots of management to come together "right" is not one I'd pick.

The evidence base against induction

Why do I discourage women I talk to from being induced?

Many reasons. But most importantly:

Induction greatly increases your risk for a cesarean.

"Elective induction of labor is associated with a significantly increased risk of cesarean delivery in nulliparous women. Avoiding labor induction in settings of unproved benefit may aid efforts to reduce the primary cesarean delivery rate." Abstract here.


Induction greatly increases your risk for a cesarean.

"Elective induction significantly increased the risk of cesarean delivery for nulliparas, and increased inhospital predelivery time and costs."
Abstract here.


If you body is not ready to give birth, induction greatly increases your risk for a cesarean.

"Compared with spontaneous onset of labor, medical and elective induction of labor in nulliparous women at term with a single fetus in cephalic presentation is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable Bishop score at admission."
Abstract here.


Unless you have a very pressing medical indication, induction is not indicated, because induction greatly increases your risk for a cesarean.

"While these interventions often are medically indicated for the well-being of mothers and infants, the evidence supporting their benefits when used electively is controversial."
Abstract here.


There is no benefit to induction because "the baby looks big". Be skeptical of offers to induce because "the amniotic fluid looks a little low".

If a doctor says that there is no difference in risk between an induction and a naturally occurring labor, that person has not read their own professional literature, or is lying.

Because induction greatly increases your risk for a cesarean.

And the answer is...

D! Maybe I made it too obvious, although people have asked me about tattoos and breastfeeding in the past. I guess I have smart readers! Just to note: it is perfectly safe, and I've seen heavily tattooed women happily breastfeeding with no change in milk color. I did win the prize for best fun fact with the fact that "Wet nurses in medieval France were allowed to nurse up to four babies at a time". Other great fun facts were that a nursing woman produces up to a gallon of milk a day, and women begin producing milk up to four months before birth. I like to go with the historical trivia because I think often we don't appreciate how very flexible and varied breastfeeding has been historically. The lines we've drawn in our culture around what breastfeeding outline only a very small part of what it can be (thus the shock over women nursing four year olds, when in fact we've just made up the rule that children should stop nursing in toddlerhood.*) My prize was - of course - a calendar of babies dressed up as different animals. I told my classmates I'd hang it up in our department's computer lab so we can all enjoy it.

Speaking of breastfeeding multiple babies, this is a great story that made the rounds after the earthquake in China about a Chinese policewoman who was nursing EIGHT babies who had been orphaned or for some other reason did not have access to milk.

*This is not to say that only our culture makes rules around breastfeeding, or that only Western cultures do so. I would say that probably almost every culture has some rules about breastfeeding; my point is that what can be normally and harmlessly practiced in one culture is sometimes forbidden in another.

Breastfeeding Today

Thanksgiving was wonderful but very busy - not much time for posting, although I have several new posts to get up soon including some thoughts about being a public health doula (vs. any other kind).

Right now I'm busy writing a paper due on Friday; we're allowed to pick our on topics, and I cycled through a bunch. I settled on one finally by picking a topic that's very current on campus right now. A rep from a student group got up in front of our Biostatistics class the other day and announced that they were raising money to provide formula (and a pot for sterilizing water to prepare it) to HIV-infected mothers in Uganda. Of course, the heads of every maternal child health student in the auditorium popped right up, and while that wasn't the moment for confrontation, someone from our department is trying to get a meeting with them to find out more about the organization they're fundraising for. While avoidance of breastfeeding does prevent some mother-to-child transmission of HIV, done in resource-poor settings it can pose a greater risk to children than HIV infection (because it increases the risk of other diseases). I decided to write my paper on the most recent research and recommendations around HIV and breastfeeding, and discuss how organizations can determine whether or not they should support formula provision in a particular setting. It's really interesting! I'll post a summary when I'm done.

After our papers are turned in on Friday, my class is having a celebration in the form of an evening cocktail party. The hostess has decided to offer door prizes for several categories, including "Best Dressed" and "Best Fun Lactation Fact". I'm hoping to win both, of course - I may have the best shot at the latter. While trying to decide which lactation fact is the most fun, I thought I'd try to spark some comments on this blog, by using my ideas to make a little quiz:

Which fun fact about lactation is NOT true (documented):

A. A woman can breastfeed up to four babies exclusively at one time.

B. Women in some cultures nurse piglets, puppies, and other domestic animals.

C. Newborn babies placed on their mothers' stomachs need no assistance in crawling to, locating, and latching onto the nipple

D. Ink from tattoos on a nursing mother's breasts can change the color of her milk.

E. Milk made by mothers whose infants were born early is different from that made by mothers of infants born at term.

I'll post the answer in a few days...

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.

Cesarean section by the numbers

One of the reasons I started this blog was to have a place to put some of the more academic musings I knew I'd be doing over the next two years. I am in the first semester of a masters in public health, focusing on maternal and child health. I knew that I'd be taking advantage of class assignments to learn more about areas I've been interested in since I became a doula four years ago but haven't had the resources or time to explore. Now that I'm a full-time student, with access to the full text of almost any journal you could name, I have the opportunity to tackle some of those areas.

I had to write a couple papers in the last week, and I wanted to share a couple things I learned from the research process from one of them. It was a somewhat open-ended assignment; we could choose a country, and a demographic, for which to pose the question "Is it healthier or safer to be a _______ [pregnant woman, infant, or child] in __________ [country of your choosing] than it was ___ [number of your choosing] years ago?" I chose to fill in my blanks with pregnant woman, the United States, and 25.

One interesting fact I discovered was that the U.S. maternal mortality rate has risen - in fact, doubled - in the past 25 years, and yet we can't actually tell if maternal mortality has changed. Because of a recent focus on better reporting maternal deaths (a hugely important undertaking), the rise in maternal deaths may be entirely due to improved reporting. I couldn't find any research out there untangling the numbers to try to determine what is actually happening out there - if any exists, I'd love to know about it!

Without reliable mortality data, I looked at cesarean rates, which have risen from 22.7% in the early 1980's to 31.1% in 2006. That figure - 31.1% - represents double the maximum cesarean rate recommended by the World Health Organization. If we take this to its logical conclusion, that means that half of all women who undergo a cesarean are having unnecessary surgery.

I also spent some time on the risks of cesarean section - often touted as just as safe as vaginal delivery (so why not schedule yours now!) - one study found deaths after cesarean to be more than triple those after vaginal delivery, in mothers who had similar risk factors. There is also significant risk of health problems associated with the surgery, and those increase with every subsequent cesarean.

All of this was the sad, stark "what", but I was really engaged in going through studies that ask "why?" Because of the way the question was set up, I wasn't exploring the "why" for its own merits, but rather to show that the increase in cesarean does indeed reflect a rise in unnecessary surgeries, and not a response to outside factors (unhealthier mothers, for example). And that turned out to be true; since 1996, cesareans have risen for women in all risk groups, of all ages. I found a lot of speculation on why; the one I think would strike birth activists as most plausible is that the "threshold of risk" has been lowered for c-section - doctors are now more willing to jump to a cesarean for a particular indication than they would in the past - and that it may be linked to malpractice concerns and/or a changing culture of practice. The other one, not called out in the research but by almost any birth activist you talk to, was increasing levels of obstetric "management" of labor. Maybe I can take my next opportunity to search out data around labor management and outcomes...I already know, from writing the other paper on obstructed labor in the developing world, that this is also a very complicated question from a sorting-out-all-the-data perspective.

It's interesting stuff! (To me anyway.) It kind of follows on my last post about misplaced anger over cesareans. Statistically, if you got a cesarean, there's a one in two chance that it wasn't necessary. But unless you go to an ICAN meeting, you won't meet many women who will tell you their cesarean was unnecessary. Maybe it's not so hard to hide the havoc we're wreaking if you create a huge cultural perception of birth as terrifying and dangerous? And then have a third of all mothers ready to tell their story about the c-section they had because their baby was in danger?

I got pretty good feedback on the paper (although I was dinged for my use of semi-colons - I love them, but maybe a little too much) and I'm looking forward to be able to explore more issues like this. If anyone is interested in citations, I'm happy to send them to you or post my list. God I love my full-text access.

Natural birth reflections

There's a reason I have such a hard time waking up for class every morning, and it's probably related to the fact that I go to sleep so late every night. What can I say? I'm a night owl, and the new Daily Show doesn't come on till eleven. But the fact is, too, that I've always done my best writing and thinking late at night. If only the rest of the world ran on my schedule...

I've been thinking lately about the whole "natural childbirth/lactivist/breastfeeding Nazi" vs. "uncaring unthinking overmedicating automaton 'mother'" dialogue (diatribe?) that happens...well...everywhere, but especially on the internet. I have seen it more than once on Tara Parker-Pope's "Well" blog on the NY Times website. My eye is always drawn to the anything related to birth/breastfeeding/etc., and more often than not her posts - regardless of topic - provoke a storm of comments falling on one side or the other.

One of her latest posts was on a small study examining the response of mothers who had recently undergone a cesarean section to the cries of their babies. Brain imaging showed they responded less than women who delivered vaginally. To me, this is an interesting and helpful beginning to a question: do women who have cesareans have a higher risk for postpartum depression? Is that because their natural physiological processes have been altered? As a public health professional-in-training, I think of it in terms of risks. This is not a situation in which every woman who has a cesarean will not be attuned to her baby's cries; this is a situation that increases risk, and which we should be aware of so that we can take better care of moms and babies post-cesarean. This is also a small study, raising more of a hypothesis than a conclusion, that other studies can investigate and build on.

The comments on this post, however, were not tentative or investigative; they were legion and some were very aggressive (or maybe the better word is defensive). Many women who had a cesarean were very upset that someone would label them bad mothers. They offered their own experiences as proof that this phenomenon wasn't real, or at least, couldn't be applied to every woman. They worried that the "natural childbirth nazis" would seize on this as more justification for demonizing cesarean sections, or anything outside the realm of unmedicated vaginal delivery. Once again, as with almost any discussion of cesarean, women said "My cesarean saved my life and my baby's life, and I am so grateful for it."

I always finish reading those comments feeling profoundly sad. I have witnessed normal birth, and I believe that it is a beautiful and empowering experience. I want to help more women understand that birth is not something to be frightened of. It's something to learn about, to embrace, to own, to confront. It's a chance to take control of your health care, your body, and the care of your child. I think these are value-neutral statements; I have a hard time imagining that there are women out there who do not want to be in control of their health care and their baby's health care, who want to be frightened of birth. And yet the community I would like to consider myself part of - the natural birth community - seems to have alienated many women, perhaps the majority, in this country.

I am in the middle of writing a paper on why mothers in this country are less safe and less healthy than they were 25 years ago. We don't think of health care going backwards, but in this case it is. Our cesarean rate is more than twice that of the maximum recommended by the World Health Organization. This is not because there are more high risk women, because cesareans are rising for women in all risk groups. It is not because women are asking for cesarean; surveys have shown that to be a rare phenomenon (outside of Hollywood, at least) The standard of care in the U.S. has changed, to where cesarean is regarded as an equal-risk, no-fault alternative. In doubt? Do a cesarean, everyone's happy, don't get sued. Yet studies have clearly shown that women who undergo cesareans are more than three times as likely to suffer serious consequences as those who deliver vaginally, including death.

Cesarean is absolutely, unquestionably, lifesaving for some people. Hundreds of thousands of women in developing countries die every year because they do not have access. But it can be overused, just as we can overuse antibiotics; the risks can start to outweigh the benefits. And the evidence shows that half the women who undergo cesarean in this country are receiving a medically unnecessary cesarean. Do they all realize it? No, they don't. As a doula, I assure you, they're told, "The baby is too big", "The heart rate is going down", "I'm worried about you and your baby. We need to do this for your safety." The hard part is, women are not able to tell when this is really, really true. Was their labor medically mismanaged into a corner? Or would this have happened anyway?

Many women do not even know that there are even questions they should ask about their cesarean. When they hear people discuss cesarean as something lazy moms do, as something that women get themselves into because they're too ignorant to question their doctors, that half of cesareans aren't necessary and that the pain and recovery time they went through to ensure their baby's safety was just a smoke-and-mirrors facade for the doctor to get to a golf game sooner - of course they're angry. Because these women are not stupid. They trusted medical professionals who promised to take care of them, and came out on the other end alive, with a healthy baby. Millions of women around the world are not so lucky. When they hear the "natural childbirth Nazi" spiel, of course they're upset. Does this mean that some of the hard truths about cesarean aren't real? Of course not. But those of us trying to promote normal birth don't do ourselves - or the mothers of the future - any favors when we alienate women who have undergone cesareans, potentially very dramatic and traumatic experiences, with soaring proclamations about the evils of cesareans and their many terrible side effects.

Instead, although it is not easy, I would encourage us to - in my public health mindset, tonight - talk about risks. It's hard, sometimes, to remember about risks when you're not dealing with the concept every day. Risk is not about something happening to everyone. It's about accepting the size of the possibility that it might happen to you. I wear my bike helmet as I travel to school because I accept the size of the possibility that I might have an accident where I need it. I don't travel in an armored car with bodyguards, because I don't accept the size of the possibility that I will need those accoutrements.

I think our proclamations are a way of trying to hammer home the risks of medically overmanaged birth to a populations that has come to perceive it as routine and safer. But we end up creating people who just don't believe us - because of the hype. "I had an epidural and I was so happy, I didn't feel a thing. I'm not some kind of martyr." "My mother formula fed my and my three brothers and we're all healthy and smart. Why go through the torture of breastfeeding?" "I had a cesarean and I felt better within a few days. I heard women screaming in pain down the hall; I'm so glad I didn't go through that." It ends up backfiring, because there are always people - usually the majority - who fortunately escaped those increased risks, and we sound shrill and punitive. I think we need to work on helping people understand risk better, as well as showing them how much better the quality of a properly managed birth can be - "The Business of Being Born" does a beautiful job of showing births of women who are in control and not afraid. And then we need to step back. There are many paths to that empowerment; do I believe some are healthier and safer than others? Absolutely. But every woman has to make her own - informed, educated - decisions. We need to trust her. Maybe then we'll see less defensiveness and anger on this message boards.

Birth trauma shouldn't be a secret, but it is

Do you read Postsecret? Every Sunday a new set of secrets, mailed in anonymously on postcards, goes up. This week one of the secrets had to do with an unnecessary c-section (scroll down about halfway to see it). I noticed this woman mentioned that her son is healthy...a lot of women hear "as long as you have a healthy baby, whatever happened to you doesn't matter". But I think deep down they suspect that they DO matter. And I loved, loved, loved that on this website that millions of people read, they posted a response to that secret directing this woman to ICAN. I hope it serves to educate more women about unnecessary c-sections long before they have to deal with the prospect personally.

Trying again

I haven't done as much posting in this blog as I'd planned. That's not to say I can't think of anything to post - I think of things to talk about all the time! I've just put so much time and effort and thought into the posts I've written so far that to write another one like that feels exhausting to me. I think I need to dial that thoroughness back a notch. So if you feel like I'm not citing something or not thinking something through, ask and I shall expound, but otherwise I'm going to try to be a little more casual.

I started graduate school in maternal and child health this week. I'll be getting a master's in public health. "What can you do with an MPH?" everyone asks me. Well, sometimes I worry about that myself. I have a lot of interest in direct service, and an MPH often leads more towards policy, research, and program development. But the truth was, I was tired of working crap jobs and an MPH was the quickest way to get myself to a way more interesting level. I still contemplate other degrees like an MSW or even - still - midwifery, but an MPH will always be useful to me and it does have a very broad applicability when I'm out looking for interesting work.

I'm already glad I'm doing it on maternal and child health, vs. something more general like health behavior. The subjects we discuss in class already catch my ear - terms I'm already familiar with from doula work, issues I already am very curious about. So far I seem to be the only one in my entering cohort so devoted to birth issues - there's more of a family planning and child health focus. But I think that's OK. It just needs I mean to push myself to really seek out opportunities to explore those issues through my classes, and that there won't be a lot of competition for that area!

One class that seems like it will be great is international issues in MCH. Dealing with high maternal mortality in developing countries is something that I've been very interested in for a while. While maternal deaths in developing countries stem - in part - from lack of medical care, the challenge is to respond creatively with only appropriate medical care. A developing country cannot (and should not) provide an OB for every woman. Rather, one needs to train midwives to handle uncomplicated birth, and make OB services available and accessible for the 15% of women who will require them. The readings are already very interesting. It's astounding, and depressing, that reducing death rates for mothers and children is not that hard - we know how to do it effectively - and yet not happening.

iDelivery

Wow.

So my post on evidence-based medicine is a little long in coming (it's in draft form) but in the meantime I wanted to share. Looking up medical PDA applications for my mom (there are a lot) I came across something I think says a lot about the way you might deliver with a doctor.

As a doula and someone who talks with women about pregnancy and birth, I hear so many women say "I trust my doctor," or "I like my doctor," when contemplating birth choices. They believe that this will be enough to give them the healthy, normal birth experience they want. I know that there are many fabulous doctors out there - I haven't been able to work with many of them, but I know that there are doctors who practice more like our conception of midwives, than some certified nurse-midwives do! (And I have worked with some of those CNMs - never assume that because someone is a "midwife" that they have a certain standard of practice.)

But when women tell me things like "I like my doctor," I get an uncomfortable feeling. That you like your doctor is great, but that should only be the first item on your list. Like this person? Okay, check. Now let's ask: What are their intervention rates? What will they allow you to do and not do in labor? Under what circumstances? What's their c-section rate? What percentage of women in their practice deliver without medication? Would they be willing to deliver a breech baby vaginally?...etcetera.

When women say "I trust my doctor," do they trust them because they've gone through all the above questions with their doctor, or because they assume that all doctors practice identically and their doctor's training will be all they need?

And in the end, if you like them and trust them, is your doctor even in the room for more than a few minutes at the end to catch the baby? Because they could always be tracking you down in the cafeteria, or from the comfort of their own bed, with this:

For serious, people. Your doctor can monitor your contractions and fetal heart tones from their iPhone! Real time! Talk about hands-on medicine!

More information here, if you want it.

All I have to say is, if I'm ever in the position of needing an OB, my first question might well be "Will you be turning me into an iPhone application, or treating me like an actual person?"

Informed Choice: The Gold Standard

After I wrote my last post, where I discussed the rights of women to make decisions about their medical care and have those decisions honored, I got a link to a statement from a Canadian OB/GYN who is responding to statements from the American Medical Association (AMA) and American College of Obstetricians and Gynecologists (ACOG).

A bit of background: Ricki Lake, the TV talk show host, gave birth to her second child at home and decided that she wanted to make a documentary about our country's maternity care system and the alternatives available. The result was The Business of Being Born, which was released theatrically and on DVD in the past year. I have met more than one pregnant woman who decided to switch from hospital care to a home birth after seeing this movie. It's been screened all over the country and in hospitals, and it's gotten a decent amount of media attention.

This, apparently, requires action from our country's medical authorities. Both ACOG and the AMA released statements opposing home birth. ACOG's called for births to take place only in the hospital or birthing centers, and the AMA's supported that resolution. ACOG calls home birth "fashionable" and "trendy" (as someone noted, this is probably a big surprise to the Amish, who aren't generally called "trendy" yet have chosen home birth for generations). Why? It might have something to do with the fact that this movie is actually influencing women's choices, and that means less business for the OB/GYNs (although with home birth at less than 1% of the total births in this country, it's going to take a lot of screenings for that to truly tip the balance).

There are plenty of doctors who are not on board, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response. I wanted to repost it not just because it shows that there is opposition within the profession, but because of his statements about patient choice:

I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not "offering" VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT. [my emphasis]

Science supports homebirth as a reasonably safe option. Even if it didn't, it still would be a woman's choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC's prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the "model legislation."

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women's autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone's words: "We don't need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding." It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska
Yellowknife

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Next post answers Seth's second question: Why is there a gap between the evidence base and medical practice? Part of the answer lies in a conversation I had with my parents (both doctors) just a couple of days ago. Stay tuned!

Balancing the rights of women, and best outcomes for babies

OK, after a lot of writing and thinking I've started to answer Seth's three questions (see my last post for what those questions were, and what they were about). I'm going to address the first and last questions today, and the middle question tomorrow.

First, let's talk about the basic reason that the abortion rights debate is able to exist: because there are two entities at stake, and they are biologically inseparable. We do not have arguments about whether once you buy a dog, you have to keep that dog for a minimum of nine months, because you don't. If it doesn't work out, you can find a new home for it, end of story.

When women become pregnant, they have two choices: terminate the pregnancy, or be pregnant for nine months and give birth. You cannot pop a fetus out as soon as you realize it's there and give it someone else to handle. If it's going to continue, the mother is going to have to offer it a space in her body and, in whatever way she chooses, her life.

There are a lot of opinions on when "life" for the fetus begins (conception? forty days? month seven?) and a lot of opinions on how this bears on the mother's rights to control what's going on inside her body and in her life. But bear with me when I say that in the end, people seem to fall along a spectrum of positions. One extreme is "the mother has the right to do whatever she wants with anything to do with her body", and the other extreme is "the mother's body is now the host to the fetus and is always less important than the fetus' survival". There are laws being argued all along this spectrum. Does a woman have a right to a late-term abortion if her health is threatened? Should she be charged with child endangerment if she takes drugs in the ninth month?

This pairs the first and last questions very nicely:

1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?

3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)

On one end of this spectrum, the obstetrician has acted correctly. The obstetrician sees a situation in which he feels the mother is endangering her child. He goes to the hospital director and the judge, and explains why he believes this - because she is laboring after having had a previous cesarean, she has a higher risk for uterine rupture. If her uterus ruptures, the baby could die. While some states permit parents to decline care for their children - even lifesaving care - based on personal religious beliefs, this mother isn't basing her decision on Christian Science or other religious beliefs rejecting medical care. In the doctor's view, she should be legally forced to give her baby the best medical care possible.

This is where we come back to the fact that the baby is not a discrete entity. To provide Mrs. P's baby with the perceived best care, they will need to force this woman to lie down on a table, submit to anesthesia, and have her uterus cut open. She will then need to have it sewn up and undergo the long, painful healing process from major abdominal surgery. While a repeat cesarean poses risks to the mother (although a uterine rupture would also risk her life, this does not seem to be a factor in the legal decision), the perceived risk to the baby is considered more important.

This woman, who had been offered and refused to consent to a procedure, saw the law used to physically enforce one doctor's opinion - that for the benefit of her child, her body and her wishes about her body were completely irrelevant. If we believe that this is true - that when it comes to the health of the baby, women's bodies are second priority - then we could agree the doctor acted correctly. Suffice it to say that I don't fall on that end of the spectrum. In the last question, we're asking to what degree the baby's health should be taken into account. I believe that a woman who understands the risks and benefits of her choices is taking the best outcome for her child into account already. Doctors may disagree, but ultimately it's the mother's decision. Why? Because it's her body. No one should be forced to undergo medical procedures without their consent. If we accept this, it's a slippery slope to so many other infringements on women's rights.

I think looking at the medical evidence makes this even clearer. When Mrs. P refused a cesarean on behalf of herself and her child, she was indeed placing her child at a slightly higher risk - but only slightly. Some parents refuse to vaccinate their children, which carries a small, but real risk of serious illness and death. Parents who don't vaccinate may have to put up with a lot of forms to fill out when it comes to school enrollment, but they are not arrested and forced to vaccinate their children.

Childbirth Connection reviews the evidence and states that: 

"Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section."

(Click here for the original statement and more research on VBAC versus repeat C-section from Childbirth Connection.)

Many, many hospitals and doctors permit women to attempt VBACs; this doctor was certainly not acting in lockstep with every other medical professional. Rather, he was acting on a personal bias about the risk of VBACs. Why did he feel justified in sending a sheriff to this woman's house, arresting her, and strapping her to an operating table? Maybe because so many people consider women - especially in the area of reproduction - nothing but vessels. In that worldview, it's all right to force a woman to have a c-section, or forbid her from having an abortion, or live with the consequences of botched abortions and dead women. It's all the same. And that's why this story makes me physically ill.

Why Birth is Fundamental Pro-Choice Issue

As my first real post, I'm going to re-post an entry from my personal blog. I wrote this a couple of months ago, and writing it was one of the moments where I thought "Man, I should have a blog about just this stuff." I really want people to understand how all of these issues - reproductive rights, reproductive health, birth, abortion, childcare subsidies, health insurance, public health initiatives - aren't just connected. They are the same thing.

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I could go on about this for hours, possibly days, but there is so much in the birth world right now that seems to be such a neat parallel to the fight for abortion rights - until you realize it isn't a parallel, it's the same thing. That's the reason I go to such amazing birth workshops at the Reproductive Rights conference every year: reproductive rights go all the way from birth control to birth. Right now, to me, there is almost no area in which we see the state exerting more control over women's bodies. This story isn't common, but I venture to say it's only because more woman don't challenge the system. Try to refuse an intervention at the hospital based on not just your own understanding of best practices, but on solid evidence from excellent research, and watch how fast they come at you with dire warnings that you are PUTTING YOUR BABY AT RISK. Even as small a thing as refusing continuous fetal monitoring - proven over and over again to do nothing to reduce risk to the baby, but plenty to increase risk of cesarean - means snippy, angry nurses, endless badgering, and the prevailing attitude that you think you're better somehow, but you're NOT, and why can't you be like all the OTHER nice, compliant women who strap on the belts and lie in bed - THEY love their babies, why don't you? I've never witnessed legal threats, but I think it's easy for this attitude to cross the line from emotional (and physical) manipulation to stronger forms of pressure.

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And in going back to that post to get the text, I saw that my friend Seth posted some questions for me a couple days later that I never saw. Sorry, Seth! On the other hand, they're really excellent questions and now I'm going to use the answers as my next post. He asked:

My instinct is that things can't be as simple as you and the author of the linked page seem to think, but I am very poorly educated on these issues, so let me just ask some questions:

1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?

2. If there is indeed a serious disconnect between the opinions of doctors on these issues and the consensus of the scientific community, how did it arise? How can it be fixed?

3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)

All this really starts getting to the heart of how these issues are linked, and I am eager to start the discussion! That post will probably come in a couple days, as I have about 10 hours of driving to do in the next 24.

First Post

Welcome!

This is my first post, and I'm very excited about this blog. Having studied public health and anthropology as an undergraduate, trained and worked as a public health doula and breastfeeding educator, worked in a breastfeeding-oriented store, and now beginning my master's in public health with a focus on maternal & child health (whew!) - I have a lot to say!  I've posted a lot of thoughts on my personal blog, but want to put them in a dedicated place. 

I also want this to be a spot where I post news about reproductive health, women's health, and birth/breastfeeding, and a space to reflect on what I'm learning and doing in my graduate program. As the reader, I hope YOU get information to help take control of your reproductive health, learn more about all these topics, and share back with me stories, links, and information.