Friday, December 26, 2008

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.

Friday, December 19, 2008

"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.

Thursday, December 18, 2008

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.

Wednesday, December 17, 2008

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!

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.

Wednesday, December 10, 2008

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.

Monday, December 8, 2008

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.

Tuesday, December 2, 2008

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...