Octuplets and preterm birth

One of the things that is striking me, in the whole octuplets news story, is the amount of attention that is being devoted to the problem of higher-order multiples. I agree that the fertility industry is part of the preterm problem. But fertility treatments are almost exclusively used by those who have the least risk of preterm birth: people with high socioeconomic status. Class and race are huge risks for preterm birth. Black women have twice the preterm birth rate of white women, and this is a gap that is not closing. Should people spend their own money on fertility treatments, and then expect society to cover the costs of any consequences? This is an important question. But I think it's also important for us to ask how much time and energy we should devote to garment-rending over these 8 babies - who are an undeniably rare occurrence - when thousands of others die every year, having been conceived without a single fertility treatment.

Keep the keeper?

Hippie alert! I've been interested in more natural and reusable menstrual products for a while, for three reasons. First, going through thousands of pads and/or tampons in my life seemed like a real wear on the planet. Second, a lot of tampons and/or pads are manufactured with unpleasant things like bleach that don't seem innately friendly to the human body. Third and finally, I'm cheap and I don't like spending a lot of money where I could spend a little.

For a while, I used Lunapanties. I really like them, but they have a few downsides. They have to be washed - very well - which is easier when you have a convenient washing machine, which I don't always. Eventually they start to wear out, and they're not cheap. I was trying to decide whether to get more or try something new when I found myself in a feminist bookshop, standing in front of a shelf full of, shall we say, menstrual alternative products, including the Keeper and the Diva Cup. I squeezed 'em both and decided to give the Keeper a try. One cup, 10 years, sounds good to me.

I'm still trying it out, seeing how my body gets used to it and how well it works for me. But it got me thinking about alternative products and whether there's other companies or products out there that people like. Any other hot tips?

More fun breastfeeding ads!

Via Stand and Deliver, a breastfeeding promotion campaign that uses lifesize cut-outs of women nursing to encourage normalization of breastfeeding. It seems like a good idea; I'd be very curious to know what effect it has, if any.

When is something not elective? When you don't choose it

Jennifer Block (author of "Pushed") has a great piece over on RHRealityCheck called "Can We Please Stop Blaming Women for C-Sections?". Amen.

I know someone who had a c-section for transverse lie, scheduled well before her due date; her baby was less than six pounds. She actually had to resist pressure to take the baby earlier. Was that elective? Let's point the fingers at the right people.

Book recs

I've built up a reputation amongst my friends for bringing birth and/or breastfeeding into the conversation a little too often. That's one of the reasons I started this blog - to get all my ranting and did-you-know-ing and meditations out of my personal blog and into one place. I know this can be annoying; I've vowed to tamp it down. But being in a maternal and child health program has not helped. I now spend most of my time with other women who WANT to hear all about birth and breastfeeding - who constantly ask me questions about it, in fact! The other night at a fundraising dinner, we probably unnerved the only two people not in our program at the table by having a long discussion about induced lactation. My classmates peppered me with questions: can you lactate if you've never given birth? How is lactation induced? How likely is it that you can exclusively nurse a baby when lactation has been induced? I answered all their questions and I did so enthusiastically, but I swear to god, I did not introduce this line of discussion.

Even when I really, really vow to not get into the topic, it sneaks up on me anyway. I went to a basketball game last week. My friend and I were offered a chance to be down in the risers behind one of the baskets and we decided, why not? It could be fun. Little did we realize we'd have to stand the whole time, so as soon as we got there we secured spots at the back where we could lean against the bleachers. Most of the (over)enthusiastic undergraduates around us were jostling forward, so we ended up standing next to two other grad students, a man and a woman. We introduced ourselves and talked about our respective programs. They asked what kind of classes we take. We gave as an example that we were both in a class about breastfeeding this semester. That was all it took - the woman started asking a million questions about breastfeeding, and then she found out that I was a doula, and it turns out she's very interested in natural birth, and then she started asking questions about birth and birth books and doula-ing...

Mindful of my vow, I tried to change the subject - I asked her more about library science, we discussed the basketball game (to which we were paying remarkably little attention given that we had spots for the ultimate fans) - but every time we stopped for a moment to watch the players, she'd turn back to me and say something like, "I've read 'Misconceptions' by Naomi Wolf. Are there other good books I should read?"

What can I say? If you store something metal next to a magnet long enough, it will become magnetized. I have spent so much time talking and thinking about these topics, I have become a magnet for birth and breastfeeding questions. I can't say I mind (at ALL!) but it does give the appearance that I'm not living up to my good intentions.

But since this girl was a librarian and thus very intent on finding books, it got me thinking about book recommendations for people who have a lot of questions and are interested in learning more. I haven't read everything out there, some of which I'm sure is great, but I'm just going to list a few that I've read and found informative and well-written.

For a social/political background:

"Misconceptions" by Naomi Wolf is a good one, if a bit dated (I think late 1980s). She discusses birth in the context of her own experiences and has some interesting reflection on feminism and motherhood towards the end.

"Pushed" by Jennifer Block is great! It's more updated and covers a somewhat wider range than "Misconceptions". I know some doulas object to her portrayal of the role doulas play in the system, but I think she raises valid questions.

"The Business of Being Born" is not a book, it's a movie, but it would be a great primer for how and why our maternity care system is not working and what alternatives are available. Everyone I've shown this to has enjoyed it. Suffice it to say, I think everyone should see it - literally, everyone.


To learn more about birth itself, interventions and alternatives:

"The Birth Book" by Dr. William Sears and Martha Sears. Well written, comprehensive, I learn or am reminded of something new every time I open it.

"Ina May's Guide to Childbirth" by Ina May Gaskin. Ina May is in many ways the mother of the modern midwifery movement in the U.S. and this is a book written from her decades of experience.


Just for fun:

"Babycatcher", by Peggy Vincent. The adventures of a home birth midwife in San Francisco - lots of stories, great writing, and almost impossible to put down.


Hot tip: the thrift stores of college towns are a great place to build your library. I've been keeping an eye on the shelves every time I go in, and just yesterday I picked up "The Thinking Woman's Guide to a Better Birth" and a recent edition of "The Womanly Art of Breastfeeding".

Nurse practitioner removes IUD without consent

In the oh no she DIDN'T! category, a nurse practitioner (and the community health center she works for) is being sued because she removed a patient's IUD without her consent, lectured her about how IUDs were like abortion, and refused to insert a new one. According to the plaintiff, the NP said "Everyone in the office always laughs and tells me I pull these out on purpose because I am against them, but it’s not true, they accidentally come out when I tug.” So funny! You know, everyone always laughs and tells me I eat so many cookies on purpose because I like them, but it's not true, they just accidentally fall into my mouth. Read the original complaint here.

But seriously, think about this: if this is an accurate quote, the NP has done this enough times to be "always" teased about it in the office. How many other women did this happen to before she hit on one who was angry and organized enough to sue her? Why was this a cause for humor and not for concern? Like I said about the abusive OB who was being sued, for every woman who sues there are many more who experienced the same thing and did not or could not speak up.

Unassisted birth

My last year in college, I went to the Reproductive Rights Conference organized by the Civil Liberties and Public Policy program at Hampshire College. I love this conference - it is impossible to go and not leave energized, inspired, and ready to take on the world. I also love it because they have expanded their focus over time with the recognition that "reproductive rights" is a broad spectrum, and that we cannot fight for abortion rights without addressing the many other social injustices in society. This means that you could spend almost every session, for example, going to a workshop that deals with birth, midwifery, child care and/or other issues around motherhood.

My senior year was the first time I'd attended, and I had just started to get more deeply involved in this whole maternal and child health thing. I was writing my senior thesis on breastfeeding, and via that I was being exposed to a lot of writing about the medicalization of breastfeeding and birth. I don't even remember the exact name or theme of one workshop I attended, but it had to do with birth and one of the women there was a direct-entry midwife. It was my first exposure to some very radical (to me) ideas (the conference is a great place for being exposed to radical new ideas, which is one of the reasons it's so exhilirating. You come out feeling like you've just been through a vigorous stretching workout.)

One was the idea that not all midwives are created equal, and that if you are not careful you can end up with a midwife who practices like the most intervention-happy OB. I was very surprised by this, although my following year as a an AmeriCorps doula, being exposed to many practitioners, taught me the truth of it.

The other idea was that of unassisted birth. The direct-entry midwife there very matter-of-factly said that she considered all her options for birth and when it came down to it, she felt the safest place to deliver her baby was at home with only her husband present. I remember a ruffle of surprise in the room. I know I was surprised; I had never even contemplated the possibility that someone might choose to give birth alone, or only with family present. I thought to myself, "Well, she is a midwife. Maybe it made sense to her that she could take care of herself," but it still seemed...weird. Risky, and definitely inexplicable. Why would you choose to give birth alone when you could have other trained people present? How could it possibly seem safer that way?

Over the years since then, I've become more familiar with the unassisted childbirth (UC) idea (I don't think the woman at the workshop even used the phrase, but I later realized that the term applied.) There have been debates about it on the doula listserv I'm on (is it a good idea? should doulas be willing to attend those births?), I've occasionally skimmed forums for UCers out of curiosity, and I've read accounts and seen videos of UCs. I recently saw an interesting documentary on the Discovery Health channel, "Freebirth" (a term also sometimes used for UC) that followed three women through their choice to UC, process of preparation, and births. I've heard people say that UCers are irresponsible or taking the ultimate responsibility, that they are childish and rebellious, or very brave. I learned that someone I've known for a long time in my hometown, a nurse, gave birth to her first at home with a midwife and her second two at home assisted by only her husband. At the "Orgasmic Birth" screening I went to, there was a woman there who had very recently had a UC. During question-and-answer time, she went on for several challenging minutes about her experience of UCing and the lack of support she felt from the natural/homebirth and midwifery community.

All of those experiences have given me a lot of pieces of the puzzle. But I don't know that anything has given me better insight into the UC phenomenon than this dissertation. Rixa over at Stand and Deliver (formerly The True Face of Birth) has just completed and posted her PhD dissertation on why women choose unassisted birth. Warning: it's a PhD dissertation, so it's long! I stayed up far too late reading it the day she posted it, and was only able to skim the areas I was most interested in. So far I've read a lot of chapters 3, 5, and 6, being very interested in how and why women choose UC, how they conceive of the questions of responsibility, and how medical professionals perceive UC and how it has affected their care practices. If you're curious about what UC is and why it happens, this is a great place to start.

Quiz answers!

Sorry for the delay in the quiz answers - my internet at home has become achingly slow, and it's hard to motivate myself to wait minutes for pages to load. I was also offline for several days, because a few of my classmates and I went to the inauguration. It was a fantastic (if cold) experience! We were waaaay back on the Mall, to one side of the Washington Monument, but we were with a huge and enthusiastic crowd and able to see and hear the jumbotrons very well. I am so excited and optimistic about President Obama, and (to bring it back to our theme) I hope that he is able to bring change to our health care system. Our system is not built to ensure that everyone, including pregnant women and babies, gets the care they need. I believe that once we build that system, a midwifery-led model of care for pregnancy and birth will be the most efficient and safest way to go for care in pregnancy and birth.

So here are our answers to the quiz. My two participants got very close. (I might have made this one too easy again, but the only way to make it harder is to include a lot more countries and that didn't sound fun for anyone.)

Country: maternal mortality ratio (lifetime risk of maternal death*)
U.S.: 11/100,000 (1 in 4,800)
Sweden: 3/100,000 (1 in 17,400)
Ukraine: 18/100,0000 (1 in 5,200)
Afghanistan: 1,800/100,000 (1 in 8)
Canada: 7/100,000 (1 in 11,000)
Nepal: 830/100,000 (1 in 31)

*This is the chance that a woman will die of pregnancy-related causes; it's affected by both the maternal mortality ratio and the fertility of the population overall. A population where women have lots of babies will have a higher lifetime risk, because they are at more risk with more pregnancies.

Some observations: the U.S. does not do terribly in this list, but there are a lot of countries who outrank us. Sweden is an example of a country which achieves very low maternal mortality ratio with a midwifery-led model of care. Afghanistan is more or less the country with the highest maternal mortality in the world. Nepal's maternal mortality ratio is very high, but about the same as the estimated ratio for the U.S. in 1900 (850/100,000); change is possible, although it doesn't have to take a century.

All of these numbers are from 2005, according to my notes, although you'll find slightly different numbers depending on where you look (UN, WHO, individual countries' reports).

To spin off a small different topic on this theme: my class had a lecture on cesarean sections on Tuesday from someone who works for the Averting Maternal Death & Disability project. C-sections have a paradoxical role in maternal mortality. Many women in the developing world die from lack of c-section availability; others die from c-section complications. Some women in the developed world die from unnecessary c-sections, or from c-section complications that also could be avoided. How do we strike a balance, make cesareans safer, and know when we're doing too many? One interesting item she shared was that in studies of cesarean increases in developing countries, researchers found that the risks for a population began to outweigh the benefits at some point during the period where c-sections rose from 10% to 20% of the population. This is in line with the WHO guidelines of 10-15% established in the 1980s although (according to our speaker) being questioned today (both by those who think the threshold should be higher and lower).

HypnoDoula training

I have been very interested in hypnosis techniques for birth ever since I got an excited phone call from a doula I worked with in AmeriCorps. It was a year or two after we had finished our AmeriCorps term, during which we had never seen anyone use hypnosis techniques (most people we worked with hadn't even had a childbirth class and if they did, it was usually the class we taught ourselves which was very simple breathing and position suggestions). But now my doula teammate had attended her own sister's birth where hypnosis techniques were used and she was raving about it, saying how amazing it was. I was curious what a hypnobirth looked like and did a little youtubing but didn't find many videos that really showed how it could be and what techniques were used. Since then I'd heard a little about it, but never been sure what to think.

A couple months ago I heard that my current volunteer doula program would be holding a hypnodoula training - I think I was the first person to mail in my check! I showed up for my training this morning not knowing exactly what to expect and was very pleasantly surprised and very impressed. Our instructor described how she had come across hypnobirthing before her first birth because she was so frightened of birth. She started to research epidurals to reassure herself that she would get good pain relief, but ended up feeling very uncomfortable with the side effects and risks of epidurals. When she came across hypnobirthing, it appealed to her as a way to relieve pain without the risks of medication. She's now had three very relaxed, comfortable births using hypnosis techniques and is a HypnoBabies instructor. We got to see the video of her third birth, as well as many videos from different couples using HypnoBabies techniques for labor and birth, and I was very impressed.

A few things that I wondered about that were answered in the training:

- Who does the hypnotizing? Interestingly, it's self-hypnosis - the mother is in control of the process and can have outside people use words or touch to help cue her into relaxation, but can also cue herself in and can exit whenever she likes.

- Does it work for everyone? Of course not, but I was impressed by the high percentage it did seem to work for, to varying degrees. What I liked about it was that if nothing else, the HypnoBabies course does a lot of work to inform women about their options during childbirth and remove a lot of subconscious fear that's drilled in by society. I think that even if none of the self-hypnosis techniques worked for a woman, just those two things would be very valuable.

- What's the point of calling everything by a different name? Can calling a contraction a "pressure wave" really change how it feels? I think this is what I was most skeptical about it, but with more explanation I think I understood better the logic behind it. It's not as if changing the name magically changes the feeling - "Oh, that's not a contraction! It's a pressure wave! See, now it doesn't hurt!" Instead, when you use different terms over and over in preparation for birth, people have the possibility of adopting a different attitude towards the feelings they experience. If you tell someone all their lives that during their birth they will experience "pain" - probably thousands of times - it's a virtual guarantee that they will experience pain. Our subconscious does have some power. If you adjust what someone will expect to feel, they have the possibility of experiencing that sensation differently.

I'm going to send the instructor some of my cards and see if I could work with some of her students in the future, because I'd like to see how it really works in practice. But overall, it was a very exciting and energizing day!

Vaccine thoughts

Vaccines are an interesting issue, and I think I bring a different perspective than many of my classmates. Being a doula - spending time with natural childbirth promoters, being on doula listservs, working with families who are interested in non-interventive birth - exposes me to many people who question the safety of vaccines. I think most of the people in my department come from a mostly public health perspective - and often an international one - where vaccines are a no-brainer, and the only problem with them is how to make sure everyone gets them on the proper schedule.

This article in the New York Times got me thinking about the pro- and anti-vaccine camps. As I move back and forth between them, I see a lot of difficulties they have communicating around the individual benefits and risks of vaccines, and the population benefits and risks. I believe that public health practitioners tend not to understand why anti-vaccine families are doubtful about vaccine safety. But I think I've learned something about where families are coming from: the likelihood that their individual child will become suffer seriously from these diseases is very small, and they see autism (the main concern) all around. There's been enough statistical dust kicked up around the issue that even recent studies, which public health authorities consider definitive, are not enough to counteract people's fears. Families have been compensated by the U.S. government for adverse vaccine reactions that led to autism-like conditions, and stories abound of children withdrawing or "losing words" after their vaccines.

There is a tendency to cast parents who refuse vaccines as irresponsible, ignorant, or "parasitic" (because they depend on herd immunity - the large percentage of the population who does get vaccinated - to protect their children from these diseases). I think it would be a fairy accurate statement to say I don't think these characterizations are helpful. They're not helpful for public health professionals who are interested in convincing more people to vaccinate both because they demonize non-vaccinaters (who then just ignore whatever else is said) and because I don't think they accurately represent the targeted population. I would venture to say that most people who choose not to vaccinate are educated, highly caring parents who want the best for their children and are fighting hard to get what they believe is the best. They don't trust studies funded by, or done by people with connections to, the vaccine industry, and with some good reasons (the pharmaceutical industry does not have a stellar record of financing neutral research for the public good). And I don't believe they consider themselves parasites. One of my classmates who worked on vaccine issues in Oregon said that one of the most effective ways to get reluctant parents to vaccinate was to appeal to their sense of civic duty - that by vaccinating their children they were protecting babies who were too young to be vaccinated and would be much more severely affected by vaccine-preventable diseases.

I try to stay agnostic on my vaccine views; I haven't done enough research on it to know what I personally think - just what other people think. Although I do feel there's such an intense concentration on the vaccines and autism link that it's obscuring other possible environmental contributors. A study came out recently linking Pitocin use in childbirth to later behavioral problems - so many environmental factors have changed in the past 50 years that vaccines are a very tiny puzzle piece to be focusing all this energy on.

Breastfeeding video

Quiz answers coming soon. But in the meantime:



Love it!
(via Bellies and Babies)

New semester, old notes, new quiz!

Today was our first day of classes and I'm feeling excited to be back at school! I love the beginning of a semester, when all your classes are full of potential - and you don't have any homework yet. I'm planning on taking a heavier load this semester, because last semester didn't feel as tough as I expected it to. My advisor from undergrad warned me multiple times that grad school might be easier than college, but I just thought she was being nice. Turns out she might have been right, but I'm working on making it a little harder (maybe I'm crazy).

I'm going through last semester's binders, tossing old notes and filling them up with fresh, blank new sheets of lined paper (remember what I said about exciting potential?) I came across one page that I decided to turn into a blog post - or rather, another quiz: match the country to its maternal mortality ratio!

(What is a material mortality ratio? It is the the number of pregnancy-related deaths per 100,000 live births. Put another way, if you had 200,000 live births and 20 women died of pregnancy-related causes, your maternal mortality ratio would be 10 per 100,000. Make sense? I had to take a lot of epidemiology so it now makes sense to me, but it takes a little mental wrangling to get your head around the math sometimes.)

First, the countries:

1. Ukraine

2. Nepal

3. United States

4. Afghanistan

5. Canada

6. Sweden


Now, the mortality ratios (remember, this is per 100,000):

A. 7

B. 1,800

C. 830

D. 11

E. 3

F. 18


You could guess them all or just take a shot at the ones you think you know. I'll post the answers soon (along with a woman's lifetime risk of dying of pregnancy-related causes in each country, which is also really interesting.)

Early c-sections increase risk

This new study shows, I think, more of what happens when we decide that something about birth just can't be that important. Since babies can be considered "term" any time after 36 weeks, why not take them whenever you feel like? Ignoring the idea that maybe we don't know everything going on in the last weeks of pregnancy, and if the body doesn't go into labor spontaneously there might be a good reason.

If you've seen "The Business of Being Born", they point out that most interventions in obstetrics are adopted first and then studied after the fact - when damage is already done. What really caught my eye was the doctor who said of scheduling an early c-section, "I really hadn't thought much about it until now." Some standard practices in use today - like continuous fetal monitoring - were introduced, later studied and proven not to be helpful, and then were too entrenched to root out.

Happy new year and new post: attachment parenting

The holidays have involved a lot of family and a lot of travel, but I'm planning to get back into posting this month. I'm about to start the second semester of my master's program. A two-year program goes very fast - it will already be half over in 5 months and I feel like I've barely started!

This long and very interesting post by kneelingwoman got me thinking about attachment parenting (AP). I haven't posted about attachment parenting before but lord knows I've discussed it plenty with my friends who care for or parent young children, doulas and non-doulas alike. I don't have my own kids yet, but I have a big extended family and babysitting/nannying has almost always been my second job (and sometimes my first). I think this actually has given me some interesting perspective in that I've had a chance to interact with parenting of many different styles without being inside the bubble of my own parenting experience. I've also read the Dr. Sears books - the bibles of attachment parenting - and as a doula and breastfeeding educator, I am trained to promote a lot of care practices that match up with AP (e.g. babywearing, nursing on demand, sleeping with the baby in close proximity).

To be sympathetic to some aspects of AP that the author is arguing against, there is plenty of dogma on the other side that AP is reacting against. I recently heard that a new mother was "spoiling" her 2-day-old baby because she was holding him all the time. There is such an intense focus on getting a baby "used to" not being held! To quote a very wise lactation consultant, "A newborn has been held continuously for 9 months. Any time you're not holding him, you're getting him used to it." Imagine what it's like for a new mother who is trying to keep her newborn happy, healthy, and fed to have her family come over and tell him she's "spoiling" him. AP reminds us that it's developmentally good for babies to be held often, to be carried where they can nurse easily and interact with the world, to sleep near their parents, and to have their needs met relatively quickly (eat when they're hungry; comforted when they cry.)

Unfortunately, the pendulum can swing just as far in the AP direction, especially when it comes to older children. I have seen AP used between parents against each other - "you weren't home to nurse him! he was CRYING! how COULD you!" - and it's not pretty. There is an obsessiveness about it that places the relationship with the child above every other relationship. It boggles me sometimes to see parents who seem literally married to their children - they no longer talk to or spend time with their partners in any meaningful way. I start wondering whether those people just used each other as tools for conceiving a child and then forgot about each other. The post I linked to above touched a chord with me because I agree with the author that out of all the mothers I've known, the happiest were not dogmatic about any one style of parenting, and they most certainly did not surrender their whole identity to mothering.

When I was writing my senior thesis in college, I came to agree with Linda Blum's hypothesis in her book "At the Breast" - breastfeeding (in developed countries) is wonderful to the extent that it empowers women, re-embodies them, and provides a positive relationship with their children. When it is a source of guilt, shame, or overwhelming burden, it is no longer a positive act. Don't get me wrong: think that breastfeeding is very positive for public health and for the health of individual babies and mothers, and too many culturally constructed barriers are thrown up in front of mothers who try to breastfeed to keep them from experiencing the positive benefits of breastfeeding. But in a developed country, almost any baby can be reasonably healthy on formula, and to use infant feeding as yet another way to guilt women is not a feminist act. I feel similarly about AP and a lot of its practices; having Dr. Sears encourage you to co-sleep and give you good reasons to do so is great. Then you know it's a good option, and if your family is happier bedsharing, you have someone to bolster you when your mother-in-law comes over all, "Is he going to still be in there when he goes to college?" Feeling like you HAVE to sleep in the same bed with your child or she won't be psychologically healthy - that's not great.

So that's my agnostic view of attachment parenting, as with so many other things in the baby/birth/breastfeeding world - great when done at the right times in the right situations, and not so great otherwise. What do you all think?