How to make a birth plan

Notice I didn't say write a birth plan! Why? Labor Nurse has a great post up about why writing your birth plan for hospital staff should be the last step in getting your needs met. It's a long and very comprehensive post about what questions to ask your care provider and on a hospital tour, why choosing the right provider and birthplace is so important, and what parts of your birth plan you should negotiate with your provider before ever walking through the hospital door. All this ultimately informs what you need to write down for hospital staff - and it's probably going to be a lot more user-friendly and helpful than some stock plan you print off the internet.

Breastfeeding & social marketing

This week for my breastfeeding class, I'm hard at work on a social marketing project. My idea is to market to health care providers (in this case doctors) to encourage them to talk to their patients about breastfeeding. Despite good evidence that doctors' encouragement does make a difference, I think a lot of doctors don't know/believe it or don't know how to start the conversation. My goal is to give them a little evidence to nudge them forward, and the tools to do it (pocket cards with ideas for how to start the conversation).

The hardest part has been the required focus group - I wanted to focus group it with OB or family practice residents who do prenatal care, and one of my classmates is a family practice physician at a nearby university. She tried to help me think of ways I could snatch a tiny bit of the residents' time, but we came up empty. Apparently they don't even sit down to eat lunch because by then they're running behind. So I'm focus grouping it with med students, who have a more flexible schedule but not much hands-on practice experience. This just serves to illustrate another reason for not discussing breastfeeding: no time.

It is sad, though, to realize that no matter how hard I work on this project, I may never come up with a breastfeeding social marketing campaign as fantastic as this:



I forwarded it to a couple of friends who used to live in Thailand, and they assured me that this is very representative of Thai soap operas, although probably without the list of vitamins found in breastmilk.

Oh, the induction

A Twittered induction-turned-cesarean. A cesarean for a baby who is just "too big" - at 7 lbs. 12 oz.

One more story to add another little nudge to our culture's perceptions that babies are too big, that all c-sections are necessary, that induction has nothing to do with it.

While we're on breastfeeding, a link

Mothers step up to breastfeed motherless infant

A schedule was put together with feeding times at 9 a.m., noon, 1:30 , 4 , 6:30 and 8 p.m. Six times a day a different mother has been feeding Moses for the past two months. During the night, Goodrich bottle-feeds his son breast milk that was pumped by the women.

"What amazes me is they are so committed," Fraire said. "They would do it for anyone because they believe in this. They didn't take it lightly and they don't miss a day."

Goodrich added: "It's commitment, passion - it's love. It's an act of love."

"The Case Against Breastfeeding", Part 2: thoughts on the actual article

And that leads into part 2: my thoughts about the article.

After talking about the responses a little bit, I want to talk about the article. I think Rosin gets a lot of things right in her case against all the other, non-breastfeeding issues I discussed in my previous post. What disappoints me is that in her case against breastfeeding, she basically tosses all the benefits to the mother out the window (way to be feminist there), and overall she focuses on health alone. I’m going to snag a paragraph directly from my undergraduate senior thesis, because I think it says it well (albeit mostly via Linda Blum):

“Linda Blum, whose book [At the Breast] formed the basis of my early thinking about these issues (as well as much of my later thinking), emphasizes on several levels the importance of “unfixing” breastfeeding. She argues against “fixed” biological meanings for breastfeeding... She advocates breastfeeding more for the benefit of mothers than for babies, in an unusual reversal of typical priorities; for Blum, breastfeeding (under the correct circumstances) can reclaim female and especially maternal bodies. Thus additionally and on a more conceptual level, she also argues against fixed concepts of breastfeeding’s meaning: 'To nurse our babies at the breast may offer a way to revalue our bodies and force a public reevaluation of caregiving – or – at the same time, it may represent acquiescence to dominant regimes of self-sacrifice, overwork, and surveillance. It can blur into a disembodied regime and threaten an overriding sense of failure' (pgs. 198-199).”

I believe that last bit is what Hanna Rosin is talking about; but what I, and many others, would like to talk about is the first part. Let’s revalue women’s bodies, revalue the unpaid labor of parenting, and provide true choices for infant feeding.

I also am puzzled by what Rosin, exactly, wants to see happen. I buy her argument that we can’t guarantee breastfeeding’s benefits for every child; I wrote a post about it already. But I also pointed out that while it may make sense for a mother to decide not to breastfeed, based on her weighing the risks and benefits of formula feeding for her life, that is because when we talk about breastfeeding’s advantages we are discussing them on a population level. We know that the risks of formula feeding, spread over a whole population, will lead to worse outcomes. This is why we encourage individual mothers to breastfeed, and why we should do less of that and more of the structural changes that need to happen to make more breastfeeding possible.
Still, mothers will always have a choice about how they want to feed their infants. We can provide a year of paid maternity leave and free lactation consultants, but if we don’t make some efforts to shift our culture away from formula feeding we may not see enough women taking advantage of those structural changes. This involves us saying to women, in essence, “We suggest you breastfeed for the following reasons.” Rosin does not just argue against individual choices to breastfeed. She critiques the policy statements by major organization promoting breastfeeding as the norm for at least the first year. What really knocked me over, though, that a major complaint is that it wasn’t sensitive to working mothers. Right, medical organizations should tailor their recommendations not to the best science, but to the social and political climate. If we’re making policy statements based on what’s possible, let’s also recommend that only rich people get medical care.

I think that Rosin wants public health and medical authorities to just back off. Stop telling women to breastfeed, because it’s making the people who can’t feel guilty. I think she truly believes that not just on an individual level, but also on a population level, it doesn’t make a big enough difference. This week, I came across a recent blog post where she compared her article to the new evidence that prostate screening does more harm than good. She felt this was evidence that all the medical authorities could agree for years – eand still be wrong. So we should dismantle all our efforts to promote breastfeeding, dump the pumps at WIC, stop certifying hospitals baby-friendly and provide no more tax credits for corporations to provide lactation rooms. Right? I mean, this is her argument taken to its logical end, correct? If breastfeeding is just a lifestyle choice, mothers do not deserve any special support.

The only reason I hesitate to conclude that this is what she really wants is that she is a breastfeeding mother. She breastfed her first two children and after she had her illumination about the pointlessness of breastfeeding, she kept breastfeeding her last. He gets formula when she goes out, but she nurses him at home. Why? Oh, just because it’s nice to do. No, I won’t say, as one of the essentialist posters did that “this is [her] biology calling”. But this is her hypocrisy calling. As a further count in support of that, she concludes at the end that breastfeeding is probably better! Just not enough to outweigh all the downsides. So now after finishing up her breastfeeding career, she now gets to look back and tell everyone else it wasn’t worth it and don’t bother, and while I’m at it maybe we should also dump all of those supports you might want, you know, to help with the downsides. And if Hanna Rosin doesn’t think that’s what she’s calling for, then I’d like to know what she thinks she is arguing in favor for. Because I’m still not sure, but I don’t think it’s good.

"The Case Against Breastfeeding", Part 1: thoughts on the response

Well, if you’re involved in the birth/breastfeeding/public health worlds in any way, you must have spent the last couple weeks under a rock not to hear about “The Case Against Breastfeeding” by Hanna Rosin. For my class presentation this week, I asked if I could present on the article and the various responses to it. This launched me deeper than I probably wanted to go into the debate. There are helpful and interesting takes on this all around the blogosphere, as well as policy statements by several organizations, but after a while my head started to spin. So I’m going to post about this in 2 installments: first, my take on the debate; second, my take on the article itself.

First, I just have to say: Wow, patriarchy! Once again, you have managed to pit women against each other instead of their real problems. Let’s scapegoat breastfeeding as the thing that makes mothers overwhelmed and guilt-ridden. Not their measly 12 weeks of unpaid leave or unequal parenting duties. Then let’s have women attack Hanna Rosin and each other for being terrible or neglectful or crazy or judgmental or pathetic. (I lost count of the number of blogs and comments that said, “Hanna Rosin is obviously a sad person who doesn’t like being a mother and is in an unhappy marriage.”)

Having waded through probably only a fraction of a seemingly bottomless pool of blog posts on this, I can assure you, patriarchy, that if women spent this energy on dismantling you, you could be in serious trouble! But thank goodness, they are not. Patriarchy, as an institution you are really on top of your game. You know, it kind of makes me not want to have children if this is what mothers spend their time doing to each other.

In that vein, I was particularly disturbed by blogs that came at Hanna Rosin from a biological determinist standpoint. OK, mostly this one. You shouldn’t have children if you don’t want to breastfeed? Women shouldn’t have children if they don’t want to “birth, nurse, and raise them”? In the 1950s, we didn’t have to promote the scientific benefits of breastfeeding because women “naturally assumed” their “proper role”? This is throwback stuff and it’s a little sickening to me.

I also disagree with another blogger who said feminism should rethink its ideals to regard mothering is the “most amazing thing a woman can do”. Can we just say “one of the most”?

I agreed far more with all the posts that said the article really isn’t a case against breastfeeding. It’s a case against a lack of paid maternity leave. It’s a case against unrealistic expectations of women to “do it all” while being Mommy Perfect or to divide different roles into different parts of their lives. It’s a case against an “equal” system that by treating men and women “equally” ignores women’s needs (at the expense of men as well). It’s a case against guilt-based, prescriptive parenting. It’s a case for better information when women are making their feeding decisions. It’s disappointing that Hanna Rosin made the focus just this one piece of mothering, and sparked all of the typical Mommy Wars Bingo-playing.

I am at a conference this week and yesterday one of the speakers discussed the idea that for many women today, motherhood may be their first experience with explicit sex discrimination. We’re not talking about sexual harassment here, or the many ways sex discrimination is institutionalized and hidden from our everyday perceptions. We’re talking about “Wow, I am expected as a woman to do x, y, and z and it is physically impossible and I get no support, and now for the first time in my life, my options are radically different from those of my male counterparts, and in a bad way”. So guilt and anger over that get displaced not on the system, but on other women and, sometimes, on breastfeeding. I wish Hanna Rosin had explored those issues in her article. Because if you drop breastfeeding from the equation, how many other inequalities are you left with?

And that leads into part 2: my thoughts about the article.

You are responsible for your birth, and for your provider

There's a new article out in New York Magazine about the midwife featured in "The Business of Being Born", Cara Muhlhahn, called Extreme Birth and saying she is "The fearless—some say too fearless—new leader of the home-birth movement."

Right off, this phrasing is weird. Cara may be featured in BoBB and be very popular in New York City right now, but I would say there are much more prominent homebirth leaders (Ina May Gaskin, perhaps?) She's a full-time practicing midwife, which doesn't leave so much time for activism, even if she managed to get a memoir out. But that's just the headline and maybe it was written by a copy editor, not the author. Moving on.

Next comes the statement that "She...doesn’t practice like a typical midwife. Personal experience has led her to dismiss many of what she calls the “myths” that are still taught in school as the bedrock of safe practice." Examples are large babies, VBACs, breeches, and twins. The article continues in this vein. It's like the author, a man whose wife is considering a homebirth with Cara Muhlhahn, thinks she's Rasputin. His wife "laps up" the "home birth pitch" even though her husband is uncomfortable with them choosing a homebirth because of his wife's lupus diagnosis. There's a few things he puts in to balance his mostly negative treatment, but it's mostly bad. He finds a couple that had a negative experience and interviews them. He talks about a lawsuit that resulted from a shoulder dystocia. He points out she doesn't carry malpractice insurance. He gives the impression that this midwife treats too many things as normal and is willing to take too many risks.

I don't know Cara Muhlhahn; I haven't read her memoir yet and all I know about her practice is what I saw in the movie. But I do think that this would be a poorly-written article about any midwife. I have met a lot of midwives happy to deliver VBACs at home. I think it's the atypical midwife (at least among those who practice homebirths) who doesn't at least want the option of delivering VBACs at home. Breeches, twins, and large babies are more debatable (although a lot of midwives would debate a prenatal diagnosis of size). Shoulder dystocia is unpredictable and the outcome she was sued for, Erb's palsy, can happen as easily in a hospital as anywhere else. Many midwives don't carry malpractice insurance, often because they can't afford it.

Asserting that Cara Muhlhahn is different or especially risky is strange to me. And ultimately I think there's something this author doesn't get. I think most homebirth midwives have another important thing in common: they are OK with parents taking more responsibility for their level of risk. If you march in and say you have lupus and want a homebirth, they have to decide if they are willing to take on that level of risk. If they are, that doesn't mean your midwife has just magically made you the exact same risk as everyone else. It means it's back on you to decide if you are willing to assume those risks too, for yourself. There's a difference between trusting your care provider and handing all responsibility over to them.

Put another way: if you want an elective c-section, your doctor might turn you down, citing the risks. You can shop around to every obstetrician in town until you find one who's willing to take you. This person might even read the literature differently and see no excess risk from elective c-section, and tell you so. But this person has not magically changed the evidence out there in the world, or how it applies to you. They just see it differently. It is up to you to do the same research and decide if you see it that way too.

You can go midwife shopping the same way. You can look and look until you find someone willing to take on your homebirth after 3 cesareans. It helps if you feel very comfortable with their training, credentials, and experience, and trust their ability to handle any emergencies appropriately. But ultimately, you will live with the consequences of your decision and have to decide if you feel comfortable with what you're planning.

You have to do your homework for birth, and that's true of the planned hospital birth as much as it is for home births. You should ask about a hospital's c-section rate the way you would ask about a home birth midwife's transfer rate. It's comforting to think about handing over all the responsibility to someone else, but I think ultimately it's unrealistic.

Link round-up

I've fallen off a bit in posting, mostly due to the fact that I went to the Midwifery Today conference over spring break. That alone gave me about a hundred ideas for new posts, but since I was gone/busy all of break I came back to a large amount of homework/groupwork/work in general. Then I had a birth in the middle of the week, which threw off my already nearly-destroyed sleep schedule!

So I thought until I could sit down and write more, I'd do a link round-up. As I go through my Google Reader I star posts to come back to later, or that put me in mind of a topic I want to write about. Now I've got so many, I think I just need to clear that list out. Here we go:

The Well-Rounded Mama on why it's so important for women of size to get the right size blood pressure cuff. I just learned at the conference how important it is to have the correct size and how to measure for it, but I have worked in many clinics and never once seen anything but the "standard" size.

Radical Doula's piece in RH Reality Check on The Cost of Being Born at Home. It can be very challenging, depending on the state you live in, to get Medicaid to cover all or even part of your home birth. How can we promote birth alternatives while ensuring equal access?

Blood and Milk's round-up of Favorite Posts of the Year. This is a blog about international development and there are some good posts on voluntourism, and how to make sure you are doing more good than harm when engaging in projects overseas. Being in public health, we are asked to think about this often, but probably not often enough.

Research you can use when "Saying No to Induction". Saying no to things is a huge step for women. I am surprised by the number of women who aggressively educate themselves, but when push comes to shove, they back down even with all the evidence on their side. To say no, you sometimes have to piss people off, inconvenience them, be belittled, questioned, or threatened. Women are socialized to avoid causing a scene in any way. It's hard, but with evidence to back you up you can feel more confident.

A depressing post from Gloria Lemay with e-mails from OB nurses. I don't think they reflect all hospitals or all nurses, but they show how bad things are in some places.

Why all expectant parents should tour a birth center even if they don't plan to use one.

A lactation consultant talks about how breastfeeding is not the best, or special, ideal, or optimal. It is normal - the norm for feeding human babies. Not some mountaintop pinnacle we should be aspiring to.

Why you should do your homework - not just "wait and see" - before birth. Homework is the mother of prevention!

That's all I have time for (that's probably more than I had time for but it gets addictive...)

A doula pet peeve

I would like to invite all people attending a birth to practice a special piece of compassion for laboring women. It bugs me in ways I can't quite express when someone shows up in hour 6 of an induction and starts nagging at the mom to "get that baby out!" I know it's usually said all jovial and maybe sounds like it's a joke, but it's based in this idea that "getting this baby out" any time soon is possible. One of induction's (many) drawbacks is that it takes a really, really long time and you have to spend that entire time in the hospital. When most people in spontaneous labor would be arriving at the hospital, you have been there for at least 24 hours. And to be honest, the same thing gets said to women who show up at 3-4 centimeters.

I know it is well-meaning and intended to be encouraging. I also know it comes from television/movie/media impressions of birth where a woman doubles over with sudden, intense contractions, is rushed to the hospital and seemingly immediately delivers her baby. (It's funny that people love to tell "horror" stories of births that last for days, but they are not cinematic enough and don't seem to get imprinted on the subconscious quite so well.)

But birth takes time. Birth, most often, takes a lot of time. It takes prelabor contractions, early labor, start-and-stop contractions, walks around the block, trips to get checked out at the hospital and come home again, triage, getting checked into the delivery room, and settling in and then often you STILL have hours of labor even with the hospital's (very) conservative estimate of 1 centimeter per hour. With inductions, add a night of cervical ripening, and then sometimes another day and night of Pitocin and THEN get to the part where you still have hours of labor.

There are lots of clocks hanging over women's heads in the hospital. There's the 24-hours-after-rupture clock, the 1-centimeter-per-hour clock, and the I-want-to-go-home-for-dinner-let's-call-a-c-section clock. And if a woman is fearing (or justly trying to fight) these clocks, don't add your own impatience, even jokingly.

So friends and family members (and nurses, and midwives, and doctors, who should know better!), do a favor to moms and partners and doulas who are trying to keep a positive-yet-realistic attitude: come in with the same attitude. Come in saying supportive complimentary things, discuss topics that aren't how-long-do-you-think-it-will-be, and leave saying more supportive complimentary things. (And for family/friends, also don't stack up like planes circling O'Hare in her delivery room, hoping she'll magically give birth like NOW and telling her she "has to have the baby by 11 because I have to leave then".)

A short history of the cesarean rate

Why did c-section incidence - fewer than 10% of births in the 1970s - rise in the 80s, fall in the 90s, and then rise again to where 1 out of 3 women give birth by cesarean today? The more I learn about it, the more I realize it's a pretty interesting story that says a lot about what shapes maternity care (hint: it's not always the evidence). The Well-Rounded Mama has a great post about the recent history of c-sections in the U.S.. It's completely worth reading, especially if you've been reading my posts and wondering "What's the deal with VBAC?"

How to keep a woman from breastfeeding.

Hee. Remember when I posted the Ten Steps for Baby-Friendly Hospitals? This is like the Anti-Ten Steps.

"Make sure she doesn't call a La Leche League Leader, Lactation Consultant, breastfeeding peer counselor, or anyone else knowledgable about breastfeeding." This is the last rule and in my opinion the most important. Most breastfeeding problems are culturally manufactured (notice I didn't say cultural! A cracked nipple is biological. But having no one to support proper latch-on can cause that problem.)

I've said it before and I'll say it again: breastfeeding is natural, but it doesn't always come naturally. There's this idea that if you can do it with no help it was meant to be, and if not, well, it wasn't, and forget all those breastfeeding nazis and their talk about "instinct". But find me a culture in the world where the majority of women breastfeed without any assistance, advice, or role models. If anything is "unnatural", it's our idea that breastfeeding should occur in a vacuum.

Breastfeeding book giveaway!

I have seen a few great reviews of the new bookBreastfeeding With Comfort and Joy lately. It looks fabulous, just a great way to help women understand breastfeeding not only by talking about it or showing a video of "the perfect latch", but also being able to see many other women breastfeeding in many different contexts.

Now Woman to Woman Childbirth Education is hosting a giveaway...check out how you can enter.

More on breech!

And now hot on the heels of my last breech post comes this fabulous editorial from an Australian newspaper by a woman who asks, among other things, two very important questions:

1) Why do people admire men who climb mountains, but scorn women who have unmedicated births?

2) Why is it so hard to find someone to deliver a breech baby?

I admire her for asking questions and seeking out providers who can give her a second opinion on breech delivery, and I hope she writes again to talk about how her baby's birth goes. I hope many women read this and start asking more questions.

Breech waterbirth

The topic of breech presentation has been coming up for me lately from a few different venues! Someone asked me today what I would do if I had to make the choices of whether to attempt an external cephalic version to turn the baby, whether to schedule a c-section. I know that I would avail myself of acupuncture, chiropractic techniques, somersaults in the pool...every gentle way I could think of to turn the baby! I would have to weigh the risks and benefits of a version, as I would of a c-section.

One of the challenges I would be weighing, though, is how hard it can be to search and fight for the right to vaginal delivery for breech. Even in New York City, where I used to live, doulas would trade around the precious names of the few doctors who did breech deliveries. That's in a city of millions! Upstate, I knew a woman whose midwife wouldn't deliver her breech at home, but helped her find a doctor who would. He was from an African country, and thought breech was perfectly normal. He was happy to deliver her breech baby as he had many other babies in his own country. But you have to be hardworking and lucky to find a practitioner who is experienced with, and willing to do, a breech birth.

And finding a practitioner, of course, depends on you knowing and feeling confident that a breech birth is even possible. I absolutely believe that many people - even those carrying breech babies - do not know that vaginal birth and breech are not mutually incompatible.

Thinking about all this, I started rummaging around on the internets for breech info. I came across this video, and was struck by how beautiful and simple the births were (and exemplify "hands off" breech!) You're able to see breech babies emerge very clearly because of the unique birth tub used, and then you can watch them swim around a little before they're brought up to the surface! The little box that pops up at the beginning says this is in Belgium. I wonder if vaginal breech is common in Belgium, or only at this hospital. I'd certainly feel more comfortable choosing a vaginal breech delivery, though, if I had a great place like that to deliver! And this is proof that vaginal breech can indeed happen, under the right circumstances.

Beautiful story on milk banking

I heard this story was coming down the O Magazine pike, but now it's here and you can read it for free!

Seriously. Read it. Just go.

I love their description of the benefits of human milk - especially for premature babies - and about the amazing commitment it can take to provide it in difficult circumstances. It's also a great discussion of the benefits of milk banking and highlights the work of the Human Milk Banking Association of North America (HMBANA).

Connected to this, at some point soon there are several posts coming on the non-profit/for-profit milk banking debate - I find it really interesting and potentially very important to the future of milk banking.

Eating in labor

Eating during labor is safe and is important to help maintain a mother's energy.

Two responses:

1) Uh, yeah, obviously. But thanks for the evidence!

2) Let's see whether this changes the policy of a single hospital.

I was once with a mom who was so starved during labor that she talked about it while she was pushing, and as soon as she had her baby, she sent her husband out for Taco Bell and then ate a bag full when he brought it back. Imagine being so hungry at the birth of your baby that you think more about food than the fact you're about to meet your child! I was happier to see another mom (a nurse by profession) sneak a Snickers during an induction (I looked the other way). It's sad that women have to either sneak food or starve in labor.

Self-education is essential

Diana at Birthing at Home in Arizona has a nice post up about why you need to self-education (and self-advocate!) in health care. She has a great list of examples of having to do this during her pregnancy. I am often surprised by how willing people are to accept whatever a healthcare professional says. Midwives, doctors, nurses...they're all humans, who can make errors, forget something, or make assumptions, and who can only hold so much knowledge in their heads at one time. We all need to be the experts on our own health in order to best work with care providers!