Friday, July 31, 2009

Things I don't get about the health care reform debate

Here are a few things I don't understand about the health care reform debate. In particular, things I don't understand the media keeps letting the Republicans repeat ad nauseum:

I just don't understand how Republicans can keep making arguments that a government plan, or a public option, will lead to some new and terrifying "rationing" of care. "Oh, no your doctor will recommend something and some government bureaucrat will deny it!" We ALREADY HAVE rationing of care. Ask any doctor in this country - private insurance companies ration care by denying treatment all the time. And if you don't have insurance, then your care is rationed simply by your ability to pay. God forbid we ration care differently than we do now - say, by its effectiveness - because let's be honest, medical care is rationed now and always will be. Why? Because medical care, like any other resource, is not infinite or free.

Ditto for the scaaaaary talk about not being able to go to any doctor you want. Have these Republicans ever heard the phrase "out-of-network"? I'd say most Americans are already used to having to choose their doctors from a list provided by their private insurance companies. (And those who don't have insurance - if they can even afford to go to anything but the ER - are lucky to find a doctor who will take them at all.) Please don't pretend that the Fatherland is going to start assigning every person, without recourse, a single doctor (god forbid we have that kind of continuity of care anyway).

Finally, Republicans, please stop talking about the government being forced to pay for abortion under health care reform. Much as I would personally like to see every insurance company mandated to provide abortion coverage - most already do - AND the public option cover abortion, it will not happen and we all know it. Yes, theoretically it is possible that you could give someone a subsidy for health insurance, which they would use to purchase a private plan, which would cover abortion, which they would then need and receive. You also already give people money via the welfare system which they could use to pay for abortion, and give them food stamps which they could use to buy food which would then free up money that they could use for an abortion. If you don't want people to get abortions, then you should not give anyone money ever in any way, because they could theoretically use it to pay for abortion, since - funny, this - abortion is legal.

So those are a few things I don't understand. If any Republican members of Congress who read my blog want to explain them to me, please feel free.

Wednesday, July 29, 2009

Update your links

On my short list of blogs you should be reading (besides mine) is Jill's The Unnecesarean. She recently had a sad case of domain-stealing, so update your links from to (or add it now if you haven't yet).

Just recently she has had in-depth information and discussion on how refusing an unnecessary c-section led to loss of custody, the outcome of charges against a doctor for being abusive towards a woman in labor, and noted the new Cochrane Review stating that use of antibiotics for GBS in labor is not supported by evidence. See? You don't want to miss this! And I can't link to all of it (just a lot).

Tuesday, July 28, 2009

Saving women's lives in Afghanistan

Afghanistan has one of the highest maternal mortality ratios in the world (only Sierra Leone's is worse). In a culture where women grow up without proper nutrition, are married off and begin childbearing too young, are denied education and basic human rights - things start bad and then just get worse.

Pashtoon Azfar is working to change that; she's the president of the Afghan Midwives Association and she's been pushing education in not only technical skills but interpersonal skills. This is crucial as women who aren't accustomed to using medical personnel for births aren't going to trust someone who's, well, not nice.

“Does she greet the mother properly?” she asked. “Offer her a chair? A drink of water? Introduce herself? Let the mother ask questions? They are trained. They have to do it.”

Such simple steps that so many maternity care providers could use! It's not just about technical skills - it's also about trust. Read more here.

"These midwives, they are champions. Oh, I love them. They are my heart."

You can VBAC in a car, you can VBAC near or far

OK, sorry about the title. But anyway: Mother VBACs in speeding car.

Not just any VBAC - a VBAC after 3 c-sections (I'm assuming - they say their older three daughters were also born via c-section, although if some - or even all - were multiples that would reduce the total number).

After the "breech baby born in speeding ambulance" this story is suggesting to me if you want a vaginal birth, the best place to get it might be in a speeding vehicle?

Monday, July 27, 2009

IKEA misses the memo - breastfeeding in public is legal

A mother at the Ikea in Red Hook, Brooklyn was asked to move to the bathroom to finish breastfeeding her daughter. The comments on the blog post are pretty standard, including a former breastfeeding mom who puts down this woman's "poor planning" in not having pumped a bottle of milk in advance. Whoops! The mother who was asked to move must have forgotten that babies are born to be breastfed only in private. Perhaps the commenter was also forgetful, as she forgot - as the Ikea security guards seem to have - that women have a right to breastfeed in New York State anywhere they are legally allowed to be. As several more astute commenters pointed out, the security guards had no more right to escort her to the bathroom for openly breastfeeding than they did to escort someone to the bathroom for being say, openly black.

Here's the bottom line for me, and what a lot of the commenters don't seem to get: you don't have to like certain things. You don't have to like breastfeeding in public, or gay people holding hands, or someone wearing skimpy clothes. But these things are legal. If you choose, you can be a jerk about those things you don't like. The law doesn't and can't prohibit dirty looks or rude words; only common decency does. But companies and their employees are subject to the law, and by law cannot force a breastfeeding woman to move just because they don't like public breastfeeding. The end. What happened in Ikea shouldn't have happened and shouldn't happen again.

I find the whole thing particularly ironic since Ikea is Swedish and Sweden is an international model for its very high breastfeeding rates. I find it hard to imagine a mother in a Swedish Ikea being escorted to the bathroom for feeding her baby. They would have to escort something like 80% of them. I assume that's why their p.r. person gets it when she says: "This incident is being looked into as this totally goes against our culture and focus on family." Maybe the Swedes forgot that their American employees would need some extra training? (Interestingly, the thread where the original Ikea story was posted has another asked-to-stop-nursing-in-public story at a New York H&M, also a Swedish chain.)

(It's also not a great store location for this to happen in, given that scaring up a crowd of Brooklyn moms for a nurse-in would be as easy as walking around the playground.)

In any case, it sounds like both sides are responding actively to what happened, which is good. I'm curious to see what more (if any) news comes of this...

(Thanks to my friend and classmate Adriane for passing this along!)

Saturday, July 25, 2009

"From Worst to First" - Getting hospitals to change their ways

There's an inspirational campaign going on in New Jersey called "From Worst to First". With New Jersey at a 39.4% cesarean rate, they are publicly naming and shaming hospitals with high cesarean (and episiotomy) rates. Once there are women out front of a hospital with brightly colored signs saying "Bad Maternity Care Harms Women", most hospital administrations seem eager to at least meet with them.

The Worst to First website is here - if you scroll down to "Status of New Jersey Hospitals Addressed by NJMCWTF2010" you can click on individual hospitals and see photos of each protest and a short report of what happened.

I learned about this campaign through e-mails via a doula listserv. The e-mail reports were longer and more detailed than the reports on the website, and I thought I'd share an excerpt of one here:

We met with the Administrative staff of Saint Clare's Hospital in Denville
on June 8th, 2009 for a meeting to discuss the first steps towards our "Worst to First" Campaign.

In attendance was the Administrative Director of Nursing, the Maternal Child
Education Coordinator, the Communications Manager, the Executive Vice President of the Hospital, the Patient Care Manager, the Maternal Child Heath Coordinator, the Vice President of Public Affairs, the Labor and Delivery Staff Nurse and Doula, Quality Manager of Maternity, and the Director of Clinical Quality. Stacey Gregg Action VP for NOW-NJ, Anne Mitchell Stacey Gregg's Summer College Intern/Activist, & Morris County NOW Secretary Doreen Manno.

For the first hour and a half of the meeting, Stacey and the administration went back and forth about the condition and quality of patient care and how it was reflected negatively in the statistics that we're trying to break with our campaign.

Unfortunately before this point, the hospital staff present was unwilling to admit their statistics. They were trying to question the validity of the state's statistics of the ten hospitals that already really have episiotomy rates below 5%.

It wasn't until Stacey made the analogy between the unnecessary cutting of woman during birth and how if a woman was a rape victim, you would not be discussing the reasons why a rapist does what they do. You would only be concerned with coming up with solutions and ways to protect her. She gave the examples of a rapist claiming any justifications "didn't have enough time, it takes to long the other way"," that's the way I was trained to do it", "the women want it or they ask for it", and "they don't mind it this way", the way a doctor might defend his high rate of episiotomies. She stated that she did not want to discuss how they got here it just had to stop, and she took one of the signs that we had bought with us into the room that stated "STOP Violence Against Women" and stated that Women are being harmed. ...

"There are ten hospitals with low episiotomy rates that are doing things differently; obviously they're not doing the same things that are going on around here." Stacey said. ... Discussion was held about how to get the doctors to best respond and change the way they practice. From there, we began to formulate an action plan to reduce episiotomy rates at Saint Clare's.


On the doula listserv I get these e-mails through, doulas are saying "We need to do this in OUR state!" Is it too much to hope this goes nationwide? I'll head up my state's chapter!

Thursday, July 23, 2009

Newflash: breech baby born vaginally

I like the breathless tone of this one - "Even though the baby was turned the wrong way" he somehow survived!

Breech baby born in the back of a racing ambulance.

Wednesday, July 22, 2009

Don't count on your epidural

I used to work with a great midwife who gave a presentation of research on women's satisfaction with pain relief in labor. She said "If women are expecting pain relief and don't get it, they are not satisfied. If they are expecting unmedicated labor and end up with medications, they are not satisfied."

I thought of that when I read Reality Rounds' great post on expecting an epidural...and not getting one.

This is something I wish more women understood. Just because you expect to get pain relief in labor, you may not get it. You may never get it: you may have a fast labor, or show up too late, or have to wait too long for the anesthesiologist and by the time he shows up the baby is crowning. (If he ever shows up.) You also might have to wait for hours. When you get one, your epidural may not work, or only work partially. (My least favorite kinds of epidurals.) And most women do seem to feel a baby emerging from the vagina, regardless of the epidural.

I agree with RR: every woman should take a class that teaches them non-medical forms of pain relief. If your expectations for pain relief are met and you never needed those techniques - great. But if you need them, they could come in pretty handy. Above all, of course, keep your expectations flexible - then it's harder to be disappointed.

More on birth plans - and how to plan for birth

I've written before about preparing for birth and what birth plans are and aren't good for. Here's another round of helpful posts on them:

At Your Cervix on how to evaluate your birth place and provider and find out what interventions you may need to actively decline in labor.

Nursing Birth writes a great post (as usual) with tips for writing a birth plan that's useful to you and your care providers.

Once you've done your due diligence on provider and hospital, and know what you do and don't need to put in your birth preferences, it's much easier to write something like this: a Hypnobabies birth plan that's short and sweet.

Laura at Navigating the Mothership talks about what she did to make an unmedicated birth possible. Her tips include knowing WHY you want a natural childbirth, doing your research, and (natch) hiring a doula.

When is formula medicine and when is it nutrition?

So apparently the IRS has denied a family's attempt to set aside the cost of formula as a medical expense - despite the fact that the mother had undergone a double mastectomy and was physically unable to breastfeed.

I have to say I'm torn on this one. On the one hand, I would probably be pretty pissed if I wanted to breastfeed (this mom breastfed her previous child), couldn't because I had cancer, and had the IRS deny my request for tax relief for formula (which is expensive - this family spent $1,000). As the news story points out, footpads and prescription sunglasses are OK, but food to keep your child alive is not? The dad of this baby makes an excellent argument that this is a medical issue of the mother-child dyad - the baby needs formula because the mother's medical problem has interfered with his natural food source. That's no different from having footpads because your flat feet have interfered with your ability to walk comfortably - and food to keep a baby alive is considerably more important than flat feet.

On the other hand, I see arguments for the other side. There's a difference between formula and footpads. Footpads (and massage and hypnosis, which are also covered) are very unlikely to hurt you if you don't need them. But formula does carry risks and ideally should only be used when there are no other alternatives. Yet if you start OKing tax-free formula for some women, where do you draw the line? A woman with a double mastectomy definitely can't breastfeed. But lots of women will tell you they "couldn't" breastfeed (didn't make enough milk, for example) when the real problem was poor breastfeeding management and/or lack of support. How do you certify that a woman who does have breasts is actually physiologically unable to produce enough milk? What if she claims psychiatric issues - are those "good enough" reasons to formula feed and to have insurance cover? We start getting into when a formula is "medically necessary" and when it's just "personal choice".

On the third hand (isn't there always a third hand?) think about the father's argument that: "There is no alternate product to give the baby. It’s not like the baby can eat a granola bar and get developmental nutrition from a prescription product, which would be deductible. It’s breast milk or formula or the kid dies." True, but there's nothing that says it has to be the mother's own breast milk. I wonder if the IRS would see things differently if they had gotten a prescription for donor milk and purchased that instead?

Anyway, it's an interesting one. Thoughts?

Thursday, July 16, 2009

Links - breast reduction, questioning your OB, and midwives as health care reform

I have multiple posts in the pipeline but my work is making it tough...sitting in front of the computer for 9 hours a day at work makes me want to do anything but, once I get home! And I'm leaving tonight to fly cross-country for a wedding. Which will be awesome, but will not leave me any more time for posts. So in the meantime I leave you with some starred posts from my Google Reader:

What one woman heard when she started asking her OB the tough questions (she has decided to switch - sounds like a good choice.)

FABULOUS post on why "you can't get there from here" - that is, you can't get from a medically managed first stage to a physiologic second stage very easily. You can't get from a Pitocin induction to an unmedicated labor very easily. And when everyone starts with interventions, of course any other way seems impossible.

Important things to know about breast reduction surgery and breastfeeding. I am not a big fan of breast reduction surgery, partly because I know what a difference the right bras can make, and also because I believe it's another way in which our society medically legitimizes the "abnormalization" of ALL women (small breasted, large breasted, etc.) I also don't think there's good information out there about its effects on breastfeeding.

Interview with a homebirth midwife who is doing research on, and developing a protocol for, interactions between OBs and DEMs. Super interesting perspective on the OB/DEM relationship. She talks about "birth story telephone" and why both professions hold skewed version of each other.

Radical Doula writes on the connection between health care reform and midwifery care in the American Prospect. Awesome!

My flight leaves in about 4 hours...have a fun weekend!

Monday, July 13, 2009

Male doulas & the power dynamic

Interesting article up about the first male doula certified by DONA. It got me wondering whether a male doula would experience fewer, more, or the same number of power-struggle encounters doulas sometimes face.

Rarely, but occasionally, I have encountered hostility from nurses and doctors. I have heard plenty more stories from other doulas about this. Recently, a doula posted to a listserv about a terrible experience where the medical staff were extremely hostile to her - it wasn't an issue with her specific practice, they just didn't like doulas. They essentially assumed she was there to undermine and sabotage them. Their hostility escalated until they were threatening to throw her out just for doing her job (like requesting the parents have time to think over their options in a non-emergency situation).

Thankfully I've never experienced anything this bad, but in the hostility I've encountered the power struggle is still there - over who the patient trusts, asks to advocate for her and turns to for advice. Sometimes, particularly with nurses, I think there is a concern about being replaced as the primary caregiver. As 99.9% of doulas are female, 99.9% of L&D nurses are female, and a growing percentage of OBs (and doctors in general) are female, I wonder if adding a male doula to the mix shakes up the power dynamic. Should gender affect this? No. Would it? I have to wonder. Would he be more or less welcome? More or less threatening?

Friday, July 10, 2009

Doula love

Interview with a mom on why she chose a doula and what her doula did for her:

I think the best thing about Kym was the way she stood up for us at the hospital. We did not anticipate that we would be intimidated (who would?) as it turned out we were. When the nurses (and later the doctor) pressured us to succumb to their wishes, Kym was assertive enough to argue with them. I don’t think Jon was quite up to it at the time. It was all pretty ridiculous, but these are the important things. One nurse wanted me to have an IV, despite what my doctor had agreed to in our birth plan, and continued to argue that I was going to get dehydrated. So while I was in transition, Kym and the nurse had an argument about whether one could stave off dehydration by drinking water.

Yup, that sounds about right. I was once with a mom who had a nurse try to convince her that she needed an IV because "labor is like running a marathon". The mom said "I used to be a marathon runner and I'll stay hydrated the same way I did then - by drinking water a little bit at a time!" That mom knew what she wanted and was assertive but as she got farther into labor and complications cropped up, I like to think it helped to have me and the other doula who was with her there. We were able to run a little interference, back her up when needed, talk through options with her, and reassure her that she was making OK choices. I think that's what a doula does for a lot of women/families: reassure them that what they want is not crazy, that they do not need to be intimidated, and that things are proceeding normally.

Wednesday, July 8, 2009

"Pit to distress" around the birth blogs

I think the first place I heard "pit to distress" must have been in Marsden Wagner's book "Born in the USA". The term refers to the practice of turning pitocin up to the point where the uterine contractions it stimulates put the fetus into distress.

Just in the past few days there has been a lot of discussion about it around the birth blogs. It started with Jill at Keyboard Revolutionary who discussed her recent discovery of the practice. She interprets "pit to distress" as done to provide a pretext for a c-section. This is what she thinks of it: "I have spent the last five years of my life angry at the medical establishment for what happened to me in the hospital. But I just might be more pissed off right now than I ever was before, after hearing about 'pit to distress.'"

Jill at the Unnecesarean linked to that post and followed up with a number of links that cite "pit to distress", from nursing textbooks, nursing forums, and a newspaper article. "I imagine all of us who have openly questioned the practices of obstetricians in the U.S. have been hit with the same backlash. We must be selfish, irrational and motivated by our own personal satisfaction. ...Nah. It’s stuff like “pit to distress” that made me run for the nearest freestanding birth center. If I had to do it all over again, I’d stay home."

These two posts have elicited a number of responses, especially from practicing nurses and midwives.

Ciarin at A Midwife's Tale discussed the context in which she's heard it used, namely "The term was used in situations where the baby was looking less than stellar during latent labor and it was already predicted that the a c/s would be likely for this reason. The pit to distress term would simply mean, go ahead and pit hard so we can section the baby."

Labor Nurse CNM on Rebirth also said that she had never seen the practice as described but had seen pitocin pushed to the point of fetal distress. She pointed out that nurses could lose their licenses for administering medication that way.

Along those lines, Reality Rounds looked at it from the angle of how nurses can go about refusing physician orders, or at least communicate their way out of it. She states: "A nurse is ethically, morally and professionally obligated to advocate for her patients. ... A nurse CAN refuse to carry out a physician order. A prudent nurse should refuse any order she feels would cause harm to the patient".

And nurses have posted stories of doing just that:

Prisca at N is for Nurse had recently discussed requests to "pit to distress" that she has had to push back against: "They wrote pit orders on a woman who was already hyperstimming by herself, bleeding and baby looked like crap. I was really hating my job that night--fighting three residents is loads of fun. So, I hung the pit at 2 units and didn't touch it for 2 hours. I also watched mom like a hawk and made my general displeasure known (and charted it all of course) to my charge who agreed with me and the attending who didn't want to 'cut' this woman in the 1st place. Dude, she needed a c-section, just NOT a crash section."

Nursing Birth tells her own stories of fighting pit to distress orders. She clarifies that no one has to write "pit to distress" in the orders to make it happen: "...[T]he account that you have just read is called 'Pit to Distress' whether the pitocin order was actually written that way or not. What Dr. F gave me was a VERBAL ORDER to increase the pitocin, regardless of contraction or fetal heart rate pattern, until I reached 'max pit,' which he acknowledged would hyperstimulate her uterus. This goes against our hospital’s policy and the physical written order that this doctor signed his name under."

One thing that's been wonderful about building up a Google Reader full of birth-related blogs has been getting the chance to see an issue from multiple perspectives, and hearing many experiences. As a doula and a public health professional, I want to educate myself in complexity - not "All OBs do this" or "Pitocin is Bad" - but to understand what's really going on and where.

Reading these has also made me wonder - has this order ever been given for one of my clients? It's certainly possible, but I'll never know now. How can I prevent this happening to clients in the future, other than encouraging them to ask to have the Pitocin turned up slowly?

Tuesday, July 7, 2009

Electronic fetal monitoring = FAIL?

This is what I learned in epidemiology. When deciding whether to use a test, you need to look at several characteristics, including:
Specificity: How good it is at correctly identifying negatives (does it successfully identify healthy people?)
Sensitivity: How good it is at correctly identifying positives (does it successfully identify sick people?)
Reliability: How consistent is it - will it give similar results with multiple retests? If it is subjective, do multiple assessors give similar scores?
Validity: Does it actually measure what you are trying to measure?

So how does electronic fetal monitoring measure up, according to this recent New York Times article?

Sensitivity & specificity: more than 99 percent of cases, predictions based on the tracings that the baby would have cerebral palsy have proved wrong.


Doctors differ greatly in how they interpret tracings. In a study in which four obstetricians examined 50 fetal heart rate tracings, they agreed in 22 percent of the cases. Two months later, the same four doctors re-evaluated the same 50 tracings and changed their interpretations on nearly one of every five. Furthermore, when the baby’s outcome is already known, interpretation of the tracings is especially unreliable, the guideline report says.


...monitoring the fetus during labor does not affect the risk of cerebral palsy, because 70 percent of cases occur before labor begins and only 4 percent result solely from a mishap during labor and delivery.

So EFM doesn't accurately measure risk to the baby and is interpreted very differently by different clinicians, and even very differently by the same clinicians at different times.

“Honestly, the technology got rolled out before we knew if it worked or not,” Dr. George A. Macones, an obstetrician at Washington University in St. Louis, said in an interview.

Oh, so maybe we should perhaps reduce routine continuous EFM?

Apparently not - just interpret it better, with three new categories of risk:

[ACOG] hopes the revised guidelines will reduce misinterpretations and inconsistencies in the understanding and use of readings on fetal monitors, although experts are not optimistic that the rate of Caesareans will drop.

I don't think it would take an expert to tell you that.

Monday, July 6, 2009

New webisode series - celebrity births

Ricki and Abby are at it again! Next up it's a celebrity webisode series, of celebrities discussing their births. I kind of wonder what the exact point of it is - just judging from the trailer, there seem to be some alternative birth choices in there (Laila Ali having planned a home birth, for example), although not all. Maybe the idea is just generally to attract more attention to the fact that there ARE choices in birth by having celebrities talk about their choices. Anyway, I'm a sucker for both birth stories and People magazine, so it sounds OK to me.

Via Empowered Birth.

Sunday, July 5, 2009

Just someone else's normal

I often find myself wishing everyone could take an anthropology class with my college anthro professor. I took three courses with her, all variations on medical anthropology, and they were amazing, and probably life-changing. I grew up very scientifically-minded. There was one way of knowing how to do things - western science/medicine - and if it didn't work, then you were out of luck. Other cultural beliefs were sweet and quaint, but they all needed to get busy catching up to us.

Studying medical anthro cracked my world open and let a lot of other possibilities in. My professor used to say, "Culture is to people as water is to fish." It's very hard to notice and analyze because you're already living in it. She once explained that she taught her classes in a careful sequence - she started by having us look at cultures very different from our own, and then slowly brought us closer and closer throughout the semester until we were able to start seeing the water we were swimming in.

Since then I've found it so useful, when I am accepting something as fact or "how it has to be done", to think of other parts of the world. Do they have an alternate system of thinking, and how does it work for them? This is well-illustrated in the birth world by the contrast between the British RCOG's support for homebirth and the American ACOG's condemnation. These are two developed countries that have strong historical ties, have similar populations and standards of living, and share a common language and can read the exact same evidence - yet they reach opposite conclusions (and in the UK's cause their way seems to work just as well as, if not better than, ours).

I also end up using cross-cultural comparisons for a lot of breastfeeding discussions. I feel pretty strongly about speaking up when I hear people making negative comments about things like extended breastfeeding or nursing in public. With extended breastfeeding, I talk about Kathy Dettweiler's research on age of weaning in non-human primates, to show that there is little biological evidence for early weaning, and discuss the variability of age at weaning around the world. For public breastfeeding, I point to the many cultures that do not sexualize breasts and where nursing your baby in public is as normal as giving your child a handful of crackers. (This mother calls out our ideas of being "the most liberated": "I imagined the women of West African villages looking at the enlightened mama cloaked in a Hooter Hider or nursing in the bathroom with that same mix of sympathy and bewilderment and condescension I catch myself using on a Muslim woman trudging through the summer heat in a black burqa.")

I really hope this technique does work. I do think it's helpful, in that it's the kind of thing I can say in a calm, offhand kind of way: "Oh sure, that's what we've gotten used to, but actually in other countries they do it this way and it's actually got some really great benefits". (As opposed to the other arguments like "Why is it any of your business and if you don't like it stop looking" which tend to involve a little more righteousness and spittle.) Especially with people who are already schooled in multiculturalism and open-mindedness, they just need a little nudge to see this as something that's not beyond the pale of all human experience - it's just someone else's normal.

Anyway, if you're interested in learning more about culture and health/medicine, I highly recommend the book The Spirit Catches You and You Fall Down by Anne Fadiman. It's filled with those "aha!" moments where you get to see your own culture/water. The only drawback is that it may be hard to get enough sleep because the story is so compelling, it keeps you up late reading.