True story

Our LC training is in a hospital-based conference center with various workshops going on in other rooms. Yesterday, right across the hall from us? A "Nestle Infant Nutrition" workshop.

Great new blogs, and a minor LC update

You can take a look at my blogroll (greatly in need of updating) for many of the blogs I love. But I thought I'd highlight a few new (or new-to-me) that I've been enjoying:

First the Egg is not exactly new, as it's a expanded reincarnation of Feminist Childbirth Studies, but it's new enough! It's not just a blog but also a "nonsexist space for people who want to learn, reflect, commiserate, or laugh about being pregnant, giving birth, and helping children grow up whole and happy." There are feminist resources on pregnancy & birth (including breastfeeding), parenting, and women's health.

A Midwifery Journey is the blog of a nursing student who has been applying to CNM programs. She blogged a bunch about her impressions of various schools and opportunities, and has recently decided on Yale. It's been an educational and helpful read for me, given my constant personal swirling vortex of thoughts about the future ("midwife? yes? no? yes? no?" would be a short version, maybe someday I'll post the long version). I'm looking forward to hearing more about her experiences!

The Academy of Breastfeeding Medicine's new blog is great! With posts on the science, medicine, and policy of breastfeeding, this is quickly becoming a new favorite for me. Check out the post on how to critically evaluate media reports of breastfeeding studies, and the studies themselves.

That's all for today! I have a training all day, every day this week for my LC course. It's a review workshop for people interested in lactation support/planning to be LCs/planning to sit the exam. It's a mix of good, interesting stuff and a little more boring, less useful stuff, as is almost every workshop and/or conference. It does feel like a very solid review of everything we've learned this year which is both good and bad: good to review everything and get it compressed into one place in our heads (and notebooks) before the exam. Bad (or at least less good) not to be learning so much new stuff. We were talking in the car on the way back about how since we're the first class to go through this LC training, we're the guinea pigs for things like our textbook (there will be a different one used next year) and this review course (TBD if they require it again next year). The disadvantage is, of course, being guinea pigs for the things that don't work; but considering the plans to expand the training next year, I feel so lucky to have been a member of this first small class. The close relationships we've been able to forge with each other and with our precepting LCs have been so wonderful. And even when I'm getting bored in the workshop, I sit there and remind myself how incredibly lucky I am to have gotten the chance to do the training this year. I just cross my fingers that I can find a way to keep doing clinical, hands-on work with breastfeeding dyads. It is one of my favorite things in the world to do!

Letter for the last weeks of pregnancy

Lately, I've been wanting a link to an article or blog post that I could pass on to friends and doula clients in their last weeks of pregnancy. That is such an impatient, vulnerable time, especially because almost every mom I've ever worked with has thought their baby would come early. To think you're about to give birth any day starting at week 38...and then still be pregnant at 40+6...not fun, and ripe for induction (not the cervix - the mind). How best to counsel patience? This doula does it so well:

Dear I-feel-like-I've-been-pregnant-forever

(via Enjoy Birth)

Proud of my doula client

Switching care providers twice to find someone who would support a trial of labor for VBAC.

12 hours of labor at home.

24 hours of labor at the hospital.

Slowly, slowly progressing - beating nearly every deadline set, just in the nick of time.

Unbelievable strength, patience, and dedication.

Trying every position, waiting as long as possible for any pain medication, even with transition contractions and no progress.

Putting up with some not-so-nice, not-so-encouraging care providers.

Getting so, so, so close - and then looking at the situation and agreeing that a repeat cesarean section was the best choice at the time.

In the midst of exhaustion and discouragement, still negotiating what was most important to happen at the surgery - like getting to touch and stay with baby, and breastfeed as soon as possible.

As a wise midwife once said and a doula friend reminded me, labor is about the journey, not just the destination.

And I know who I'm passing my medal along to.

Sunday evening research tip

Another good installment in Science and Sensibility's Becoming a Critical Reader series is up. Evaluating evidence! Reading critically! It warms my little public health heart.

Public health researchers (and students!) spend a lot of time collecting, reading, and evaluating literature. My assistantship this year has involved doing a heck of a lot of that, mostly using RefWorks, one of the many commercial citation managers available (there's a lot of hatin' for RefWorks out there, it seems, but it works fine for me and most importantly, it is free through the university.) I recently found out that many of my classmates were not aware of the following helpful trick I've found invaluable when amassing dozens or hundreds of citations. I felt so sad for all the people who didn't know about it, I decided to share it with all of you.

When using Google Scholar, click "Scholar Preferences", to the right of the search box. Scroll all the way down, and where it says "Show links to important citations into" select your citation manager and then click "Save preferences". When you go back to your search page, you'll now see an option under each search result to import it into your citation manager. Click on that, and it will open a new page in the citation manager where you can check, edit, and save the reference. So easy! Google Scholar has its drawbacks, but this is such a great feature that when I get citations from other sources I'll search for the source in Google Scholar just so I can import it. It saves so much time that I had time to write a whole blog post about it! ...But now I need to get back to work.

Dad demonstrates sling technique

Shoot this one at all the young hip dads who want to use slings (right after they gently kiss on their newborn baby's head, yes this is adorable):



I especially love how he tucks her hand in at the end. "Hm, where does this go?"

Via Offbeat Mama, who said it made her ovaries "shoot out [her] nose". Very nice.

Is it wrong to talk about the public health importance of breastfeeding?

So there was this article in Pediatrics that estimated there are 911 preventable deaths a year in the U.S. due to lack of breastfeeding.

Should we not say that? The comments sections of a lot of the media coverage of this article, and several bloggers, think so. Apparently, saying that lack of breastfeeding has real public health consequences is making women feel bad. Because there are a hundred ways in which women in this country get poor support and/or have their breastfeeding attempts outright sabotaged, a lot of women don't manage to breastfeed successfully. So we should stop saying that breastfeeding has important public health effects, because then some women will feel guilty that breastfeeding didn't work out for them. Do you follow? I don't. I really, really don't.

I see an implication in those comments that no one is grappling with the structural issues that affect breastfeeding success, that breastfeeding advocates are not interested in those issues. I beg to differ. At the Breastfeeding & Feminism conference (which was awesome, and I only wish I had the time and brainpower right now to talk about the many facets of awesomeness) you could meet dozens and dozens of people who grapple with these issues in a vital part of their academic, professional, and/or personal capacity. If you feel like all breastfeeding advocates are doing is trying to guilt or shame women into breastfeeding, you aren't looking very hard at breastfeeding advocacy in this country.*

Just at my university and the associated hospital, I can think of the following breastfeeding advocacy projects happening right now: improving child care centers' breastfeeding-friendliness, working for the hospital to go Baby-Friendly, getting funding for free pumps for NICU moms, providing breastfeeding support training for physicians and medical residents, improving lactation room information and access on campus, encouraging businesses to identify as breastfeeding-friendly, training lactation consultants, teaching prenatal breastfeeding classes, referring to local WIC peer counselors, providing discounted pumps to university students & employees, offering a local breastfeeding support group for African-American moms, and studying the impact of each Baby-Friendly step on hospital breastfeeding rates.

With all of that work to facilitate people reaching their breastfeeding goals on a structural and community level, you can understand why I'm so frustrated when articles like the one in Pediatrics get the reception they do. Which of those activities is targeted at making women feel guilty? Which is just about trying to control women's bodies and tell them what to do?

In fact, let's take a look at the conclusions section of the article itself which reads, in its entirety:

"By being incredibly selfish and not trying hard enough, 911 American mothers kill their babies every year by not breastfeeding. Clearly, public health and medical authorities have failed to make women feel guilty enough for not breastfeeding. Further efforts are required to make all mothers feel shame for any amount of formula that they offer their babies, regardless of their individual circumstances."

Oh, whoops! That wasn't the actual conclusions section. I got confused there for a moment. Here's the real one:

"By allowing breastfeeding rates to continue at their current levels, rather than implementing supports to help more families follow medically recommended guidelines, the United States incurs billions of dollars in excess costs and hundreds of preventable infant deaths. Action to improve breastfeeding rates, duration, and exclusivity, including creation of a national infrastructure to support breastfeeding, could be cost-effective."

I don't see a single mention in there even of education targeted at consumers. I don't even see individuals mentioned. I hear talk about "implementing supports" and "creation of a national infrastructure". I see an admonishment to our country to facilitate breastfeeding success. When people talk about "articles like this making women feel guilty because a lot of women can't breastfeed" and "don't they know that breastfeeding is hard", my jaw just drops. The whole point of articles like this is to point out that we need to do better at making breastfeeding less hard, at enabling more women to overcome breastfeeding difficulties, to illustrate to policymakers and public health authorities that those efforts are worth it for very concrete human and financial reasons. To make them feel guilty for the piss-poor job we do of supporting breastfeeding specifically, and mothers in general. If we don't talk about the reasons breastfeeding is important, how can we advocate for system change?

There are hundreds if not thousands of public health professionals out there trying to make the system changes that people responding to these articles often point out. How can we support breastfeeding if we're not supposed to say WHY?


*Let's note that "looking hard" does not mean "reading blogs and comment sections". Can I bait a flame-war about breast vs. formula with people getting obnoxiously self-righteous on both sides? Yes; I can also start one about Pepsi vs. Coke, but that doesn't mean Pepsi is actually putting out ads calling Coke drinkers elitist jerk-offs.

Doula pet peeve: directed pushing

The next Healthy Birth Blog Carnival has begun, this one on "“Avoid giving birth on your back and follow your body’s urges to push." The "follow your body's urges to push" really caught my eye, because directed pushing is one of my pet peeves.

My experience with this stretches back to my first birth as a doula. I was very nervous and working with a young woman with a very large family, many of whom were in the delivery room as well. She had an epidural, so when it was "time to push!", the nurse got her pushing standard: PUSH PUSH PUSH while counting to 10, take a breath and QUICK QUICK START PUSHING AGAIN while counting to 10, and ONE MORE GIVE ME ONE MORE REAAALLY GOOD PUSH counting to 10 and now RELAX RELAX JUST RELAX STOP PUSHING WAIT UNTIL THE NEXT ONE. At the time I knew in principle that non-directed pushing was better, but I also grasped very fully its appeal to the other people in the room who weren't really sure what to do at the moment. The mom's whole family got in on the act, 5 or 6 people loudly counting at her for every push, and hey, I totally got it. I wanted to feel useful too, and this seemed like a really simple way of doing so.

I still get the motivation, but the practice has begun to grate on me more and more. This happens even with the births that have been lovely, calm, quiet, physiologic labors right up until the magic ten centimeters. Everything goes great until pushing and then BAM, all of a sudden we're back to the worst of the medicalized model. The second a woman is judged to be "complete", everyone in the room suddenly gets license to, quite frankly, be a total jerk to her. Before she has pushed even once, there is the presumption that she is going to push "wrong". She is never even given a chance to try pushing in different positions or for a few contractions to get the hang of it. Instead, the nurse spells out the position she should assume (chin to chest, pulling back on her thighs, on her back? but of course!), support people are given her legs to hold, and she gets the 3-pushes-per-contraction speech. Then from the first push she is loudly coached, counted off, and urged on MORE MORE MORE KEEP GOING PUSH HARDER HARDER HARDER and that's about when I start grinding my teeth.

Why do I hate this so much? First, it's not evidence-based, leading to greater risk of pelvic floor damage and perineal tears. So really, nobody should be using directed pushing unless they really have to anyway.

But to me, it's not just the non-evidence-basedness of it; how it's done is really the signifier for how our system thinks it's okay to treat women when they're pushing out their babies. And in my opinion, it's a pretty crappy way to treat a woman giving birth. Even if before there was lots of murmuring and support and encouragement, all of a sudden she's treated she's constantly failing. Generally, directed pushing involves a lot of yelling directly into her face, telling her to try harder no matter how hard she is already trying, forcing her to hold her breath, exhaust herself, and then ordering her to relax as soon as pushing is over. This happens even if she's making great progress: a primip who pushes out a baby in 20 minutes still gets this treatment. It also recruits all-too-susceptible support people into this aggressive treatment. They get the chance to do something! take action! after hours of labor in which they often didn't feel very useful. They get at least as hepped up and sometimes get more aggressive than the medical staff. Sometimes I hear myself talking to the mom during pushing and realize that I am the only person giving her any positive feedback or encouragement whatsoever. It's honestly sad.

It also imparts a generally false sense of urgency to the mother. I have heard or read multiple women say "Everybody was yelling at me to push, so I thought something was wrong and I pushed really hard and my baby flew out and I tore really badly". If you are yelling into a woman's face and telling her to push as hard as she can, she will often interpret that as a sign that something is wrong and she needs to, in fact, push as hard as she possibly can, which is not always the way to preserve the perineum. It's also a frightening experience for many women and, again, that's not a respectful way to treat someone who is giving birth.

Even more concerning to me, it's a "boy who cried wolf" issue of not being able to impart to the mother when pushing hard is ACTUALLY urgent, or allow her to have reserves left. When you yell at her for an hour and a half straight to push, and then the heart rate starts dropping, you've probably expended a lot of her energy, not to mention her emotional response to the "emergency" narrative. It would make me nervous, personally, to be with a provider where I couldn't tell the difference between when things were going normally and when it was an emergency.

So! What can you do to avoid this? My suggestions:

1) As always, choose your provider and birthplace wisely if you can! Remember: doulas know what your provider is like in the delivery room. They are there to see that behavior. Before you choose a provider, ask a doula who has worked with that person (or practice).

2) Express your wishes to your provider. Talk about how you don't want to be coached (or another least favorite, the two-fingers-in-the-vagina "push my fingers out!" I sometimes want to lean over and say "OR YOU COULD JUST TAKE THEM OUT YOURSELF") unless there's a reason that they need to speed things up, or you request some help.

3) Remember that the nurse often starts the pushing even before the provider arrives. On your (short, simple birth plan), you can note that you would like to follow your body's urges to push and would prefer to begin pushing without direction, and that you are open to suggestions if things are not progressing well.

4) Actively decline it and/or just ignore it - you can clarify first that there's no emergency, then either ask for quiet or just do your own thing. Bring a pair of headphones! I've never seen it in person, but this seems to work well for some Hypnobabies birth stories I've read! Mom just pops her headphones to listen to her hypnosis tracks and ignores all the outside hullabaloo. If you have your eyes closed and your headphones in, it's pretty obvious that you're not looking for any outside help.

So those are my pet peeves, and my tips! Let me clarify: directed pushing is sometimes helpful and I have seen women request direction while pushing. My objection to it is using it across the board, regardless of the situation, and the aggressive way it's done. As always, if you're working with a provider & in a place that you trust, you should be able to trust them to handle pushing appropriately. But if you're not, plan in advance to avoid what is often the last pitfall of plans for a physiologic labor.