On the road

Posting lull as I'm on the road - visiting family and friends, then heading to a wedding. Welcome to any of you finding this blog through Facebook - one of my favorite posts on "trying" to have a natural birth is making the rounds, I see!

More posts when I get home again, including (maybe? could it be?) the end of my MPH series.

In the meantime, enjoy some talk about women's bodies and the responsibility society places on women to police their own sexuality:

The lesson, ladies, is that great cleavage comes with great responsibility. People who shame women for wearing “too-revealing” clothes like to center their objections on women’s clothing “choices,” but make no mistake—this is not about what we choose. This is about the things we don’t choose—having chests or butts or legs or necks or hair or any other part of our human bodies that others decide to project their particular sexual interests—and their slut-shaming—upon. The man who is horrified at a woman’s “overly exposed” breasts will likely never have to worry about wearing one shirt—one shirt out of a lifetime of shirts—that happens to accidentally set off some random person’s slut meter, because of the way his body just is. And because my breasts are smaller, less visible, less imposing than other women’s breasts—because there’s less boob there—I can feel free to wear the more revealing top without attracting claims of public obscenity. It seems that some women’s bodies are just naturally sluttier than other women’s bodies—and all women’s bodies are naturally sluttier than men’s bodies.

This is also about the things we "choose", like "choosing" to breastfeed, which is a normal and physiological part of mothering, having all this same b.s. projected on them. It's a shame we ladies are just so normally and physiologically slutty.

Opportunities for doula work internationally?

It's ask-the-readers time! I recently got this e-mail from Leila:

I live in the Boston area and am currently in the process of becoming a doula. I also plan on getting my masters in public health soon after I finish college. Your blog brings me lot of hope and excitement as I wet my feet in the field of public health! Maybe you can offer me some advice- I'm trying to find ways of working/volunteering as a doula somewhere in the Third World and I can't find anything! Do you have ideas or know of organizations I could look into that might offer such positions?

I had only one or two possible leads, and I have heard similar inquires in the past and not really known where to send people then either. Does anyone out there have suggestions for her?

Reply turned post, on a 360-degree view of the doula's role

Birthday Nurse wrote a post recently on, in part, the role of the doula in the birthing room:

One thing I always seem to struggle with when I have patients who have doulas is when they ask their doulas for "permission" before they do anything. The patient was thinking about getting an epidural after 10+hrs of backlabor and no real cervical change. She had been talking about it and going back and forth and I asked her if she wanted me to start her fluid bolus prior to her block. She looked right at her doula and said "what do you think?" When her doctor wanted to start pitocin a few hours later after she was comfortable and still not changing her cervix...again she looked at her doula and said "what do you think?" (after waking her doula up from the nap she had been taking on the pull-out mattress) HELLO!! This is not your doula's labor! This is your labor, your baby, your body, your experience! You don't need your doula's permission!!! Doula's are great support people, they're awesome, don't get me wrong. But (most of them...and especially not the one in the previous scenario) they're not trained medical personnel...they're not your doctor or your nurse...don't ask their "permission"!

My reply turned into a post of its own, here in somewhat edited form:

I have a couple perspectives to share on the "permission" thing. Sometimes as a doula I get clients looking to me for "permission". I understand what they're doing, they hired me in part to be a sounding board and an independent voice, and they want to know what I think. Because it's not my role to give them medical advice, I generally try to turn it around and talk them through the situation and ask what more information THEY need to make a good decision. I wouldn't want a client asking me for actual permission if her doctor told her she needed a c-section. But if she turned to me and asked what I thought, and it meant I could help her talk through the facts that baby was showing no distress and that her progress was slow but was happening, that might be a good thing for her having what she needs to make an informed decision about whether or not she wanted to consent to the section. If you have the independence as a nurse to give her the space, time, and support to potentially question her doctor's recommendation, that's fabulous! But many nurses don't, or won't, and I feel that's where the doula's ability to be an independent sounding board comes in.

And sometimes I also recognize that as someone they shared their birth plan with, and trust, they just need emotional validation for the path they're about to choose. It would be nice if they could get that validation from the medical staff, but unfortunately many people who hire doulas are doing so because they do not completely trust the medical staff - and sadly, with good reason in some cases (this brings us back to the need for an independent sounding board.) They need someone who they know is totally on board with their birth plan to affirm that it's OK to deviate from it. So in those cases I can be the one to say "You seem so exhausted, I agree an epidural sounds like a great idea", or whatever it is they need to hear to feel good about their decision. A doula friend told me recently that she actually asks her clients, "Do you need me to give you permission to _______?" as in, do they just need some help to feel OK about their decision?

I have experienced this from the other side (albeit less often) doing lactation support where the mom looks to her doula when I recommend, for example, a nipple shield. "Do you think I should try it?" And I get this flash of irritation - "Your doula didn't train for this work and take the LC exam and work with hundreds of breastfeeding dyads, why are you asking HER?" - and then I go "aha, this is what the L&D staff must feel like when my doula client turns to me!" So in that moment I remind myself that I have just met this woman - why should she trust me? She trusts the person who she met and has been working with for weeks, and just went through many hours of labor with, and she is trying to make an informed decision that (gasp) may not be what I recommend. She is going to consider her options and make a decision instead of just agreeing with what I suggest, which is a strange feeling for me but a good one to get used to. I may not agree with her decision but she will be the one who lives with the consequences, not me, and I have to make room for the possibility that I am wrong and she is right. That this is so uncomfortable for me to do has been an excellent learning experience and given me a lot more sympathy for all sides!

Which growth chart to use?

In the past few months, I have happened to talk with three different mothers who told me about their breastfed children's growth "slowing down" around 4 months - the baby's weight percentile dropping and the baby slipping down the growth curve. Somewhat fortunately, all of these mothers were told by their pediatricians that this was "common" or "normal", and none of the pediatricians pushed supplementation or were very aggressive about starting solids.

Unfortunately, while the pediatricians were right not to change the baby's diet, they were wrong in giving moms the impression that their child's growth slowing - while perhaps "common" - was "normal". In fact, they were wrong in giving moms the impression that it was slowing at all! And once that idea is planted in a mother's head, it's hard to erase the underlying anxiety she might have, despite reassurance to the contrary, that her milk is no longer quite keeping up with her baby's needs.

The fact is, many pediatricians' offices still use growth charts developed in 1977, based on a small sample of babies in Ohio who were primarily formula fed. Similarly, even the 2000 Centers for Disease Control (CDC) growth charts are based on a sample of mixed breast/formula feeders. Formula fed babies grow more slowly than breastfed babies in their first few months of life, then begin to grow more quickly than breastfed babies. When we chart breastfed babies on the formula fed growth chart, it makes breastfed babies look nice and high on the chart for the first few months, and then start to look like they are faltering.

What does it look like when breastfed babies are tracked on charts that accurately reflect their growth? To do that, the newest World Health Organization (WHO) growth charts are a far better choice than any of the CDC charts. The WHO charts are based on a worldwide sample of infants who received optimal breastfeeding and complementary feeding.

This article from the Journal of Nutrition does an excellent job of discussing some of the differences between the CDC and WHO growth charts. They have several great illustrations as well to help you visualize how the growth charts differ:

This chart shows the difference between weight-for-age curves in boys ages 0-60 months. You can see how around 4-6 months, the CDC chart line crosses over the WHO line and generally stays above - sometimes quite high above - the WHO line up through age 5.

I like this chart even better, which shows how an average infant from the WHO sample would track on each chart. A baby who tracks normally on the WHO chart (staying fairly even in growth after an initial drop) looks very different on the CDC chart: after an initial rise the baby appears to slowly fall down the growth curve from the age of 2 months on.

One of the moms I talked to went back and plotted her children's growth on the WHO charts and was pleased to see that all of a sudden, instead of slipping down the chart, they were tracking beautifully along the growth curves. She knew all along that they were healthy and feeding well, but it's always nice to have it confirmed that the charts were wrong - and mom was right.

Happily, the CDC is now formally recommending that all clinicians switch to the new WHO growth charts for ALL infants and toddlers up to 2 years of age. (Note that this means not just breastfed babies - the CDC recognizes that those charts reflect optimal infant growth, and that the more rapid growth of formula fed babies is a potential cause for concern.) If you have kids, do you know which charts their pediatrician or family doc is using? Do your care providers know about the CDC encouraging the growth chart switch?

P.S. Let's also keep in mind the relative importance of growth charts. I've had some great conversations in breastfeeding-related courses about the overall silliness of the American obsession with having every baby "above average" on the growth charts. It's as if scoring 95th percentile on the growth chart is like getting an A on an important test. Growth charts are tools to be used in conjunction with other indicators of a baby's health and intake, they do not reflect the normal growth of every child, and it is just as normal and healthy for a baby to consistently be in the 5th percentile as in the 95th. Phew! I've said my piece.