Wednesday, April 29, 2009

Two more great birth stories/videos

Have you added Nursing Birth to your feed reader? Because while I would, I can't link to every single one of her posts - this blog would start looking like kind of a rip-off. She's a great storyteller and has important stories to tell!

And here are two more great birth links:

Rixa at Stand and Deliver just had her baby and has posted his birth story along with videos from right after the birth. A great story and sweet little baby! Congratulations, Rixa!

Diana at Birthing at Home in Arizona posted this great video of a hypnobirth (although not hers) (it's a bit long, the birth happens toward the end but what's so notable is how calm and peaceful things are throughout.)

Monday, April 27, 2009

5 things that being a doula changed about me

I think being a doula changes everyone who does it, to some extent, but I think it may have changed me a little more than average, because I took kind of an unconventional path to becoming a doula. There are many reasons people go through doula training and start attending births, but probably most start out with a real passion for natural birth and for supporting women during this special time in their lives. I thought those things were really interesting, but I also wanted a job. I was graduating college and I wanted a job where I would move to a new city, try out this whole "public health" thing, and hopefully get some new skills out of it. And I got a job in Denver that fit those criteria, through AmeriCorps, where I would do various things including be trained and work as a doula.

If I hadn't been hired for that job, I would have taken one in Minneapolis working for a refugee health organization on issues like tuberculosis control and mental health services. My guess is I would never have pursued doula training independently - I would have been interested, but never interested enough to actually put the money and time in.

So unlike other people who go through doula training, I didn't have any strong belief systems about birth going in. I had always been fascinated by birth - I watched "A Baby Story" religiously in high school. But I thought the epidurals on "A Baby Story" looked pretty sweet, and based on the stories my aunt told about her labors I had already decided that someday I'd get me one of those. I had started to get more familiar with issues of medicalization by writing my senior thesis on breastfeeding, but knew little about birth. I was not at all comfortable with homebirth - I thought it sounded unnecessarily risky. But that was kind of it.

By the end of the year I had attended over 30 births, all in hospitals, taught childbirth classes, newborn care classes, and done breastfeeding support. How did all that change a birth neophyte?

1) I became much more proactive about all aspects of my own health care. I no longer expected that health care providers would just tell me the "right" thing to do, because I realized that in many situations, there was no one "right" thing to do. Instead, I followed up medical advice with my own research and judgment. I asked more questions in the doctor's office ("What do these numbers mean? What would be normal? What if instead of taking action, we wait to see what happens?") Ultimately, I realized that I made my own medical decisions - and always had, even if that decision was just to do what the doctor said.

2) Correspondingly, I also came to believe that the goal of all women's health care should be empowerment. Pregnancy and birth are a great time for women to begin to take ownership of their health care, because it's such a crucial time period and involves so many health decisions. But why wait until then? Every significant interaction with the health system - annual paper smears, check-ups - should be a chance to involve women in their sexual and reproductive health.

3) When it came time for me to give birth, I no longer wanted the automatic epidural. Yeah, it looked pretty sweet on "A Baby Story". But they didn't show (or at least attribute) the stalled labors, or women itching and itching because of the medications, or such heavy epidurals that women had no idea how or where to push, or epidurals with a "hot spot" of pain. They didn't discuss how a woman with an epidural can't move around to speed her labor or move a malpositioned baby. I wasn't anti-epidural: I saw them as a great tool, where women stuck at 6 cms. for hours finally relaxed, and progressed to complete in 30 minutes. But applied indiscriminately, it seemed like they caused more problems than they solved.

5) I no longer wanted to give birth in a hospital. Over 30 hospital births taught me that anything I wanted that was out of the norm would likely be an uphill battle, and that a lot "norm" practices caused problems. It's not like I saw all uncomplicated births. I saw c-sections for fetal distress. and instrumental deliveries, and shoulder dystocia, but none of them made me feel like I would be better off in the hospital - just that I'd be fine with a hospital easily accessible if needed. Watching women spend their whole labor fighting just to have their wishes respected was exhausting and depressing. There were the occasional exceptions - like the birth story I just posted - but those (like that story) resulted from "textbook" labors where women got exceptionally lucky (not a single nonreassuring heart tone, 1 centimeter of dilation per hour, etc.)

5) I became more aware of disparities in our health system, and more committed to working to overcome them. I am coming from a place of relative privilege in getting all empowered and owning my health care and thinking about out-of-hospital birth. I have the race, class, educational, and financial privilege to easily contemplate all of these things. The women I worked with did not. Many of them did not speak English, nearly all were on Medicaid, very few had access to higher education, most were women of color. They did not have many options for their medical care and they did not have anyone suggesting to them that things could be different. When I get excited about spreading the word about birth alternatives, I have to remind myself that while I may want to make sure all my friends hear my spiel, this is one of the ways privilege works. We need to change not just our own attitudes, but the system. That's ultimately why I'm getting my MPH now - because being a doula and fighting the system one person at a time wasn't enough.

What has being a doula/involved in birth work/learning more about these topics changed about you?

Saturday, April 25, 2009

Score one for the big babies!

Earlier this week, my phone rang in the early afternoon from an unfamiliar number. It turned out to be the husband of doula client, telling me she was in early labor. Those are such fun phone calls to get! I spent the rest of the afternoon studying for my comps, checking out a couple of apartments for next year, and anticipating going to a birth...the last one for a while.

Around 7 pm I got a phone call that they had just checked in at the hospital and she was 6 cm. I knew she was a primip, but that call still sent me careening around the apartment, throwing off my clothes and throwing on my doula outfit - I grabbed my bag and was out the door in probably less than 5 minutes. I didn't think she'd go fast, but I wanted to make it if she did!

When I got there, she wasn't going fast but things were getting more intense. She couldn't sit down, or lie down - she had to be standing or kneeling by the bed, where she would lean over the birth ball and rock back and forth, and vocalize loudly. Her husband was an amazing support, a great cheerleader who said all the right things, very hands on (although she didn't always want to be touched). I just backed him up, encouraging her, rubbing her back, bringing her water. She turned to me at one point and said, "What's transition like? Because I can't imagine it getting worse than this." I said, "For all we know, you're in transition!" I suggested she try the shower and she stayed in the bathroom in the shower/tub for at least an hour. It's a tiny room so her husband stayed in with her and we just checked on them once in a while.

Noticed anything yet about this scene? She was not hooked up to ANYTHING! She had even declined a heplock for the IV (she hates needles, this was a big priority.) She was getting intermittent monitoring probably every half hour or so, but very briefly and every time the nurse would say, "You don't need to move for this. Just pay no attention to me." She could go wherever she wanted, sit, stand, rock, get in the tub - no restrictions. There was another doula working with her who got there a little later, and she said, "Oh, it's so great how there's nothing attached to her. I haven't been to any births like that lately!"

After she got out of the tub, she really wanted to know what we could do to speed things up, and agreed to have her water broken (after being checked and almost complete!) The midwife really worked proactively with mom's positioning to get the baby rotated optimally, and after a while she began pushing spontaneously. It's been a REALLY long time since I've seen someone allowed to do that! Only because she was so intent on speeding things up, the midwife did some gentle coaching on pushing. The midwife also kept her position changing - hands and knees, side - to keep the baby rotating well. In under an hour, baby was at the perineum and crowned at the end of a push. The midwife let the half-out head sit there until the next contraction - which took a little while - and just encouraged the mom to pant and let the head emerge slowly. Once the next contraction came she was out in two more pushes, crying right away, a big baby girl!

How big? Over 9.5 pounds! Over an intact perineum!

This birth was so invigorating and inspiring. This mom got almost every one of the wishes on her birth plan respected and supported by her birth team. Whenever she said, "I can't do this!" no one said "I can have the anesthesiologist come and talk to you if you want." Everyone said, "You ARE doing it, you're doing great, you're so close." She could move freely and do whatever her body told her - she was never attached to anything except her brief stint on the monitor and the occasional blood pressure. No one got in her face and yelled at her to push or counted to 10, just explained to her that the longer she could hold a push, the faster it might go. She had a midwife who paid attention to the baby's positioning and used it to guide mom's positioning. And she had a great midwife who let her push slowly and did a very controlled and gentle delivery.

So often after a birth that ends in c-section, I run through the "what ifs". This birth is one where you can easily run the what-ifs in reverse: what if she HAD been induced? Then she would have been hooked up to the IV and the monitors and could at best have only stood next to the bed. What if she hadn't been able to use the tub? Then she might have asked for the epidural. What if she'd gotten the epidural? Then she might not have been able to change positions, and would have had a big OP baby. What if she hadn't been able to push effectively? Then a long pushing stage and possible c-section (and "No wonder you couldn't push this baby out, he's too big for you!")

What if! Hopefully even if those had happened, the cascade wouldn't have gone all the way to c-section, but it's easy to see the potential pitfalls, and I am so glad it went the way it did. This mom prepared so well: by taking a class so she knew what her options were and what to expect, writing out a simple, clear birth plan with her most important wishes, and above all choosing a birthplace and care provider that matched her needs.

So score one for the big babies! And score one for women being informed, respected and empowered.

I am sad that this will be my last birth for a few months, but I'm looking forward to the fall, and to a summer practicum that will give me the skills to crunch the numbers to provide the evidence base for empowering births!

Thursday, April 23, 2009

Article on hypnobirthing

I really like this reporter's tale of her birth assisted by hypnobirthing techniques, in part because she spends relatively little time on the birth itself. Instead she discusses her wish to avoid her region's 45%(!) cesarean rate and how she had to "break up" with two different OB practices (actually, one broke up with her) before finding a doctor she trusted. I wish more women were unafraid to leave their OBs when they realize it's not a match! I love how she notes that her doctor never told her to push - even the most calm and non-interventive care providers so often ramp things up at pushing time.

Since I did my hypnodoula training I've been so interested in attending a birth that uses these techniques! I'll be in another city this summer for a (very) full-time practicum for my master's, but I hope when I get back in the fall I'll be able to offer my services to some parents in the area who are doing HypnoBabies classes. It just seems like such an empowering birth technique.

Tuesday, April 21, 2009

Exam time for me, quiz time for everyone else!

I'm studying for final exams this week. I only have a couple - most of my classes have final papers or projects. The biggie is my oral comprehensive exams for my master's, which will be next week. We'll be asked two of five questions, have to give a five-minute spiel as an answer, and then answer questions for 10 minutes. We have the five questions in advance, and can choose one to answer, but the other will be a surprise. Fun! (Not really, but what can you do?)

As prep work, I'm refreshing my international MCH knowledge. I thought I'd do a quiz! This one is pretty quick. And I promise I'll post the answer soon!

Worldwide, over 10 million children under the age of 5 die every year. There are preventive interventions that we could use to reduce these deaths, but there is far from universal coverage of these interventions. From 1-5, rank which preventive intervention would save the most children yearly, and which the least, if applied universally?

- Antiretrovirals and replacement feeding to prevent mother-to-child HIV transmission
- Measles vaccine
- Zinc supplementation
- Breastfeeding
- Insecticide-treated materials (to prevent malaria and other mosquito-borne diseases)

Monday, April 20, 2009

Reactions to the Spanish mattress commercial

I was curious about reactions in Spain to the homebirth mattress commercial (what a strange set of words to put together!), so when I came across a Spanish blog that was posting about it I asked. I also asked about how often it was shown. If you don't speak/read Spanish, the blog's author says in reply:

"The commercial is shown as frequently as others, and has created debate. You hardly see her naked body, because she's dressed in a pink shirt during the birth. It's a great social hypocrisy that permits the television and commercials to continually show images of bloody accidents, violence, torture, and explicit sex in all the commercials and that we're frightened by a natural birth and breasts with milk." [Warning: my Spanish is rusty so my translation may be imperfect, but this is the general idea.]

I agree about the hypocrisy! And while it's disappointing to know that this ad is controversial, it's not surprising. In fact, in the blog discussion comments there are plenty of people who feel it's too explicit, and others saying that at least it's prompting a discussion about natural birth in Spain. The fact that this commercial can be shown at all on Spanish television shows they're far, far ahead of us...

Thursday, April 16, 2009

Newspaper columnist calls home birthing mothers "spoiled" and "complacent"

Melanie Reid prefers to have her babies in the hospital, so she's written a (UK) Times Online column about why everyone else should too. It's a bizarre argument, though, because while it's prompted by the new Dutch home birth safety study, and while she discusses and never challenges its premise that home births were, statistically, as safe as hospital, she then goes on to slam home births for their lack of medical care:

...the only intelligent, progressive, logical place to give birth is within shouting distance of the benefits of 21st-century medicine... this is about quashing the entirely whimsical, perverse idea that we should turn our backs on modern medicine's starring role in safe childbirth.

She accuses the Dutch of "evangelizing" because lots of them give birth at home (unlike "other sensible parts of the developed world"). So if you have evidence to show that what your country does is safe, even if it's different from everyone else, it's evangelizing? I can't really make sense of this argument. But I suspect we'll see a lot more of it in response to this study. "Right, yes, home birth has been statistically shown to be as safe. But why would you give birth away from the hospital? What if something happened?" Around and around the arguments go...

New blog I love

I'm so excited about this new blog, Nursing Birth. It's by an L&D nurse and she's started a great series called "Don't Let This Happen to You!" based on real stories of patients she's cared for.

Her first story is a great one, about induction for "low amniotic fluid". What happens next isn't surprising, but the conclusion is! Read it here:
Part 1
Part 2

Her second story is also an induction story (find out what a "back door" induction is) and only half done:
Part 1

I'm so much looking forward to the rest of her stories. I love how they show not just a nurse who isn't afraid to advocate for patients, but that she also discusses how patients can (or could) advocate for themselves. Based on all the comments on her posts (including from doulas like me wishing we worked with more nurses like her!) it's clear that nurses like this are in the minority. So in the absence of more, tips on where patients can step in are invaluable.

Home birth in a mattress commercial

Thanks (as usual!) to Jill at The Unnecesarean for the link to this unlikely-but-beautiful commercial for yes, mattresses. I'm curious how much this was aired in Spain. When even TV shows in the U.S. that warn you "CAUTION: Scenes of ACTUAL BIRTH will be shown" blur out vaginas, no commercial this explicit could ever, ever be aired here. I'm sure things are more chilled out in Spain, but I do wonder, how chilled out?

Anyway, watch this with a tissue handy. (It's funny, I don't usually cry when actually attending a birth. It's the touching music that gets me in these birth videos!)

Wednesday, April 15, 2009

Barbie breastfeeds!

Did you know breastfeeding is glamorous? Sure it is! Barbie does it!

New study on home birth vs. hospital birth - deconstructed!

Jill at The Unnecesarean posted today about a new study out comparing home and hospital birth outcomes in the Netherlands. I was, to put it mildly, excited. I have read a lot of the critiques of previous home vs. hospital comparison studies. I wanted to see if this one was going to overcome some of those limitations. The BBC article she linked to doesn't exactly go in-depth, epidemiologically, so it was one of those moments when I was so glad for my full-text access! Being a student has its perks. (If you want the article, let me know.)

I knew I was going to take this study apart anyway and thought I might as well make a blog post out of it. I also thought I'd see if I can explain some of the epidemiological/statistical terms and principles that are important to studies like this. Let me know if I'm talking too far down or too far up.

First off, the study methods. This was a nationwide, retrospective cohort study. Let's break that epidemiological talk down. "Nationwide": the researchers used the records all the women who delivered in the Netherlands over a 6-year period (Jan 1 2000 to Dec 31 2006). That gives the advantage of a very large sample size and correspondingly high statistical power to detect differences between groups. The "retrospective" piece has the disadvantage that researchers had to use data collected in the past (no chance to go back and fix problems with data collection), and not for the exact purposes of this study.

The "cohort" piece means this was not a randomized controlled trial. The researchers took did not assign women randomly to place of birth; women made their own choices about place of birth. This is a major objection to almost any study of place of birth. Maybe women who choose a particular place of birth also tend to have other economic, social, and education indicators that are associated with better or worse birth outcomes. We can try to adjust for those indicators (as this study does) but we can't be sure we're catching all the confounding factors in the study. Maybe there are intangible factors we can't measure, like how well a woman takes care of herself, or how confident she is, that also influence both what birth place she chooses, and her birth outcomes. An RCT is by far the best way to assess risks.

Unfortunately, it's really hard to find participants for an RCT of place of birth. So we're mostly stuck with cohort studies. Back to the article, and how well they do in getting the most accurate results possible.

The researchers excluded births outside of low-risk definitions: multiples, non-cephalic (breech or transverse) presentations, VBACs (we could debate this, but), prolonged rupture of membranes (>24 hours) without contractions, congenital abnormalities, and intrauterine fetal demise before onset of labor. They also excluded women who were cared for by obstetricians, even if they were low-risk. So this is really, best said, a comparison of planned home vs. hospital births for low-risk women under midwifery-led care in the Netherlands.

To classify women into groups, the researchers used an intent-to-treat model. That is, women were assigned based on their intended place of birth. This is appropriate because the goal of the study is to determine whether it's equally safe to plan a home or hospital birth. If you judge it based on where people end up giving birth, you run the risk of skewing to high-risk cases ending up in the hospital, or unplanned home births going awry. If a person plans a hospital birth but ends up giving birth in her front hallway on the way out the door, or if someone plans a home birth but is transferred to the hospital for fetal distress, each should still be classified based on intent.

The researchers also collected information on maternal age, ethnicity, gestational age of the baby at birth, socio-economic status, and parity (primiparous or multiparous). All of these may be associated with both choosing a particular place of birth, and to perinatal outcomes. Again, because you can't randomize people, collecting this kind of data is important for statistical adjustment later on.

Because of the retrospective nature of the data collection, the researchers found that some records did not have the intended place of birth recorded. The midwives in those cases may not have recorded it, or the women may not have decided until after labor began. So there were 3 comparison groups, Home (60.7%), Hospital (30.8%), and Unknown (8.5%).

To compare the perinatal mortality outcomes of the two groups, the researchers calculated crude and adjusted relative risks of perinatal mortality and NICU admission. The "hospital" group was set as the norm (1.0). This is a good example of where statistical adjustment comes into play. The crude relative risk for home birth was .90, with a confidence interval of .69 to 1.17. That is to say, it's trending towards home birth being slightly less risky, but because the confidence interval crosses the mean (1.0), it's not statistically significant. The adjusted relative risk is 1.02 (confidence interval: .77-1.36). Now it trends slightly more risky - because they compensated for the fact that a statistically lower-risk group of women chose home birth - but again, the difference is not statistically significant.

In the end, the only statistically significant relative risk that researchers found was that babies in the "Unknown" group were more likely to be admitted to the NICU (RR 1.33, CI: 1.07-1.65). There was no difference between groups for perinatal mortality, and no difference in NICU admission between home and hospital groups. They also did not find any interaction between risk factors (like parity) and planned place of birth (in other words, there's a higher risk of perinatal mortality for babies of primiparous women, but that risk is the same regardless of where they give birth).

Overall, this struck me as a fairly well-done study. It has the advantages of a very large sample and a comparison of "apples to apples": low-risk women receiving midwifery care. My main question about this study would be whether there are other confounding factors that might be missing from the statistical adjustment. An important limitation of this study is its generalizability. The Netherlands has a well-integrated system of midwifery care and home birth, and can provide continuity of care from home to hospital. While this is an excellent argument that home birth can be as safe as hospital birth, it doesn't necessarily translate that home birth is as safe as hospital birth in every setting.

Still, it's exciting and probably the largest validation of home birth safety thus far. I hope it has some good effects around the world, as well as here in the U.S. (although Amy at Giving Birth With Confidence thinks not.)

Questions? Thoughts? This is super long, I know. At least it helped me think the study through!

Tuesday, April 14, 2009

Breastfeeding premature babies

The video below, a news report on the benefits of breastmilk for premature babies, has been making the rounds. I forget that not everyone knows stuff like this! So let me say that while I see both sides of the breastfeeding/formula debate for healthy term infants, we need to acknowledge that breastmilk makes a much more life-and-death difference for premature babies. This semester in our breastfeeding class, we've heard about necrotizing enterocolitis (NEC) multiple times. In NICUs where all babies get breastmilk, it is virtually non-existent. Among the many other benefits of breastmilk for premature infants, this is a very clear-cut one that combats a life-threatening illness.

If you know a mother with a premature baby who for any reason can't breastfeed or pump, you should 1) Help her find a lactation consultant who can assist her and 2) Get her in touch with a milk bank so her baby can receive donated milk.

Watch CBS Videos Online

Tuesday, April 7, 2009

Who will lose under universal health care?

A lot of posts in the last couple days. I blame it on the end of semester crunch. I'm on the computer all the time to do work, and then I get distracted by Google Reader and start reading things that are more interesting than a final paper on teamwork, and...then I have to write about them.

At Stand and Deliver, Rixa is has just posted about discovering (at 8 1/2 months pregnant!) that her insurance company is going back on previous promises and will not cover her midwife. It got me thinking about a presentation I went to tonight by Dr. Nick Gorton. He does a lot of work in transgender health, and as part of our school's Trans Health Week (I know, how cool is that?) he came and gave a lecture. He discussed who covers sexual reassignment (hormone therapy, surgery) and who doesn't. Who does: a few city and state governments, some universities, some employers, Medicaid. Who doesn't: everyone else - including Medicare and the VA.

One of the things that really got me thinking was his discussion of what areas could be the big losers under universal health care. He had 4 main categories: reproductive health, transgender health, non-punitive drug treatment, and 1 other that I'm forgetting at the moment (sorry!)

Obviously we hope that in a single-payer system, evidence-based medicine (e.g. midwifery care, access to birth control) would prevail. It seems to have prevailed to a greater extent in countries with that system - because it's cost-effective. But there are a lot of special interests in this country - we already saw them at work with Medicare Part D (drug coverage), essentially holding a government insurance plan hostage to the pharmaceutical companies.

There are also a lot of political third rails that the government will hesitate to touch. "I don't want my tax dollars going to..." has already worked for abortions under Medicaid, and just this year for reproductive health care funding. What else could it work for?

I want universal coverage as much as the next person, but Dr. Gorton did get me thinking about what might be sacrificed. If you're a transgender person seeking sex reassignment surgery, you probably don't have coverage for it. But in our current system, at least there's the possibility that you do, or could in the future. In a single-payer system, it's all or nothing. And that goes for every other kind of coverage, too. How can we protect a single-payer plan from special interests and political hot buttons?

Reply turned post, on the need for education

I started writing this in reply to Tiny Cassidy's post on how the maternity care system may be in crisis, but most women don't even know it. Here slightly modified and expanded:

I've been to so many meeting lately where all of our discussions boil down to the need for cultural change. When women see all birth as frightening and dangerous, all medical procedures as necessary and good, and people who say otherwise as "natural childbirth nazis", it's hard to make headway. Midwives who attended years of school and went through a lot of effort and anguish to set up practices in order to support normal birth find themselves searching for patients who want to birth normally. I spoke to several midwives recently who talked about fighting their patients on induction - the patients demanding to be induced, and even coming up with ways to get a "medically indicated" induction like saying they felt the baby moving less. How do we transform these attitudes?

I do my small part by showing friends and family "The Business of Being Born", telling them stories from my doula work, and encouraging them to question the standard of care. But that's not the large-scale change we need, and I'm not exactly sure how to do that. At many of the meetings, we talk about the need to start this education early. Nine months often is not long enough to unlearn everything you've learned for your entire life. Can we teach about birth, and breastfeeding, in high school? In elementary school? How do we do this?

Monday, April 6, 2009

The risks of egg donation

When you're a woman in your twenties, you and/or your friends are likely to be hard up for money at some point. For young women, egg donation can seem attractive. It's a lot of money for a completed cycle (the ads I've seen offered from $2500 up to $10,000) and doesn't seem like that big a deal - after all, to donate their sperm all guys have to do is a little business into a cup!

Not that the money wasn't tempting, but after reading about what it entails, I tried to sound a note of caution with my friends who were thinking about it. We already know that there are potential cancer risks linked to estrogen and phytoestrogen exposure, and egg donation requires big doses of hormones to stimulate the ovaries. I think it's one thing to undergo it if you're doing it to conceive your own children, but it's another to take on those risks for cash, without knowing for sure what your future holds in terms of future reproductive life plans. Now, learning more about the growing concern of egg donation risks, I'm wondering how we can really educate young women about what being an egg donor might entail, and how we can push research that explores what kind of risks women are exposing themselves to by donating eggs.

Do you have personal (or friends') experiences with egg donation? What do you think?

Sunday, April 5, 2009

Two great lectures! Lecture 1: OB care in the UK

Sometimes being a student is a drag. Like today - it's a beautiful day, the birds are chirping, the sun is shining, and all I should be doing is writing papers and working on group projects (well, with a little break to write a blog post). But sometimes I'm so grateful for the chance to be exposed to, and connect with, people doing amazing work in maternal and child health.

I went to two great lectures recently (I'll cover the second one in the next post). The first was by Holly Powell Kennedy, incoming president of the American College of Nurse Midwives, presenting on her recent research as a Fulbright Distinguished Scholar in the UK. Her research was an ethnographic study that included interviews and participant observation in a hospital birth center. She was interested in both how the health care practitioners defined "normal birth" and "optimal birth", as well as what the system of care looked like.

She did her research at a hospital in London considered "the best of the best" of the UK maternity care system, and I will say - it sounded incredible. Here are the things I was most impressed by:

One-to-one care: In this birth center, they used a combination of midwifery care (over 50% of births), doctors in training, and obstetricians. With the midwifery care at least, it is all one-on-one. There are no obstetric nurses - the midwife does all the nursing and midwifery care and is with the patient more or less continuously. Powell Kennedy pointed out in her pictures how empty the corridors were - because everyone's in the rooms with the patients! The two reasons she gave for this are the one-on-one care, and also...

No central monitoring, and no routine continuous monitoring: Go into a hospital and you get very familiar with the nurses' station full of people keeping their eye on 2-3 patients via computer screen. In this hospital there is no electronic fetal monitoring unless there is a clinical indication - it's intermittent auscultation using a doppler or even a fetoscope/pinard horn - and no way to watch even the continuous monitoring if you're out of the room. (There's also no strip on admission!) When it's time for the birth, the midwife only pages for help if she (or he) needs it - there's no flood of 2-5 people suddenly in the room staring at your crotch!

Hands-on, and hands-off skills: She never saw midwives or OBs doing ultrasound for position - they were confident in their skills to tell by feel, and she never saw any misses. They also had a strong belief and skills in observing external signs of labor, and did few vaginal checks.

Does any of this sound like homebirth midwives you know? It's so similar to that ideal midwifery model of care! But what struck me most was how in this hospital system, when they embraced homebirth, they were able to have such seamless and better care. Powell Kennedy highlighted one midwifery practice that cares for a very poor population but that has excellent outcomes. One of their standards is to have the 36-week visit at home, with the mom and her planned support people. They give her a home birth kit and say "Don't decide now where you want to give birth. When it's time, we'll come here and labor with you as long as you want to stay home. If you want to go to the hospital (or need to), we'll go. If you want to stay here, we'll stay." Imagine!

Powell Kennedy really remarked on some fundamental differences in belief in this sytem: they trust in women and give women the authority. Women carry their own records - bringing them to their appointments, bringing them to the hospital at birth. Let me make that clear: the office keeps no records on them. They carry their own records, lab tests, the whole thing. There's also a strong focus on spontaneous labor and birth, as a normal physiologic event, and the idea that health care providers should master the art of doing "nothing" well.

I was sitting one row in front of the midwives from the hospital practice where I've volunteered as a doula. You should have heard them whispering to each other and sighing with delight during this whole presentation! But Powell Kennedy really emphasized that this hospital was not necessarily typical of the UK system - only, it seems, what is possible within that system (and so far impossible in ours, with rare exceptions). Even within this hospital, things aren't perfect - there isn't necessarily continuity even across midwifery teams in all these practices. Still, it was so impressive - more or less like a vision of heaven! I was pleased that it was part of grand rounds for the hospital, so there were some OBs/residents/med students there able to hear that this isn't just hippie crazytalk - other health systems actually use these standards of care.

Two final notes that I don't know much about but would like to learn more: Powell Kennedy commented on the use of nitrous oxide as a pain reliever during birth. She said it was as ubiquitous as oxygen - available at the bedside, at home births, even in the labor room bathrooms! They had a very low epidural rate (10%) but almost 50% of the births she observed, the moms used nitrous oxide. I know almost nothing about it and its use for pain relief, but now I'm curious.

She also referred us to this website, Birth Choice UK, which is supposed to have statistics for every maternity care practice in the country! Not all the statistics are complete, and I haven't had much chance to investigate it, but imagine if we had that here?

Wednesday, April 1, 2009

Reply turned post, on how to promote breastfeeding without coming on too strong

Over at Mom's Tinfoil Hat, she's writing about stories of "breastfeeding bullies" and wondering where those stories come from. She sees far more women being disrespected and the targets of pushy behavior from formula-advocated nurses and doctors than she sees nagging, pushy lactation consultants. This was my reply (now slightly edited and expanded):

I agree that I have never seen LCs actually do this - just heard stories from moms without getting to see/hear the other side of the story. I don’t disbelieve that there are a few bad applies out there, but I agree with Labor Nurse that some stories might come from a mother’s reluctance to say out loud “I want to quit” and the LC not picking up on whatever signals the mother thinks she is giving. Hands-on postpartum, I have seen nothing but positive support, patience and working toward’s a woman’s breastfeeding goals, whatever they are.

I will say that prenatally I could see more of a challenge, because that’s I think when people feel comfortable being a little more hardline, and it is hard to advocate breastfeeding without stepping into a minefield. Just a few weeks ago I was at a birth where the mom told me that at the last minute, she had made up her mind to formula feed. I asked her why, then let it go for a while.

But it was a long birth, and I kept sitting there and thinking, Was I letting this go too easy? Maybe she just needed someone to nudge her back in the other direction, since she had been equivocating so recently. I didn’t think her concerns (returning to work, getting baby used to the bottle) were such big barriers as she saw them. But maybe they were proxy reasons for some deeper issues. Would I be a good doula by giving her more facts? Would I be a bad doula by not supporting her decision? Might she think a year later “That dumb doula at my birth who nagged me to breastfeed” or might she think “I’m glad she sat down and talked to me, because that helped me decide to give it a try and now I enjoy it”? I think sometimes my drive, or an LC’s, to give all the facts could be seen as nagging even when we are doing our best to be nonjudgmental and supportive.

I confess I had a few other things on my mind. I realize that I softpedal my behavior when I'm talking to someone who in my mind is unlikely to breastfeed. If a fifteen-year-old says she's going to formula feed and her mother is sitting right there nodding, is there any point in me saying anything? They've made their decision. She has more on her plate to deal with at the age of fifteen than I have in my entire life. Why should I start nattering on about fewer ear infections?

What about African-American women? As a white woman, it is so easy for me to feel awkward about promoting something that far more white women do, and have the privilege of being able to do, than black women. I have only begun to understand the complex cultural dynamics behind those differences. Should that awkwardness get in the way of the discussion?

What about single mothers, poor women who have to return to work right away, women whose whole families have formula fed, women who have formula fed their other children? Am I doing them a favor or disservice by keeping my mouth shut?

You could say I'm doing them a favor by respecting their decisions. But is that what every other person they interact with in the health system thinks too? Are they going to be frustrated someday realizing that because of their race, class, culture, or other stereotypes about them, they were not given the same information as other women? For all I know as a doula, maybe that's exactly what has happened and I am the last person available to say, "Just so you have this to think about..."

So while I don’t see LCs haranguing new moms “Don’t give up! Or you’ll kill your baby!” I understand where the nagging label might come from. Because eventually I pulled up a chair next to the mom's bed (she had a very effective epidural at that point, so I wasn't trying to harass her during contractions!) and I told her I thought she might want to give it a shot, and I gave her some reasons. She said "OK, I'll think about that." I think she was just being polite. I wasn't able to stay after the birth as long as I usually do, so I wasn't there for any first feeds. When I came to do my postpartum visit, I didn't ask, much less nag or yell, about how she was feeding the baby. But I still don't know how she would label my talk to her before birth. So maybe there are some LCs out there who are doing something we could call nagging prenatally. I just hope most moms understand that it's not done in that spirit.

Breastfeeding in a restaurant? The debate rages

One of my classmates mentioned that there's a heated discussion currently going on in the Washington Post restaurant discussion group. A reader complained about a woman openly (gasp!) breastfeeding her baby in a nice restaurant (because you should only breastfeed your baby in a not nice restaurant? Not sure about how that works.) The debate spans from "don't bring your children to nice restaurants at all" to "go do it in the bathroom" to "don't tell me what to do!" My favorite comment is that a woman breastfeeding her child in the dining room has "ruined" the dining plans of everyone else there. Oh no! Because that baby is eating now we can't eat!