Thursday, March 22, 2012

Guest post: All you have to do is be there

My next series of guest posts is from my friend and fellow doula, Chris. Chris and I became friends and doulas at the same time, on our AmeriCorps maternal and child health team. She has remained my friend and doula sister ever since - years later I still sometimes call her to process a tough birth. Chris is an awesome doula, a great friend, and a smart cookie! She's is expecting her first baby now (hooray!) and her posts for this blog are on her experiences with prenatal care, birth preparation, and (eventually) her birth story.

Before that series begins, I asked Chris if I could introduce her with a piece she wrote at the end of our AmeriCorps service. As part of the intro for the incoming MCH team, we each wrote up one birth story to help them get an idea for what our doula work was like.

Chris' story was really beautiful and I have found myself retelling it often recently as novice doulas have sought me out for advice about being a new doula. These newly trained doulas are expressing their worries about how they won't know how to help or what to do in the birthing room. I remember these concerns so clearly, along with the worry at births that I should always be doing and/or saying something because if I wasn't "doing something", I couldn't be doing anything, right? Yet like Chris, often the births where I felt most useless or helpless were ones where I was thanked effusively later by the mother and her support people.

The more births I attended, the more I realized the value of presence alone. I started to let my presence be enough: if something needed to be done, I did it; the rest of the time I could just be - be positive, be calm, be present. I tell new doulas this story to help them work through those concerns about knowing what to "do" and help them feel more confident that their presence is perhaps the single most important thing they bring to the birthing room. It is also a great story about the importance of doula support for all women and how we as doulas need to work hard to make sure we support programs that offer doula support to those who need it the most.

Some details have been changed to protect the client's privacy.


I was on my way out of the hospital after being a doula at a truly amazing birth when I got the call that a doula was being requested at a different hospital. Coming off such a beautiful delivery, I was still feeling great - energetic, excited, and in love with my job. By the time I drove across town to the other hospital, I was feeling the weight of the day and starting to drag.

The birth I had just come from was wonderful - very natural, lots of labor support from family, a wonderful midwife. When I walked into the second delivery room, the atmosphere could not have been more different. Instead of a sunset coming in through the window, there was fluorescent light. Instead of soft music, there was beeping from the IV pump and thumping from the fetal monitor. The mother, Elena, was all alone, hooked up to Pitocin, receiving IV pain meds, and thrashing and moaning through contractions. Just as I walked into the room, the nurse gave her another dose of medicine.

The thing about meeting a woman for the first time when she is in active labor is that she doesn't talk much. In fact, women in active labor without an epidural usually don't want to talk at all - they've got something much more important to focus on. I took Elena's hand, and helped her breathe through the next contraction. I didn't feel like I was helping - I figured that the reason she was calmer was the pain meds. She slept in between contractions and moaned when she was in pain, and for hours I sat next to her, holding her hand and rhythmically stroking her belly through contractions. She hardly spoke to me; the extent of our interaction included waking her up to say (in Spanish) "Elena? The nurse wants to know if you want more medicine." The nurse told me that Elena's husband was in jail, and that this was her first baby. I had no further information about the situation.

Elena progressed steadily, and sometime after midnight she was ready to push. She pushed out a healthy baby girl she named Stefania Espiritu. As they took the baby away to be examined and cleaned, Elena burst into tears. They seemed to be more than just tears of joy over the birth of a baby, and I asked her what was going on. "It's my husband," she said, "I just wish he could have been here. He's in jail. He got caught driving without a license and they were going to deport him back to Ecuador today." Her husband was an undocumented immigrant who happened to get caught doing something many other people do. But now he was separated from his family and had no way of even knowing about his new baby girl.

As I spent more time talking to Elena, I realized what a big moment this was for her and how important it was that I had been there. She had previously thought that she couldn't have children, though she had tried and tried. When she finally conceived, she and her husband were overjoyed. She kept repeating, "I didn't think I could ever have a child, and here she is." Her mother worked the overnight shift and couldn't be with her at the hospital, and she had no other person to support her. She looked to me and said "Thank you so much for being here! You helped me so much - with the breathing, and with the pain - I couldn't do it before you got here."

For hours I had felt pretty useless - the whole time she was in labor I thought I wasn't helping at all. To hear her thank me and to find out that I was such important support for her was incredible. I was so glad I could be there so she could share that moment with someone, so she could show off her baby, so she could tell someone her story. The staff at the hospital, while competent and sympathetic, couldn't be there for her in the way I was as a doula. I may not have done much, but my presence made a difference.

I spent several hours with her postpartum, just letting her talk. She had so much to share! By the end of it we had established a strong connection and I realized what a valuable service I had provided. Being a doula isn't just about breathing through contractions or changing positions or massaging through back pain--it's about being there, believing in a woman, and listening to her. A midwife once told me that doulas always help, every time. The more births I go to, the more I believe what she says.

I will never forget Elena or her story, and I am sure Stefania Espiritu will grow up to be as strong and beautiful as her mother.

Friday, March 16, 2012

Everyone should read this: "The Right Not to Know"

In the midst of all the war-on-women contraceptive/ultrasound/domestic violence legislative insanity that I haven't been blogging about in part because, unfortunately, there's so damn MUCH to cover, there are a few pieces that have really stood out to me. This piece really, really stood out to me. It isn't the first account like this I've read, but it's so timely and I think it is so important:

My counselor said that the law required me to have another ultrasound that day, and that I was legally obligated to hear a doctor describe my baby. I’d then have to wait 24 hours before coming back for the procedure. She said that I could either see the sonogram or listen to the baby’s heartbeat, adding weakly that this choice was mine.

“I don’t want to have to do this at all,” I told her. “I’m doing this to prevent my baby’s suffering. I don’t want another sonogram when I’ve already had two today. I don’t want to hear a description of the life I’m about to end. Please,” I said, “I can’t take any more pain.” I confess that I don’t know why I said that. I knew it was fait accompli. The counselor could no more change the government requirement than I could. Yet here was a superfluous layer of torment piled upon an already horrific day, and I wanted this woman to know it.

“We have no choice but to comply with the law,” she said, adding that these requirements were not what Planned Parenthood would choose. Then, with a warmth that belied the materials in her hand, she took me through the rules. First, she told me about my rights regarding child support and adoption. Then she gave me information about the state inspection of the clinic. She offered me a pamphlet called A Woman’s Right to Know, saying that it described my baby’s development as well as how the abortion procedure works. She gave me a list of agencies that offer free sonograms, and which, by law, have no affiliation with abortion providers. Finally, after having me sign reams of paper, she led me to the doctor who’d perform the sonography, and later the termination.

The doctor and nurse were professional and kind, and it was clear that they understood our sorrow. They too apologized for what they had to do next. For the third time that day, I exposed my stomach to an ultrasound machine, and we saw images of our sick child forming in blurred outlines on the screen.

“I’m so sorry that I have to do this,” the doctor told us, “but if I don’t, I can lose my license.” Before he could even start to describe our baby, I began to sob until I could barely breathe.

Read the full article here

Heartbreaking, enraging, and the truth. I want the legislators who wrote that bill to read this piece and understand what it means to intrude on the most intimate decisions people can make.

Check out the new

While I've been busy being a blog-derelict, Jill over at the Unnecesarean has been busy starting an entirely new site to document and publicize cesarean rates in the U.S. It includes cesarean rates by state, and within each state by hospital (when they are available). It also has the most recent information available on VBAC bans (via ICAN). This is a really exciting project and I hope it will help place more pressure on states that do not make their rates regularly and publicly available. You can do your part (and learn very interesting facts about your local hospitals!) by visiting the site and - if you're not finding the information you need - use the contact info provided to let your state officials know that you would like cesarean rates documented. You can also submit pictures of your local hospitals to be included in the slide show on the first page!

Click here to check it out:

Friday, March 2, 2012

Guest post: Midwife vs. OBGYN

I am excited to be presenting several guest posts in the upcoming weeks. While I've been feeling lately like I might have temporarily run out of things to say, a lot of the wonderful women around me are going through experiences that have given them a lot to say - and I've been shamelessly recruiting them for guest posts.

The first comes from my cousin, Maggie. We lived far apart growing up, but were close in age and shared a lot of phone calls – mostly on the topic of American Girl dolls, if I remember correctly. Now we text about breastfeeding instead! (But yes, I do have Samantha and Felicity in a box somewhere.) Maggie is pregnant with her second baby (yay, more babies in the family!) and I asked her to share her thoughts on the difference in care between her first and second pregnancies. I was so happy to get this post and see what a more positive experience she is having this time around.

Guest post: Midwife vs. OBGYN

I just went to my 34 week doctor appointment today and the first thing I told my husband after I left the appointment was, “The closer I get to my due date, the more I realize how glad I am that I changed to the midwife group.”

To give you a little background, I am pregnant with my second baby and going to a midwife group that is associated with a hospital. This means they deliver at a hospital and still have to abide by hospital rules and regulations, but they are a lot different than a typical OBGYN group.

I went to an OBGYN group during my first pregnancy. They deliver at the same hospital I am delivering at now and overall, were a nice group of women (all the docs in the group were women), but I just never felt like they cared about me. Every time I met with them I felt like I was just a number. They took my blood pressure, listened for the heartbeat and I was out the door.

I didn’t do much research about labor, pregnancy, etc until I actually was pregnant with my first and had already started to go this practice. What I know now is that I could have switched, but then I was too nervous. I felt like it was the wrong thing to do and my care would somehow be compromised. Not that I didn’t get good care there, I did, but the biggest difference between them and the midwives is that there I felt like I was just a number. They had their way of doing things and overall, they were doing it no matter what their patients wanted. I feel like the midwives treat me like a person that has opinions and feelings about how her pregnancy and labor should go. To me, that is the most important thing you can ask for in a provider, no matter who they are.

I thought the best way to really portray the difference is to give you some examples of my care at both places.

Example 1: Birth Plan

The OBGYN office did not discuss birth plans with you. The midwife office does and requires each woman to fill one out around 34 weeks. My cousin (who writes this wonderful blog) helped me put together a birth plan for my first pregnancy. I brought it to my appointment with the OB and asked her to look at it just to make sure I was on the right page. I had something in the birth plan about the hospital staff not asking me if I wanted any pain medication. The doctor’s response to this was laughing and saying, “What are the nurses supposed to do when you are lying on the floor screaming in pain?” Needless to say I left the appointment completely shaken up, crying and even more nervous about the labor.

I discussed my birth plan today with one of the midwives at my 34 week appointment. This birth plan is a lot more simplified. One thing I learned after my last pregnancy is that everything will not go according to plan and I can’t get discouraged if it doesn’t. I basically stated that I would like to try to go naturally and use certain techniques that have always helped me relax. The midwife was wonderful when going over the plan and even gave me suggestions about things to add in.

Example 2: Extras

I am not sure what to call all of the additional things that happen after the labor such as cord cutting, skin to skin contact, nursing immediately etc, but I will just call them extras. These extra things were a cause of worry for me when my first was born. Waiting to cut the cord, not cleaning the baby right away, etc were not routine for the OB practice I went to. It was just one more thing I had to worry about getting included on my plan and making sure they would follow. (Luckily they did.)

I went to a “Meet the Midwives” open house when I was first pregnant with my second and trying to decide if I should go to their practice or not. Some of the women there asked questions about cord cutting, skin to skin, etc and midwives said these are not even things that need to be included in the plan because they are all routine at their practice. In fact, the midwife I met with today even told me about a study that the hospital is doing called “Kangaroo Care” and to make sure I tell the nurses I want to be a part of it. That way I am guaranteed that all the nurses follow these procedures from birth to discharge.

Example 3: Induction

I ended up getting induced with my first. Yes, completely different than what the plan was. I was 41 weeks and the doctors recommended I get a non-stress test. Of course, we failed! My daughter’s heart deceled one time during the test and the doctor told me that I needed to get induced. Actually she told me we needed to go straight to the hospital, not to eat anything, and that I couldn’t go home and get my bags. I was freaking out! After 30 hours of Cervidil, Pitocin and an epidural my wonderful daughter was born. In the end, the labor didn’t matter. I had her vaginally and I was blessed with a wonderful, healthy daughter. But, do I want to go through that again - no way!

I discussed my last labor with the midwife today and have discussed it with my new group in the past. They basically have told me that because they are associated with a hospital if a patient gets to 41 weeks they have to recommend a non-stress test for liability reasons. Would the OB docs have told me it was a liability issue, again, no way!

They have also told me that there are more false positives than positives in a non-stress test. In fact, when I met with the midwife today I told her that I think my daughter’s heart rate never decelled. I told her that the monitor moved while I was being monitored and I believe that is when it recorded the decel. In the next 30 hours of labor my daughter’s heart rate did not drop one time. She laughed at me when I told her that. Not because she thought I was uneducated or naive, but because she could tell how strongly I felt about the whole thing. She actually went on to tell me that if I get to 41 weeks this time and get a non-stress test that I need to make sure I drink plenty of water, eat a lot before the test and “watch the monitor like a hawk.” She said if the monitor moves at all I need to pull it off, call the nurse and tell her to come put it back on. That way no false decel is being recorded. I almost grabbed her out of her chair and started kissing her when she told me that! A medical professional that is listening to me – what a novel concept!

Overall, I have had a lot better experience at my midwife group. I feel like they listen to my concerns, answer my questions and most importantly want me to have a role in my pregnancy and labor instead of just sitting back and being a passenger. That is how I felt at the OB group.

My recommendation to any pregnant women thinking about what type of practice to choose is to educate yourself first. Maybe you are okay with being a passenger, maybe you want to be in the driver’s seat. Either way, decide how you want to approach your pregnancy and pick a provider that offers you that. It has made my second pregnancy such a better experience.

Getting the most out of your MPH

While I was writing my guide for applying and getting into MPH programs, someone suggested a "getting the most out of your MPH" kind of companion piece. I thought that was a good idea, and now I'm finally getting around to it!

Your goals

So remember how I talked about knowing very clearly what your goal is before you apply to MPH programs? That's not just to decide whether you should get an MPH, and which program you should choose. Your goal(s) can carry through your entire academic experience and guide what you do to get the most out of your MPH (which isn't to say they can't change - but if you don't have any to start it will make things much more difficult.)

Are you in an MPH program for specific skills, contacts, credentials, or work/research experience?

If you end up in an MPH program that is very structured and by design gives you exactly what you need - great! But generally you will have a fair number of choices about how you structure your experience in school, and need to be proactive to get certain experiences that you're looking for. Think as you move through your program whether you're getting closer to your goals and whether there are still things you want to fit in. You don't want to end your experience frustrated that "my program didn't give me _____", and then realize later that you could have made it happen.

Getting the most out of your academics

Use your goals when thinking about structuring your academics - that includes thinking about:

- What classes you choose for your electives - qualitative analysis? SAS programming? reproductive health policy?
- Topics for class papers or projects - maternal mortality in West Africa? children with special health care needs in the U.S.? global HIV/AIDS policy?
- How you choose to focus your efforts - is your data analysis about getting something publishable, or is it about learning the software in-depth?

For maternal child health-minded people with highly specific interests - c-section rates, breastfeeding promotion, utilizing midwifery care, etc. - know that you will probably not find a professor/academic niche tailor-made for you, unless you have specifically sought that out. And even then, it will probably be just one person or one project working on that issue. Think broadly about how what you're learning can serve your end goal, and try to network outside of your department/school in addition to your academics to find people working on your specific issues.

In the end, I think the most important thing about academics in grad school is to focus on the long-term goal vs. the short-term assignment. I would find myself stressing out about some artificially constructed goal like "500 words about ______" (how am I going to keep it to 500 words, will the professor dislike the way I structured this, etc. etc.) and then have to catch myself. Nobody would ever know or care what grade I on this assignment. I needed to focus on what I wanted from the experience, which was often the excuse to investigate something I wanted to learn more about anyway, and to get feedback on my academic writing so I could keep improving. My high school and undergraduate education at what I fondly refer to as my "hippie schools" definitely emphasized learning for your own sake and not for arbitrary grades, and I found that to be a very helpful lesson in graduate school. I think everyone is happier for this realization; it helps you focus on what you actually need to stress about.

Getting the most out of your practicum and thesis

I put these together for the same reason, which is that I found I needed to dial my expectations way down when it comes to both of these experiences. I was much more satisfied – and got more out of them! – because I did.

Your practicum is a 2-3 month experience, often where you are parachuted into a new organization in a new location. Sadly, it won't and can't be everything you want it to be: practicing and getting every skill you want, burnishing your resume, working in exactly your chosen location and field, networking with the perfect people, AND accomplishing something concrete and meaningful to show for your time/work. I think people are happier if they pick ONE thing (max, two) they want out of the practicum and focus on that. I decided I wanted to get solid experience with data analysis and the quantitative side of public health research in general. This was both to get it on my resume/get better at it, and also to figure out if I liked it enough to take a job that was data-heavy (answer: no.)

Financial considerations will also play a big factor, since many internships (particularly abroad) don't pay, or pay minimally. If the practicum you want is unpaid, investigate whether your school has funding for practicum experiences and apply to all the funding sources you can. Think about the cost/benefit – an unpaid internship with a really great organization may set you up enough to be worth it down the line, but it also may not – it’s up to you to decide.

Your thesis, likewise, is not a dissertation, and (thankfully) won’t define the course of your career. It's actually just another, slightly longer, paper that you're required to write, within various guidelines established by your department. Pick a goal for this experience as well – whether it’s developing something for publication, creating a useful document for an organization, exploring a topic you want to become more familiar with, etc. I used it as an opportunity to help the Centering Pregnancy program I worked with develop a new curriculum module.

Getting the most out of grad school life

Don't be a stranger! Join (or start) student groups, journal clubs, etc. This can be hard for people with a lot of outside commitments like work and family; don't make commitments that add more stress, but try to find ways to connect with your classmates, even if it's just being friendly, and chatting before and after class. I have heard from people many years out of their MPH programs that they are still working with/hiring old classmates. These are your future colleagues in what sometimes feels like a very small field.

The same goes for faculty - get involved in research if you can, reach out to faculty who are working on things you are interested in, and seek their help when networking for things like practicum placements and jobs. Again, they are your teachers, but now that you're entering this field they're also your colleagues - you may end up working for/with them in the future. Nurture those relationships!

So, in summary:
- Don't expect to have people who understand your specific interests - make your own path
- Know your goals and be proactive about achieving them - don't expect your program to spoonfeed you or to be especially useful in the ways you want it to be without putting out significant effort on your part
- Your practicum, thesis etc. should be part of this plan - not envisioned as some amazing perfect all-encompassing crowning achievement, but as realistically-sized means to your ends
- NETWORK - don't be a stranger - this applies to both other students and the faculty


This is TRULY the coda to my MPH series! I hope it's been useful to people out there. It does seem to get a fair number of hits! Again, if you're planning to e-mail me, please read through the whole series first to see if I've already answered your questions, and know that I'm not a professional grad school admissions advisor - I'm just someone who's been through the process and has some tips from the other side.