Links - how important is birth? problems with research, VBAC questions, and more

Enjoy Birth and Stand and Deliver and Talk Birth all meditate on the importance of birth - how it shapes women, how it shaped them - and whether or not it is important in shaping women as mothers. All provoked by this post at Sweet Salty. Excellent food for thought.

No Fat Talk Week - I personally celebrate this 52 weeks a year, and invite you to join!

Winning entries from the National Advocates for Pregnant Women writing contest. How's this for a title: “In the Manner Prescribed By the State”: Potential Challenges to State-Enforced Hospital Limitations on Childbirth Options. I like!

Melissa lists questions to ask a VBAC provider.

Amy at Science & Sensibility asks Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?. She says, "Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice." Read the rest on how this is a bass-ackwards way to go about things. It's alerted my eyes to look for the same issues in breastfeeding research.

Aaaand a new favorite (via, as so often, The Unnecesarean), Arwyn explores the analogy between athletics and childbirth:

"Everyone has heard of and no one doubts the existence of “runner’s high”, so why do we start plugging our ears and rolling our eyes and flapping our tongues when we speak of “birthing high”? ... Even discounting that, or in its absence, there is potential for pride and a sense of accomplishment: something we value so much in athletics, yet scoff at in childbirth, where our effort benefits both us and another. We deny women that pride in accomplishment (for which support of athletics is so vital to girls’ sense of self and women’s equality), that boost in self-esteem and feeling of competency, right when we need it most: at the start of parenting, one of the most demanding journeys a person can undertake."

And that's enough for tonight!

Reply turned post, on the comments sections of feminist blogs

I posted a week or so ago about the comments on Joy Szabo's case over at Feministing. Dou-la-la noted that the same story, and similar comments, have gone up at Jezebel. I wrote a comment that started turning it into its own post, and Anne said it should just become its own post, so here it is! (slightly revised.)

It seems like so much birth guilt/trauma/processing comes up in those discussions by women who had c-sections. I feel like I see a lot of "My c-section was NECESSARY and I have decided to STOP FEELING GUILTY about it." Hooray! What does that have to do with this case? "My c-section was NOT A BIG DEAL so stop equating it with RAPE!" So glad to hear you were happy with it! And yet your consented c-section has nothing to do with this other woman's situation. So why are we talking about it?

I browsed by (as I occasionally do when I forget my better judgment) Dr. Amy's site and she had reposted from a piece about breastfeeding written by a mother who had supply issues and decided that terrible mean people were making mothers feel guilty about not breastfeeding. Cue dozens of comments like "Thank you, I had to feed my baby formula and then I felt guilty! Shut up, breastfeeding promotion!"

I feel like our culture gets women juuuust far enough ("vaginal birth good", "breastfeeding good") and then dumps them at the gate. "Good luck with your vaginal birth in a country of 30% c-sections and breastfeeding in a country with low breastfeeding rates and no paid maternity leave!" No further education, no support, nothing. And then when those things don't happen, they feel guilty and like failures (because why we encourage women to blame the system when they could blame themselves/each other?) And then to feel like less of a failure, they have to hate on the things that make them feel guilty (see above re: blaming each other). And they process all those feelings in the comments sections of these posts.

If I had a c-section and couldn't breastfeed for some reason, I'd be upset and pissed. But I accept that c-sections and formula feeding (OK, I would probably search out all the donor milk I could, so mixed feeding) are reasonably safe things, and were the best options available to me. That doesn't mean they are a universal good and it doesn't mean they're equal to the alternatives. Nor does it mean that other people need to STFU and do what I did without complaint so that I can feel better.

Just today in class we had a guest lecture by my breastfeeding/LC professor. She does a fantastic job of showing nothing but the evidence and demonstrating that formula kills, in this country and around the world. She showed a slide saying that our attitude in this country is "Breastmilk is best, but there's nothing bad about formula." One of the regular professors said something to the effect of, "Well, that seems reasonable - I mean, is formula poison or something?" You could see the breastfeeding advocate stiffen and then she looked around and said, "What do other people think?"

And me, because I have a big ol' mouth, I raised my hand and said (I paraphrase), "First of all, there have been cases of formula poisoning. The melamine case in China, other instances of formula recalls and formula poisonings. So no artificial feeding method is without risk. However, I would say that I and a lot of people in this room were raised on formula and feel perfectly fine. We are healthy. But as public health professionals, we cannot ignore the evidence. At an individual level, formula feeding may be fine. But we have a responsibility to admit that lack of breastfeeding contributes to infant mortality and that we have to work to promote breastfeeding. You can find someone who smoked every day of their life and never had a health problem, but as a public health professional you know and see that tobacco use is harmful. Similarly, at a population level, YES, formula IS dangerous."

Guilt and mothering and feminism are all tangled up in these issues and I don't want to deny them or say they are not important - they are important and obviously need more outlets for reasoned, informed discussion. But we can't deny the evidence either. We don't ignore the evidence about smoking because someone is addicted to nicotine. We don't ignore the evidence about exercise because someone doesn't like to get off the couch. We shouldn't ignore the evidence about breastfeeding, or c-sections, or anything else just because we do a piss-poor job of supporting women to be as healthy as possible and then make them feel guilty about it.

And that's my rant for the day!

EDITED TO ADD: I read this over and it was appropriately rant-y for a rant, but I failed to say that while I do get frustrated with women who process their guilt by blaming others, I sympathize with them, hugely. They were the ones who got taken just far enough and then dumped. Their pain and regret and anxiety are real, and like I said above I'd feel similarly if the same thing happened to me.

I would also NEVER, EVER tell a formula-feeding mother that artificial feeding kills or any of the other crazy crap people say to formula-feeding moms because they think they know what's going on in another person's life. Like I said in my little rant in class, I was raised mostly on formula and so were a lot of people. It's not a death sentence. It's just a risk, and I am speaking from a public health standpoint, not an OMGZ UR BABY WILL DIE crazy person standpoint.

Vaginal breech birth: yes it is possible!

I was talking with a woman recently who had a c-section for her first baby, who was breech. I said something like, "Yeah, almost all breeches are c-sections now, although in Canada they're starting to do them vaginally again." She looked surprised and said, "Really? I thought they COULDN'T be born vaginally. I thought they would be strangled or something."

This woman was totally happy with her c-section, and it seemed like that was the right choice for her. She said she'd even consider a repeat c-section with her next baby, breech or not, so my guess is that given a choice between a vaginal breech and c-section for her first baby, she'd have chosen c-section.

But she didn't choose; what's more she didn't even know she had a choice. She thought her baby could never have come out safely vaginally. I worked with a client last year who found out at 36 weeks that her baby was breech. A doula friend had e-mailed me a series of photos of her friend giving birth to a breech baby, and I pulled them up on my computer just so my client could see with her own eyes: Yes, a baby can be born breech. Before she could investigate vaginal breech more fully (including whether there was anyone who would be willing to deliver her breech in the area), she ended up having a c-section for a combination of issues. Again, it was the right choice in her situation, but in my heart I thought "At least she saw what was possible, and she knew her options". I don't think it's OK for a woman who has a breech baby not to be informed that it is possible for her baby to be born vaginally, and to refer her to more information about that option. Would/could most women travel to find a breech-friendly provider? Probably not, but they can't if they don't even know about it. That's not informed consent.

Rixa at Stand and Deliver has just posted about her first day at the International Breech Conference. It is so wonderful to read about midwives and doctors talking about how to provide safe, skilled breech birth services to their patients. But it doesn't do much if women don't even know those options exist. Spread the word: vaginal breech is possible.

Which is more important: your birth plan or your provider's?

The Unnecesarean has a new post up, reposting a mother's copy of her OB's birth plan. (He handed it to her husband at the 26-week visit.) Here are some choice excerpts:

* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.

* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.

* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.

So much of what this guy has written is distorted or just plain wrong, it's incredibly paternalistic, and violates basic legal rights (the decision to perform a c-section is at his discretion? Um, actually it requires signed consent forms. Signed BY THE PATIENT.)

And I kind of love it. Why? Because it's honest and lays it all out. In the end, your care provider's birth plan carries a lot more weight in the hospital than yours does. This guy isn't kidding about rupturing your membranes at his discretion; at the extreme end of things, he can tell you he's "just going to do a vaginal exam" and then rupture them without ever asking you, and that piece of paper in the corner saying you want to wait until your water breaks spontaneously isn't going to protect you. Even a doula, your partner, or a committed nurse can only do so much ("Whoops! I guess they just ruptured by accident!") And that's why I would say it's more important to get your care provider's birth plan than it is to give them yours. I've said before that if you find the right care provider and birthplace, you don't need a birth plan, and that's because you have found a care provider and learned enough about THEIR birth plan to know that it matches what YOU want.

The mom who posted her OB's birth plan ended up running so far in the opposite direction that she ended up at a birth center with a midwife and was delighted with her choice. But let me say - as some of the commenters on the Unnecesarean were pointing out - that this isn't an argument for women just needing to choose different care providers. This guy is an honest jerk with non-evidence based practices, but he's still a jerk with non-evidence based practices (say that 10 times fast!), there are more out there, and many women don't have the choice to find a new provider. At the individual level yes, PLEASE, find out your care provider's birth plan and make a switch if you need to. But on a bigger level, we need to stamp this stuff out.

Because, seriously, "Delaying [cord clamping] is not beneficial and can potentially be harmful to your baby" - as one of the commenters to the original posting said, this birth plan would be modern obstetrics only if it were written in 1975.

Notes from the NICU

The last three weeks of my LC shadowing have been with LCs who cover the NICU. It's been very different from my previous experience with breastfeeding support; the work I observe in the NICU involves very little direct breastfeeding, more counseling on pumping, and a lot of logistics. Some recent experiences:

1) Conferring with the NICU head nurse on flu policies. This has been a constantly evolving discussion since I have started observing at the hospital. Right now the policy is that no one with flu symptoms, including the mom, is allowed to visit the NICU until they have been afebrile (without a fever) for 10 days. But moms are encouraged to continue pumping and send pumped milk for their infants with a family member or friend. The LC and the NICU head discussed what to tell flu-infected moms about pumping hygiene, how to clean the bottles once they arrive at the hospital, and where to store the milk. Interesting to see policy being worked out, and so nice to see the NICU valuing and encouraging pumping!

2) Boxing and moving left-behind milk. The overflow freezer for storing pumped milk was itself overflowing, so I helped the LC transfer some of the milk to yet another freezer. We used Enfamil boxes to store the milk - they're made to fit very similar size bottles - and joked about "redeeming" the boxes. I asked about the milk we were transferring and the LC said it belonged to a mom whose baby had died after several months in the NICU. The LCs are waiting to hear back from her about what she wants to do with the milk. The LC was crossing her fingers that the mom would be willing and able to donate it. After seeing it, I hoped so too - there were some bottles of beautiful golden colostrum, and bottles and bottles of mature milk - after moving it all I'd estimate there were over 300 ounces! What amazing dedication. I can't imagine how hard it would be for this mom to think about what to do with this milk she hoped to give to her own baby.

3) Seeing how breastfeeding/pumping can come in dead last on a list of priorities for any NICU mom. So, you've had a c-section in a hospital a hundred miles away, your baby was transferred emergently to this hospital with serious health problems, you've been trying to coordinate the care of your older children while trying to recover and hoping to be discharged ASAP, 4 days after the birth you've finally managed to get over to visit your baby, which someone had to drive you to because you're not allowed to drive, you have to understand what's happening medically with the baby and possibly make decisions with the doctors about care, and in the midst of this is this sick tiny infant who is hooked up to ten different machines who you can't hold. And then this lady comes in and asks you if you want to pump milk for your baby. Who can't even eat right now. Sometimes I think it's a miracle any mother says yes.

4) And then seeing how much pumping can mean to a NICU mom. It obviously meant a lot to the mom who pumped over 300 ounces. Sometimes, it is the only thing a mother can do for her baby. I learned last week about oral care, done to keep the baby's mouth healthy and hydrated even if they're NPO (nothing by mouth). The LC counseled a mother that even if she was just pumping drops of colostrum at the beginning, she could soak up the drops with a Q-tip and use the Q-tips for oral care. Then the baby could smell her and know that she's close by. The mom started to cry. She couldn't touch her baby, didn't know if her baby would live, but she could do this one thing.

I think I'm lucky to have this opportunity to see NICU LCs in action, although it seems unlikely that I would ever end up in that role given that I don't have a nursing degree (most of the NICU LCs are former NICU RNs). I am looking forward to getting back to some more hands-on breastfeeding support, but this has been a real window into what babies and families going through the NICU experience.

Breastfeed: be a star

I heard about the British Be a Star Internet breastfeeding campaign through my IBCLC class. I get the concept of it - reframe breastfeeding as glamorous (easier now that there are so many breastfeeding celebrities) - and target it at younger women (at least that's what I'm guessing by the age of the moms picked to profile).

Above is Clare, 20, from Morecambe:

Please explain why you’ve chosen to breastfeed.
Well, it’s convenient, it’s good for baby, helped me get my figure back quickly – there are lots of health benefits for both of us. To be honest I didn’t ‘choose to breastfeed my eldest son, in fact I planned to bottle feed him and I’d bought all the bottles and the steriliser too, but after he was born the midwife in hospital brought him over to me and asked if I’d like to try feeding him myself, and we just went from there: once I’d got going with breastfeeding I realised how easy it was, and that’s when I realised all the good things about breastfeeding! With my second son there was no other way I would have chosen to feed but breastfeeding, for me it was the natural choice.

The text is no-nonsense, simple, and hopefully accessible. Personally, I love the photos and the concept, but I wonder whether the photos are as accessible as the message. If teens moms actually click over to this site, are they weirded out by these pictures of women wearing sometimes weird get-ups and breastfeeding? Are they insulted by the implication that they need to be marketed to with shiny photos and fabulous make-up? Finally, does this just further the impression that to breastfeed you need to be a rich, glamorous woman? Would it have been better to show these moms breastfeeding in their regular lives - at family parties, at the bus stop, before they go out in the evening?

What do you think?

How to make a doula feel loved

I loved this interview with Dr. John Kennell - I had never heard of him before, but apparently he is a big doula supporter and a founding member of DONA (Doulas of North America):

NLJ: Dr. Kennell, you are an adamant supporter of doulas, and much of your research has focused on the benefits of having a doula present during the birth process. You are often quoted, having stated: “If a doulas were a drug, it would be malpractice not to use it.” That’s a pretty, strong statement.

Dr. Kennell: Yes it is.

NLJ: Why do you feel doulas are so important?

Dr. Kennell: When providing the mother with a doula, which is really bringing back an old, old practice, we found that it just made a remarkable difference in the obstetric outcomes. So that’s one reason. There are strong suggestions that mothers who have a doula feel much better about themselves and how they did during labor. ... So, something that makes mothers enthusiastic about their baby and about what they did themselves, that’s great.

Read the rest here - I only wish it were longer.

I will say, nothing warms my heart like medical staff who appreciate doulas. Attention supportive midwives, nurses, and doctors: give the doulas you see a quick welcome if you can. In the best hospitals I've been in, people say "Oh, you're the doula! We LOVE doulas here!" It will make your patient happier, her doula more comfortable, and everything can run more smoothly when everyone knows they're a welcome part of the team. Reading Dr. Kennell's interview made me think of all the wonderful hospital staff I've met who were excited to see a doula in the room and let everyone know it!