Birth trauma shouldn't be a secret, but it is

Do you read Postsecret? Every Sunday a new set of secrets, mailed in anonymously on postcards, goes up. This week one of the secrets had to do with an unnecessary c-section (scroll down about halfway to see it). I noticed this woman mentioned that her son is healthy...a lot of women hear "as long as you have a healthy baby, whatever happened to you doesn't matter". But I think deep down they suspect that they DO matter. And I loved, loved, loved that on this website that millions of people read, they posted a response to that secret directing this woman to ICAN. I hope it serves to educate more women about unnecessary c-sections long before they have to deal with the prospect personally.

Trying again

I haven't done as much posting in this blog as I'd planned. That's not to say I can't think of anything to post - I think of things to talk about all the time! I've just put so much time and effort and thought into the posts I've written so far that to write another one like that feels exhausting to me. I think I need to dial that thoroughness back a notch. So if you feel like I'm not citing something or not thinking something through, ask and I shall expound, but otherwise I'm going to try to be a little more casual.

I started graduate school in maternal and child health this week. I'll be getting a master's in public health. "What can you do with an MPH?" everyone asks me. Well, sometimes I worry about that myself. I have a lot of interest in direct service, and an MPH often leads more towards policy, research, and program development. But the truth was, I was tired of working crap jobs and an MPH was the quickest way to get myself to a way more interesting level. I still contemplate other degrees like an MSW or even - still - midwifery, but an MPH will always be useful to me and it does have a very broad applicability when I'm out looking for interesting work.

I'm already glad I'm doing it on maternal and child health, vs. something more general like health behavior. The subjects we discuss in class already catch my ear - terms I'm already familiar with from doula work, issues I already am very curious about. So far I seem to be the only one in my entering cohort so devoted to birth issues - there's more of a family planning and child health focus. But I think that's OK. It just needs I mean to push myself to really seek out opportunities to explore those issues through my classes, and that there won't be a lot of competition for that area!

One class that seems like it will be great is international issues in MCH. Dealing with high maternal mortality in developing countries is something that I've been very interested in for a while. While maternal deaths in developing countries stem - in part - from lack of medical care, the challenge is to respond creatively with only appropriate medical care. A developing country cannot (and should not) provide an OB for every woman. Rather, one needs to train midwives to handle uncomplicated birth, and make OB services available and accessible for the 15% of women who will require them. The readings are already very interesting. It's astounding, and depressing, that reducing death rates for mothers and children is not that hard - we know how to do it effectively - and yet not happening.

iDelivery

Wow.

So my post on evidence-based medicine is a little long in coming (it's in draft form) but in the meantime I wanted to share. Looking up medical PDA applications for my mom (there are a lot) I came across something I think says a lot about the way you might deliver with a doctor.

As a doula and someone who talks with women about pregnancy and birth, I hear so many women say "I trust my doctor," or "I like my doctor," when contemplating birth choices. They believe that this will be enough to give them the healthy, normal birth experience they want. I know that there are many fabulous doctors out there - I haven't been able to work with many of them, but I know that there are doctors who practice more like our conception of midwives, than some certified nurse-midwives do! (And I have worked with some of those CNMs - never assume that because someone is a "midwife" that they have a certain standard of practice.)

But when women tell me things like "I like my doctor," I get an uncomfortable feeling. That you like your doctor is great, but that should only be the first item on your list. Like this person? Okay, check. Now let's ask: What are their intervention rates? What will they allow you to do and not do in labor? Under what circumstances? What's their c-section rate? What percentage of women in their practice deliver without medication? Would they be willing to deliver a breech baby vaginally?...etcetera.

When women say "I trust my doctor," do they trust them because they've gone through all the above questions with their doctor, or because they assume that all doctors practice identically and their doctor's training will be all they need?

And in the end, if you like them and trust them, is your doctor even in the room for more than a few minutes at the end to catch the baby? Because they could always be tracking you down in the cafeteria, or from the comfort of their own bed, with this:

For serious, people. Your doctor can monitor your contractions and fetal heart tones from their iPhone! Real time! Talk about hands-on medicine!

More information here, if you want it.

All I have to say is, if I'm ever in the position of needing an OB, my first question might well be "Will you be turning me into an iPhone application, or treating me like an actual person?"

Informed Choice: The Gold Standard

After I wrote my last post, where I discussed the rights of women to make decisions about their medical care and have those decisions honored, I got a link to a statement from a Canadian OB/GYN who is responding to statements from the American Medical Association (AMA) and American College of Obstetricians and Gynecologists (ACOG).

A bit of background: Ricki Lake, the TV talk show host, gave birth to her second child at home and decided that she wanted to make a documentary about our country's maternity care system and the alternatives available. The result was The Business of Being Born, which was released theatrically and on DVD in the past year. I have met more than one pregnant woman who decided to switch from hospital care to a home birth after seeing this movie. It's been screened all over the country and in hospitals, and it's gotten a decent amount of media attention.

This, apparently, requires action from our country's medical authorities. Both ACOG and the AMA released statements opposing home birth. ACOG's called for births to take place only in the hospital or birthing centers, and the AMA's supported that resolution. ACOG calls home birth "fashionable" and "trendy" (as someone noted, this is probably a big surprise to the Amish, who aren't generally called "trendy" yet have chosen home birth for generations). Why? It might have something to do with the fact that this movie is actually influencing women's choices, and that means less business for the OB/GYNs (although with home birth at less than 1% of the total births in this country, it's going to take a lot of screenings for that to truly tip the balance).

There are plenty of doctors who are not on board, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response. I wanted to repost it not just because it shows that there is opposition within the profession, but because of his statements about patient choice:

I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not "offering" VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT. [my emphasis]

Science supports homebirth as a reasonably safe option. Even if it didn't, it still would be a woman's choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC's prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the "model legislation."

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women's autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone's words: "We don't need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding." It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska
Yellowknife

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Next post answers Seth's second question: Why is there a gap between the evidence base and medical practice? Part of the answer lies in a conversation I had with my parents (both doctors) just a couple of days ago. Stay tuned!

Balancing the rights of women, and best outcomes for babies

OK, after a lot of writing and thinking I've started to answer Seth's three questions (see my last post for what those questions were, and what they were about). I'm going to address the first and last questions today, and the middle question tomorrow.

First, let's talk about the basic reason that the abortion rights debate is able to exist: because there are two entities at stake, and they are biologically inseparable. We do not have arguments about whether once you buy a dog, you have to keep that dog for a minimum of nine months, because you don't. If it doesn't work out, you can find a new home for it, end of story.

When women become pregnant, they have two choices: terminate the pregnancy, or be pregnant for nine months and give birth. You cannot pop a fetus out as soon as you realize it's there and give it someone else to handle. If it's going to continue, the mother is going to have to offer it a space in her body and, in whatever way she chooses, her life.

There are a lot of opinions on when "life" for the fetus begins (conception? forty days? month seven?) and a lot of opinions on how this bears on the mother's rights to control what's going on inside her body and in her life. But bear with me when I say that in the end, people seem to fall along a spectrum of positions. One extreme is "the mother has the right to do whatever she wants with anything to do with her body", and the other extreme is "the mother's body is now the host to the fetus and is always less important than the fetus' survival". There are laws being argued all along this spectrum. Does a woman have a right to a late-term abortion if her health is threatened? Should she be charged with child endangerment if she takes drugs in the ninth month?

This pairs the first and last questions very nicely:

1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?

3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)

On one end of this spectrum, the obstetrician has acted correctly. The obstetrician sees a situation in which he feels the mother is endangering her child. He goes to the hospital director and the judge, and explains why he believes this - because she is laboring after having had a previous cesarean, she has a higher risk for uterine rupture. If her uterus ruptures, the baby could die. While some states permit parents to decline care for their children - even lifesaving care - based on personal religious beliefs, this mother isn't basing her decision on Christian Science or other religious beliefs rejecting medical care. In the doctor's view, she should be legally forced to give her baby the best medical care possible.

This is where we come back to the fact that the baby is not a discrete entity. To provide Mrs. P's baby with the perceived best care, they will need to force this woman to lie down on a table, submit to anesthesia, and have her uterus cut open. She will then need to have it sewn up and undergo the long, painful healing process from major abdominal surgery. While a repeat cesarean poses risks to the mother (although a uterine rupture would also risk her life, this does not seem to be a factor in the legal decision), the perceived risk to the baby is considered more important.

This woman, who had been offered and refused to consent to a procedure, saw the law used to physically enforce one doctor's opinion - that for the benefit of her child, her body and her wishes about her body were completely irrelevant. If we believe that this is true - that when it comes to the health of the baby, women's bodies are second priority - then we could agree the doctor acted correctly. Suffice it to say that I don't fall on that end of the spectrum. In the last question, we're asking to what degree the baby's health should be taken into account. I believe that a woman who understands the risks and benefits of her choices is taking the best outcome for her child into account already. Doctors may disagree, but ultimately it's the mother's decision. Why? Because it's her body. No one should be forced to undergo medical procedures without their consent. If we accept this, it's a slippery slope to so many other infringements on women's rights.

I think looking at the medical evidence makes this even clearer. When Mrs. P refused a cesarean on behalf of herself and her child, she was indeed placing her child at a slightly higher risk - but only slightly. Some parents refuse to vaccinate their children, which carries a small, but real risk of serious illness and death. Parents who don't vaccinate may have to put up with a lot of forms to fill out when it comes to school enrollment, but they are not arrested and forced to vaccinate their children.

Childbirth Connection reviews the evidence and states that: 

"Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section."

(Click here for the original statement and more research on VBAC versus repeat C-section from Childbirth Connection.)

Many, many hospitals and doctors permit women to attempt VBACs; this doctor was certainly not acting in lockstep with every other medical professional. Rather, he was acting on a personal bias about the risk of VBACs. Why did he feel justified in sending a sheriff to this woman's house, arresting her, and strapping her to an operating table? Maybe because so many people consider women - especially in the area of reproduction - nothing but vessels. In that worldview, it's all right to force a woman to have a c-section, or forbid her from having an abortion, or live with the consequences of botched abortions and dead women. It's all the same. And that's why this story makes me physically ill.

Why Birth is Fundamental Pro-Choice Issue

As my first real post, I'm going to re-post an entry from my personal blog. I wrote this a couple of months ago, and writing it was one of the moments where I thought "Man, I should have a blog about just this stuff." I really want people to understand how all of these issues - reproductive rights, reproductive health, birth, abortion, childcare subsidies, health insurance, public health initiatives - aren't just connected. They are the same thing.

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I could go on about this for hours, possibly days, but there is so much in the birth world right now that seems to be such a neat parallel to the fight for abortion rights - until you realize it isn't a parallel, it's the same thing. That's the reason I go to such amazing birth workshops at the Reproductive Rights conference every year: reproductive rights go all the way from birth control to birth. Right now, to me, there is almost no area in which we see the state exerting more control over women's bodies. This story isn't common, but I venture to say it's only because more woman don't challenge the system. Try to refuse an intervention at the hospital based on not just your own understanding of best practices, but on solid evidence from excellent research, and watch how fast they come at you with dire warnings that you are PUTTING YOUR BABY AT RISK. Even as small a thing as refusing continuous fetal monitoring - proven over and over again to do nothing to reduce risk to the baby, but plenty to increase risk of cesarean - means snippy, angry nurses, endless badgering, and the prevailing attitude that you think you're better somehow, but you're NOT, and why can't you be like all the OTHER nice, compliant women who strap on the belts and lie in bed - THEY love their babies, why don't you? I've never witnessed legal threats, but I think it's easy for this attitude to cross the line from emotional (and physical) manipulation to stronger forms of pressure.

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And in going back to that post to get the text, I saw that my friend Seth posted some questions for me a couple days later that I never saw. Sorry, Seth! On the other hand, they're really excellent questions and now I'm going to use the answers as my next post. He asked:

My instinct is that things can't be as simple as you and the author of the linked page seem to think, but I am very poorly educated on these issues, so let me just ask some questions:

1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?

2. If there is indeed a serious disconnect between the opinions of doctors on these issues and the consensus of the scientific community, how did it arise? How can it be fixed?

3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)

All this really starts getting to the heart of how these issues are linked, and I am eager to start the discussion! That post will probably come in a couple days, as I have about 10 hours of driving to do in the next 24.

First Post

Welcome!

This is my first post, and I'm very excited about this blog. Having studied public health and anthropology as an undergraduate, trained and worked as a public health doula and breastfeeding educator, worked in a breastfeeding-oriented store, and now beginning my master's in public health with a focus on maternal & child health (whew!) - I have a lot to say!  I've posted a lot of thoughts on my personal blog, but want to put them in a dedicated place. 

I also want this to be a spot where I post news about reproductive health, women's health, and birth/breastfeeding, and a space to reflect on what I'm learning and doing in my graduate program. As the reader, I hope YOU get information to help take control of your reproductive health, learn more about all these topics, and share back with me stories, links, and information.