Saturday, June 27, 2009

Keep on Movin', Mama!

Henci Goer has blogged for Lamaze's Science and Sensibility this week about a small study that suggests the high value of freedom and variation of mobility for laboring women.

Combine this with the ACOG's recently revised guidelines about external fetal monitoring (EFM). As a doula, as a woman in labor, I have seen how the fetal monitor seriously impedes a woman's range of motion. Movement, particularly bending over or forward, can either pick up the mother's slower heartrate or lose a heartrate altogether. The sheer frustration can make a woman surrender to the bed, despite her primal instinct to move with her labor -- if her care providers haven't already forced her to stay there for the sake of that printed read-out. But the ACOG now states that "although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions. " The low-tech and far less restrictive intermittent use of doppler radar or fetoscope, typically used in out-of-hospital birth, relays reliable information about fetal heart rate.

All the more reason for mamas to keep moving.


Thursday, June 25, 2009

Who's Birth Is It Anyway?

My customary closing, when I respond to an initial email from a woman looking for a birth doula, is "Enjoy the rest of your 40 or so weeks, and best wishes for a wonderful birth-day."

When we meet in person, I will start the conversation by asking "What are some of the ways you envision your birth?"

But who's birth is it, really? Isn't it the baby that is being born?

I admit I never gave much thought to this use of language until a friend was critical of someone else's homebirth. The woman blogged about her birth in heroic, Herculean terms, and my friend found it boastful. "It's just a notch in her belt," he argued. "And it shouldn't be about her. It should be about a healthy baby." His assumptions about the healthiness of homebirth aside, his feelings are only a reflection of the way birth is typically viewed: a medical event meant to be just barely endured. And if the birth is traumatic, the disappointment with the experience gets swept aside by saying "In the end, all that matters is a healthy baby."

Of course we all want a healthy baby. A healthy mother, too. But there are women who envision something different than a delivery that is done to them, under a cloud of fear and suffering. They want to experience the physiological process of birth: the wonder, the fear, the ecstacy, the pain, the awesome strength of her body's own power to thrust another human being into the world. Their babies will be born, and these mothers want to birth them.

To my clients, I wish them all a wonderful birth-day.

cross-posted on Massachusetts Friends of Midwives blog.

Tuesday, June 23, 2009

Birth and Death: Right Around the Corner from Each Other

In yesterday's NYT, an eloquent realization that midwives care for women and babies, and not just at the beginning of life.

Anyone who cares for a woman during childbirth -- or in this case, stillbirth -- our near-sacred calling is to create and hold space for the pain, the ecstacy, the joy, and the loss.


Friday, June 19, 2009

O, Canada!

Released yesterday, the Society of OB/GYN's in Canada has stated that breech babies do not automatically indicate a C-section birth.

Hopefully, with policy leading the way, training will follow.

And then, wistfully, I hope that the US follows another one of Canada's leads.


Thursday, June 18, 2009

Pregnancy: Secrets & Lies

On my Facebook page, I have Laura Stavoe Harm's well-known (to the birth community) quote: "There is a secret in our culture, and it's not that childbirth is painful. It's that women are strong."

Upon reading that, one of my dear friends -- a soulful, humble, graceful, and honest mother of three --remembered something she wrote in her journal during her first pregnancy, about 8 years ago. She dug it up and emailed it to me. Boldly, I asked if I could put her personal words on my public blog, and she agreed (I told you she was wonderful!).

"The big lie of pregnancy is not that it’s easy, but that it’s difficult. Pregnancy is a whole body experience of your power. Like a sleeping giant, your body unfurls unto itself, yielding moment by moment into something amazingly big and then yes, even bigger than you had thought possible. Pregnancy streches you until you think you might burst. But the greatest secret lies in just how big you can become. And I don’t mean physically. It’s as if your body is simply mirroring a spiritual process, one that once you’ve experienced you understand why menstruating and pregnant women in indigenous societies were separated into tents next to burning, sacred fires. To our modern eyes, such practices seemed misogynist. But in reality, they were honoring the power of the divine by separating it from the mundane. The question is not why women should be allowed to be with men at such a time, but rather why men should be allowed to be with women."

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Monday, June 15, 2009

Are you an Ungrateful Patient?

This week, the American Medical Association voted in favor of Resolution 710, an attempt to identify patients who are "abusive, hostile, or non-compliant."

I come from a family of medical doctors and nurses - my parents, my grandfathers on both sides, numerous cousins, and an extended family, all of whom could staff a large community hospital with all specialties. I appreciate doctors and the fact that, for many, practicing the healing science of medicine the way they dreamed of when they were students is simply not possible with our current system of medical malpractice and liability.

And so, if this resolution were about liability, I could probably understand it. In this litigious culture, it seems reasonable that doctors should have the ability to indicate simply that a patient has not complied with suggested care, and therefore the doctor is not responsible for the negative outcome that ensued.

But the introduction of the resolution is not about liability, and it certainly isn't about improving patient care or outcomes. The resolution is suggested because patients "are becoming more abusive and hostile toward physicians," and have "unreasonable expectations and demands," which includes "instantaneous cure," due to the "arrogance and/or the belief that they 'own' their physicians." The resolution further states that "the stress of dealing with ungrateful patients is adding to the stress of physicians, leading to decreased physician satisfaction." This isn't about an MD protecting him or herself from a malpractice lawsuit. This is about doctors made cranky because their patients are demanding to be collaborators in their own care. It is as simple as that.

But what's not simple are the implications. In maternity care, women who want to be supported in a low-intervention birth can indeed be identified as non-compliant, particularly when women have very little choice but to give birth in a hospital that sees childbirth as a medical malpractice suit waiting to happen. A healthy pregnant woman who wants to give birth safely and with minimal medical care is not asking for an "instantaneous cure." In fact, what she is asking for is time -- a whole lot of it -- so that her baby can descend into the pelvis as it is physiologically programmed to, and so that she can experience the sensations - yes, the pain! - of healthy, normal childbirth without the pressure of liability-based policies rushing her and quite possibly altering her body and her ability to give birth in a physiologically normal way ever again. I appreciate that doctors face malpractice threats that can indeed ruin their careers and their quality of life, if not their children's lives, but birthing women are a part of this same system, and we are fighting for our lives, too. We don't want to "own" our physicians, but we want recognition that we do own our own bodies, and that we cannot be subjected to unwanted medical procedures that are not based in sound evidence and do not increase the chance of a healthy outcome.

The implications go beyond maternity care. If an MD in any area of medicine identifies a non-compliant patient to a health insurance company, can that insurance company refuse coverage of a non-compliant patient?

Just who, in fact, does this resolution serve? Will it result in greater doctor-patient relationships? Will it create better "job satisfaction" for physicians? It will only create more sick people who are ineligible for care. And that will not increase anyone's satisfaction at all.


Sunday, June 14, 2009

The MAMA Campaign

Midwives and Mothers in Action -- M.A.M.A -- is the collaborative effort to recognize Certified Professional Midwives and the care they provide as specialists in out-of-hospital births. Comprised of the National Association of Certified Professional Midwives (NACPM), Midwives Alliance of North America (MANA), Citizens for Midwifery (CfM), International Center for Traditional Childbearing (ICTC), North American Registry of Midwives (NARM), and the Midwifery Education Accreditation Council (MEAC), the goal is to gain federal recognition of Certified Professional Midwives so that women and families will have increased access to quality, affordable maternity care in the settings of their choice - at home, a birth center, or a hospital, and with the providers of their choice - Midwife, Nurse Midwife, or Obstetrician.

Overwhelming evidence proves that Certified Professional Midwives improve birth outcomes: through a lower c-section rate, more consistent prenatal care, and fewer costly medical interventions during labor and delivery. For this reason, M.A.M.A is working to bring real change to Health Care Reform and the American maternity care.

Please visit the M.A.M.A website to endorse the campaign, as a parent, a consumer of maternity services, a partner, a midwife, a doula, or all of the above! I did, and I'm proud of it.

Friday, June 12, 2009

Oxytocin: The Love Hormone

(Unfortunately, the code on this news clip is faulty, so I can't post the video here -- but click on the title to see the video.)

My current childbirth fascination is with the hormones that start labor. Released by the brain, oxytocin is the hormone that causes the uterus to contract. Pitocin, the synthetic oxytocin used to induce contractions, is introduced directly into the veins by IV. So while Pitocin mimics oxytocin, it bypasses the brain, and the chain reaction release of endorphins that follows the release of oxytocin - the body's own painkiller - doesn't happen.

Incidentally, oxytocin is also released by the brain after you've had a good meal. So a delicious dinner and great sex makes for one fantastic evening! It's another good reason to eat in labor.

Another excellent discussion of the hormones involved in creating and sustaining a spontaneous labor is in the book Gentle Birth, Gentle Mothering, but Sarah Buckley.


Wednesday, June 10, 2009

Women Must Be Informed, Political Collaborators in Their Own Care

Dr. Tiller's clinic in Witchita, KS, one of the few in the country that provides late-term abortions, is closing. With his murder, in addition to wiping out the life of a husband and father, the anti-choice movement has taken away women's access to critical, necessary services. And while the current political make-up shows that the anti-choice movement cannot overturn Roe v. Wade, Dr. Tiller's death is a reminder that all it takes is a sniper to reduce our choices even further. And since OB-GYN's aren't racing to provide abortion services at the risk of their own lives, Dr. Tiller's practice may not ever be replaced.

When I'm not a doula, I work as an abortion counselor. Although most of the women I meet with are between 4 and 7 weeks pregnant, the clinic where I work provides abortion services up until the 23rd week of pregnancy, which is the legal limit of abortion care in the state of Massachusetts.

Your reaction may be visceral, no doubt. At 23 weeks, abortion can be extremely difficult to understand or justify, and it is not uncommon to shake your head and say "I have a real problem with that," even if you are pro-choice. It is tempting, if not comforting, to separate yourself from a woman who would make this choice by assuming that she must be a monster. And I'll be honest and say that once I sat down with a woman who seemingly had no feelings about having an abortion in her 23rd week of pregnancy. It chilled me, her apparent lack of feeling. But many more times than just once, I have sat down with couples who are heartbroken: a routine ultrasound in the 20th week discovers massive deformities; an amniocentesis details profound genetic abnormalities that at are incompatible with all but the briefest of life, and suffering is certain; a doppler at 22 weeks returns no heartbeat, reducing a wanted and cherished baby into a diagnosis of fetal demise. And sometimes, due to the time it takes to run tests, or to the human inconsistencies of those who administer those tests, or the varying reliability of technology, a pregnant woman in those situations can be beyond 23 weeks. And so what do we do in the state of Massachusetts? We tell her she can deliver her dead, deformed, or doomed baby in a labor and delivery unit of a hospital -- which is as monstrous as it sounds -- or we recommend she travel immediately to one of the few clinics in the United States that can terminate her pregnancy. And with the death of Dr. Tiller and the closing of his clinic, there is now one less place where a woman in this delicate and devastating situation can go for care that is humane and treats her with dignity.

And on the other end of pregnancy, women are also losing choices in childbirth. In my line of work, I hear many birth stories from women, and the majority of them have the same eerie arc: first, induction; second, confinement to a bed; third, bone-crushing pain; finally, forced pushing while lying on their backs. Statistically, more than 30% of those stories end in c-section, and these are in pregnancies that had been normal, low-risk, and healthy. It's also the basic formula for reality birth shows on cable TV, where birth is boiled down to a medical event that skirts death practically every time.

VBACs are becoming harder to access, despite evidence that indicates that VBAC is lower risk than repeat C-section. Providers, among both OB's and L&D nurses, have attended fewer and fewer low-risk, healthy childbirths that are purposefully unmedicated and without interventions. What results over time is that if a laboring woman wants a natural birth, she could go to a hospital and have no medical professionals with the experience or willingness to support her desires. Birth centers are losing funding, and homebirth is either criminalized or unregulated in half of the US. In the other half of the country, the standards of care that do govern it are so limiting that its practice is nearly impossible but for a few renegade midwives who are essentially providing care without the benefit of professional support in case of a true obstetric emergency. Healthy women who could experience the normal physiological process of birth are beholden to the artificial constructs of time, liability, and television drama. The art of childbirth, and the choices that encourage birth as a safe, non-medical event, are being lost.

Unless we have a vision that is greater than the arguments of pro-life vs. pro-choice, homebirth vs. hospital, natural birth vs. epidural, we will lose what is truly at stake at the heart of these issues: choices. The quality of women's health care is dependent upon choices and access to qualified care providers, and women must expect no less than to be informed, political collaborators in their own care.


What's in the Bag?

As a doula, I know the value of a held hand, whispered encouragement, and a guided breath. There is research out there stating that simply having a doula in the room -- even if she sits there and only observes -- increases birth outcomes. But still, what's in the bag?

In my doula bag, I've got heating pads -- the kind that are activated by air. I would like to carry a silk, rice-filled pouch that can be heated in the microwave and molded to a woman's body, but most hospitals don't allow them anymore. But the heat can feel wonderful against the back or belly during contractions. Conversely, I also carry cold packs, the kind that you squeeze until something inside pops, then shake, and the square becomes ice-cold. I don't use these too often, but when I do, it's often at the site of the IV or hep-lock (the port to attach an IV quickly). Some laboring moms like the ice on their foreheads or necks, when labor has them heating up, but I find that cold, wet towels are better for cooling them off. These are single-use plastic and chemical packs, so not very green; but in a hospital room, use of heat and cold is limited if available at all.

I carry essential oils. If the mom wants a massage, I'll mix the essential oils into grapeseed oil (essential oils can't be used directly on the skin). Clary sage oil is reported to regulate the uterus and organize contractions, and lavender oil encourages relaxation. Lemon verbena oil can also cut right through a woman's nausea. I don't know what the science is behind aromatherapy, whether it achieves what aromatherapists claim, but they sure do smell good, and sometimes the smells of an antiseptic hospital, or the raw smells of birth, can make laboring women uncomfortable (remember that laboring women can have acute reactions to scents, however!). Any of these oils can go on the aforementioned wet towel, or on cotton balls, which are also in my doula bag.

I carry a deflated birthing ball and pump. If there's a ball already in the labor room, great! --but mine is always there just in case.

I bring a gardener's kneeling pad, so if mom is laboring on her knees, she's not on the hard linoleum.

I have a 6 foot long beautiful shawl, which can be draped over mom if she gets chills. The texture and colors are rich and luxurious, very pleasing to the senses. One of these days, I'd like to get a rebozo training, too.

I have two combs, one that mom can squeeze in each fist during contractions. When held perfectly, the teeth on the comb stimulate acupressure meridians that encourage labor to progress. And mom can squeeze them as tightly as she likes, dispersing the sensations of contractions as much or as little as she pleases.

Two cosmetics bag -- one for me, with saline solution, a contact lens case, tooth brush, toothpaste, hairband, and breakfast bars for quick energy; one for mom with hard candies, new lip balm, and a hair band for her.

And a hand mirror. Some moms want to see their baby's heads emerging. It can be great encouragement for only a few more pushes when she feels like she's got nothing left, and it can provide a view of that once-in-a-lifetime moment as the baby crowns. Hospitals haven't figured out yet that hand-mirrors are easier. Instead, they lug these heavy mirrors on rolling stands. Such a bother, and many laboring women still don't want people to "fuss" over them.

What's in yours?

Tuesday, June 2, 2009

Your birth story is an important part of healthcare Reform

If you sought care from a Certified Professional Midwife during your pregnancy, or if you gave birth in an out-of-hospital setting, your story is symbolic of why maternity care reform is a critical part of health care reform.

Certified Professional Midwives decrease the c-section rate and provide women with individualized, nurturing care in their pregnancies, labor, and deliveries. Certified Professional Midwives are the ONLY birth professionals trained specifically in out-of-hospital birth.

The c-section rate is soaring, and women are losing choices in how they give birth. Please tell your birth story.