See What You Can Do? (And you're not even in labor yet!!)

I have a client due now-ish, someone whom I've felt a sweet connection to from the beginning. The stakes are high for her, as she wants to have a VBAC, and she deeply questions the necessity of her c-section a few years ago.

This client, like many VBAC women, has a "supportive" OB -- who has scheduled her repeat c-section for one week past her due date. And like many VBAC women, is under a tremendous amount of pressure to go into labor spontaneously and has spent many hours fretting, losing valuable sleep as she worries about how to get labor started.

She has armed herself with tons of information, so she knows that VBAC theoretically has less inherent risks than repeat cesarean. She understands that a healthy, spontaneous labor can begin at 42 weeks, which is 2 weeks past a due date. She understands the details of her own c-section and why she is particularly low risk for possible VBAC complications. In fact, a lot of this information came from her supportive OB -- the one who scheduled her repeat c-section.

She understands that hospitals have administrative protocols, so perhaps that is the sole reason why her surgery was scheduled. When the hospital sent forms for her to sign, her OB said, "Oh, don't worry about those things!" But her due date is approaching, and the supportive OB is now saying "Hopefully we won't get to that date, so let's not worry about it now."

But she is starting to worry, because that repeat section certainly becomes more possible with each passing day.

And then yesterday she had high blood pressure. She's a pregnant woman at 39 weeks, moving triple her usual blood volume and supporting another life inside her own body. She's working hard. She's also caring for a toddler. And she's anxious about her baby's upcoming birth. Of course she's got high blood pressure.

Her OB's solution to high blood pressure is to make her not be pregnant anymore (and notice that what my client has is high blood pressure, not pre-eclampsia, and it is important to know the difference). She has swept her membranes, and wants her to return in 24 hours for another blood pressure check and for another sweeping "if this doesn't work." And then the next step would be for an induction, if her cervix is favorable. And if not, c-section.

Between now and then, I gave her a few suggestions. She has been avoiding salt, but I explained to her why the body actually needs salt and so suggested that she use a little sea salt on one small thing on her plate. I also suggested soaking in epsom salt baths, maybe 2-3 times before she returned for the blood pressure check. I also suggested that she reach out to her ever-loving network of family and friends who have offered to help her when the new baby comes and tell them she needs their help NOW, to care for her daughter, to cook up a few meals, to run some errands -- because nothing is more important right now than putting her feet up, resting, drinking lots of water, and putting to use those very same meditation and visualization exercises for labor that she's been practicing for weeks.

She returned to the OB, and guess what. Her blood pressure was down. Not only that, physically she felt better. She thanked me for the suggestions, but I told her it was her body, and that she had done it. Just wait till she's in labor.

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.

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What's a "midwife?" Please let the ACNM know.

This week, the birth blogosphere was abuzz with news that the American College of Nurse-Midwives has changed its position statement on midwife certification and its definition of what a midwife is.

Essentially, what it boils down to is that the ACNM will not recognize a midwife unless she has received her academic and clinical training in a formal education program. The North American Registry of Midwives is the national agency which certifies professional midwives. After a midwife has met conceptual learning objectives and gained significant clinical experience with out-of-hospital births and prenatal care, she can become a Certified Professional Midwife. There are a number of formal education programs in which an aspiring midwife can enroll; however, an aspiring midwife can obtain her theoretical and conceptual learning through apprenticeship, under the guidance of wise, experienced and mentoring midwives. It's probably the oldest, most traditional form of learning there is.

There are many paths to learning, and it makes sense that the art of traditional midwifery honors learning through apprenticeship. NARM certification is rigorous; it recognizes different paths to learning, and ensures quality practice and standards of care through its certification process. Additionally, its standards for certification are used by the 26 states that regulate midwifery, states in which CNM's, OB's and CPM's practice collaboratively in a variety of birth locations.

It is curious that in its definition of a midwife, the ACNM wishes to split the midwives certified by NARM into separate camps, legitimizing one and squeezing out the other. It is particularly disheartening in the 24 unregulated states like Massachusetts, where the only opportunity to learn midwifery is through apprenticeship. What gain does the ACNM have in only recognizing some CPM's?

NARM has created a petition asking the ACNM to reconsider its statement and respect the knowledge and diverse training that those who hold the CPM carry. At this writing, the petition has over 1160 signatures. Please take a few moments to sign the petition, taking action to protect birthing choices, which includes access to qualified, trained, experienced Certifed Professional Midwives.

(this has been cross-posted on the Massachusetts Friends of Midwives blog)

Ummm, WHO delivered that baby?

I have been co-moderating a mothers e-group for a few years. It is a wonderful, supportive, and caring resource of information for moms in Boston. Every now and then, a newly pregnant mom asks for recommendations on an OB or midwife (usually an OB). The responses come pouring in, women sharing their stories about the tender prenatal care they received from one provider or the wonderful support given by the OB who happened to be on-call when they went into labor. But the one thing that makes me crazy is that this is said, over and over again: "Dr. (insert name) delivered my baby."

It doesn't matter how it happened: medicated or unmedicated, induced or spontaneous, vacuums or forceps. Mothers deliver their babies. Doctors and midwives attend births, assist births, catch babies, and perform procedures, but Mothers Deliver Their Babies! Even the babies who are born via the surgical skills of high-risk OB's, their mothers deliver them from the safety of their bodies, releasing them into the big, wide open, world to give them life.

Faced with a doctor gap, more hospitals turn to "Laborists" to deliver babies

Please click on the title above to read a Boston Globe front page article, published 2/22/09, about how hospitals are dealing with a shortage of OB's. This is exactly the reason why we need more birth choices, particularly in Massachusetts. Midwives, both CNM's and CPM's, can ease the burden on L&D units by creating more birth center births and homebirths, as they do in most countries around the world! The midwives would be able to attend more births, and the OB's could care for the much smaller percentage of births that actually need obstetrical intervention.

I come from a family with a number of doctors, so I have a very personal understanding of the pressures MD's face because of liability and soaring malpractice insurance costs. Because of my family, I'm also not as quick as others are to blame OB's for the medicalization of birth. But imagine if birth in this country were not driven by fear -- the OB's fear of being sued and watching a life time of work go down the drain for themselves and their families; the expectant parents' fear that the totally normal and healthy process of birth will go utterly awry unless it is interfered with; the mothers' fear when they go post-dates, because they can't spare precious maternity leave days waiting around for labor to begin.

So who is benefitting from the 15 minute prenatal visit, from theVBAC bans, from the c-section rate that is nearly 40%? Who is dictating all these policies? This really is a call for a reform of the insurance and medical malpractice industry and how it has burdened health care and effectively damaged our understanding of birth.