My Doula Identity Crisis

For a number of reasons, I'm toying with not recertifying with DONA International next year. (The reasons are best left to a different post.) When considering my options for a new certifying organization, an interesting thought crossed my mind: why recertify at all?

Think about it. Doulas are not medical professionals; there is no such thing as "practicing labor support without a license." It doesn't take a sheet of paper and a nametag to offer holistic pregnancy and labor support. It takes training, knowledge, and most of all, a committment to your cause.

Your cause. And what is my cause? This whole inner dialogue, do I recertify or not, has driven me into a sort of Doula Identity Crisis.

Credentials or not, I am a Doula. I have always been one, and while I haven't always attended births (or, for that matter, attached that term to what I do), I have always played the Supporting Role in whatever challenge my friends and acquaintances are facing. Learning this about myself has given me the opportunity to playfully attach the term to many aspects of my life. Listening to a friend work through issues with her partner? Relationship Doula. Volunteering at Transformus' Sanctuary? Burn Doula. My partner mentioned his fire department's auxiliary. What I heard? Fire Doulas.

What we've come to forget - strangely enough - is that doulas have been attending births long before it was a paid profession. In fact we hear this history when we attend the trainings: women have been assisting women through childbirth for probably as long as childbirth has existed. Many mammals (i.e., elephants!) doula each other through labor. We know this, and yet we have allowed "those who are doulas" to be separated from "those who are not doulas" by a mess of paperwork, fees, and credentials. Even my local professional association of doulas separates certified doulas from non-certified doulas with the categories Certified Doulas and Trained Doulas Working Toward Certification.

Which leads me to ask again, What The Hell Are We Doing?

There must have been something in the air, because right as I started questioning this whole notion that "doulas are paid professionals with credentials," Miriam Perez penned an article on this very topic. She muses:

I think doula work is valuable and important, and I also don’t believe the essence of doula work—non-judgmental and unconditional support for pregnant and parenting people—needs to be locked away in a system that says only a certain amount of training, certificates, or other paperwork bestows upon someone the right to provide this support. We run the risk of replicating the model we’re trying to revolutionize. And I don’t think that is where real social change happens.

Let me pause for a moment and say that, had it not been for my training and push towards credentialing, I would not harbor the knowledge and skills I have today. I see the need for these trained and certified doulas that charge for their services, and I hope to remain one of them for a very long time. The work is invaluable, and charging for services rightfully reimburses us for the hours upon hours spent with someone's family (read: away from ours). It also helps to set a standard of practice so that families know what to expect - and not expect - from a prospective doula.

But as Perez rightly notes, we could be defeating our cause by over-stressing the importance of these things.

Last month, this piece sparked some heated discussion on my Facebook feed. On the one hand, I agree with the author that valuing our work and not selling ourselves short is important. On the other, her point completely ignores the vast number of families who should not be denied trained labor support simply because they cannot front a $500-$1000+ payment to someone who, let's face it, isn't exactly a mandatory part of the birthing process. This population, the under-served and often less educated, needs doula services the most. They are more likely to lack a constant support person throughout the process. They are more likely to be "rushed through the machine" of the hospital system. They are less likely to feel positive about their experiences. They need doulas, and anyone who says I'm "cheapening the profession" by volunteering my time to help someone have the birth they want needs to reassess the reasons they became a doula in the first place.

Fast forward to today. I have a client with one of the more medical physicians practices in this city. They've scheduled an induction for Monday, four days after her estimated due date, because "baby is measuring big." After venting about the obvious issues to a friend, I found myself thinking, "I just need to stop taking clients with this practice."

Woah woah woah woah. What am I saying?

Suppose for a moment I wasn't her doula simply because of who her doctor is. And say all other doulas felt the same way. This mama would still be induced on Monday, but I wouldn't be there to support her through it. No one would, and with a practice like this, it's these women that need my support most.

I'm envious of the doulas who "only attend home births" or "only work with patients of midwives." They are helping to support a certain portion of the population that deserves a doula as much as anyone, and I'm not saying their work as doulas is less important (far from it). However, if their goal is to only work with care providers that are already extra supportive of natural chlidbirth, then I can only imagine their mission differs from mine.

Thing is, I get it. I love working with the midwives, not worrying about contradicting a care provider's advice, not having to hide granola bars under hospital gowns, avoiding unnecessary interventions, etc. I'm excited to have two clients next month who are having water births.

But my mission is to help every person have a supported and satisfying birth. For everyone experiencing abortion or miscarriage to be validated and supported throughout the process. For all my friends and people I care about to have a non-judgmental ear, to have their backs rubbed when they need it, to be reminded to just simply take care of themselves. I'm not doing that if I'm limiting the population I'm willing to work with, and I'm certainly not doing that if I'm more concerned with my credentials and fee schedule than I am my ability to simply be there.

I have a lot to think about over the next year when my DONA certification expires. Do I want to certify with another organization? Let it go and work without cert? Does it even matter? I'm not entirely sure. What I am sure of is this: if I look at myself in the mirror and can say with confidence, "I am a Doula," I know I'm on the right track.

Why Birthing Rights Matter to the Pro-Choice Movement

In the more abortion-focused circles of the pro-choice movement, birthing rights often go undiscussed.  My mentions of home birth rights specifically have brought varying responses, from supportive to ambivalent to outright hostile ("Well that is not safe!"). 

But let's be clear about something.  Reproductive justice means that everyone has complete control over if, when, where, how, and with whom they bring a child into the world.  It means that people have accurate, unbiased access to information regarding all facets of their reproductive lives, from contraception to pregnancy options, from practices surrounding birth to parental rights. It means that our choices are not constrained by politics, financial barriers, or social pressure.  In other words, how can the right to give birth at home - safely and legally - not be on a reproductive justice advocate's radar?

I mention this because we in North Carolina are enduring yet another vicious attack on the rights of pregnant and childbearing individuals.  Women seeking home births may have the legal right to do so, but just like the women seeking abortion care, these laws do nothing to protect access.  As far as home birth attendants go, our state only recognizes certified nurse midwives (CNMs), and in order for these phenomenal women to legally attend births, they must be supervised by an MD currently licensed to practice obstetrics in the state.  As you can imagine, physicians that will supervise homebirth CNMs are few and far between, and this week one of them was advised (under threats of sanction) that he cannot sign off on CNMs who are not under his direct employment.  Even though the law does not dictate these terms, the medical board's sanction left seven of our eleven home birth CNMs without a licensing MD, and countless women without a care provider.

The research is abundantly clear: when labor is progressing normally, a woman under the care of a trained midwife is as safe giving birth at home as she would be under the care of an obstetrician in a hospital.

Anti-abortion birth advocates are already taking a hypocritical stance on the matter as they decry abortion rights while asking why women's reproductive decisions are limited.  I've been biting my tongue while reading the Facebook comments of fellow birth professionals all week.  One such statement went, "It is legal to have an abortion but a woman can't choose to have a home birth with a midwife! This is crazy!"  Another, "A mother can kill her baby in all three trimesters but can't give birth at home.  The government is nuts."  [Fact-Check Sidebar: North Carolina restricts abortion access after the 20th week of pregnancy (hardly "all three trimesters"); additionally, this ruling didn't come from the government, it came from the NC Board of Medicine, an agency independent from the state's governing body.]  These ramblings are usually followed by the contradictory co-opting of pro-choice language, ripe with phrases like "right to choose" and "my body, my choice."

The abortion rift amongst birth advocates is really nothing new.  After all, to simply be an advocate for varying birthing options does not encompass any official position on the politics of pregnancy itself.  Birth advocates come to the work for a variety of reasons, while it certainly seems odd to me that a person could support the "right to choose" in one pregnancy outcome but not another, the social stigma surrounding abortion means that this rift is bound to exist. 

That home birth rights are not at the forefront of the reproductive justice movement, on the other hand, is beyond me.  The struggles are just too similar.  Every time someone points out that women might have to cross state lines to access a home birth midwife, I think of the women who still - in the year 2012 - have to seek abortion care in a state with fewer restrictions or more providers.  When we worry that women will have to give birth with midwives who operate illegally (or go unassisted), I think of the women who risked their lives going to see illegal abortion providers with no public credentials, or the women who simply did it themselves.  Medicaid and many private insurers restrict access to home birth midwives just like they restrict access to abortion, making both more or less a privilege to those with the means to pay out of pocket. 

Reproductive justice advocates who are involved in birthing rights see both - the right to an abortion and the right to give birth at home - as the same struggle.  We understand that any assault on reproductive freedom comes from a system of patriarchal self-interest that sees women not as autonomous beings, but as objects to be regulated and "fixed."  We know that any women who choose home birth have done their research and don't need "warnings" from government institutions, just like women seeking abortions don't need the ideological jargon in "Right To Know" legislation.  We know that women and their families are capable of making the best possible decisions regarding the births of their children, and we seek to create a world where access, stigma, and social pressure don't sway these decisions.  In other words, we live up to the full spectrum of our ideology... we Trust Women.

I call on the reproductive justice movement to make birthing rights a part of their pro-choice consciousness.  If we are to create a world that ensures sexual and reproductive well-being for all women and girls, no struggle to protect our choices or desires can go unsupported.

Get Yer Freak On. Doula's Orders.

Today is my May Mama's estimated due date.  Well okay, her original EDD is the 28th, but they pushed it back to today because of imaging.  Which means I'm still considering her to be due on the 28th.

When I talked to her today, she was anxious.  Her last two babies had been born at 39.5 weeks exactly, and going "past" her due date was worrying her.  I reassured her that all babies are born eventually, and besides, as her midwife already said, third babies tend to be the odd ones out.  Old wives' tale, sure, but backed up with years of observation by pretty much every midwife I've ever talked to.

Then, showing my nerd-colors a bit, I reminded her that babies, like wizards, are never late.  They arrive precisely when they mean to. 


We went on to have a good conversation about inducing labor naturally.  And no, I'm not talking about smearing your vag with evening primrose oil or doing shots of castor oil.  I tend to be cautious about those methods when a mama isn't being threatened with medical induction, since they tend to have negative side-effects that are, let's say, unpleasant.

But to simply get things going, I always say, a mama needs to simply have a really good night: get a nice long foot/calf massage, have a half glass of red wine, and have some good sex.  Or as I call it, the Sex, Booze, and Foot Rubs Method.

While the above methods tend to be looked at as mere old wives' tales, there is in fact scientific basis for their use.  And besides, unlike castor oil and assuming we're only recommending a half glass of wine, there is little to no risk of negative side-effects.

Here's why they work!

The Sex

Oxytocin, the so-called "love hormone," is at least partly responsible for three distinct physiological events in a woman's reproductive cycle: orgasm, labor, and breastfeeding.  As a sex-positive doula and lactation educator, you might say that oxytocin is my homegirl.

The female orgasm was once thought of as relatively inconsequential to the reproductive process.  In fact, some fertility specialists have even suggested that orgasm "dilutes" a woman's chance of becoming pregnant.  (I call bullshit.  Also sexism.  But that's another post.)  Au contraire, says a bulk of new-ish research that essentially reaffirms what lay-health workers have been saying for years: orgasm increases your chances of conception.  See, when a woman orgasms, her body releases even more vaginal secretion than she does when simply "aroused," helping to lubricate the sperm's path to the egg.  Additionally, the oxytocin released via orgasm contracts the uterus, lowering the cervix (the "neck" of the uterus) and making the uterus more accepting of a fertilized egg (ever wonder what that tight feeling in your lower abdomen was?).

Sidebar: Oxytocin is also associated
with trust, which helps explain why
women who have good relationships
with their care providers tend to have
smoother labors.

So oxytocin contracts the uterus.  Hence labor.  But the wonder-hormone's job isn't over when the placenta is delivered.  Oxytocin is also responsible for the milk "letting down" during breastfeeding.  See, when a woman first lays eyes on her baby, she's essentially OD'ing on oxytocin, as is baby.  That's the love hormone doing its job.  Baby will hopefully find her/his way to a nipple and begin suckling.  When the nipples are stimulated, oxytocin is released from the posterior pituitary gland, contracting the tiny myoepithelial cells inside the milk ducts, forcing milk out of the breast and into baby's mouth.  That oxytocin release is still doing it's job "down there," helping mama's uterus to clamp down post-delivery, thus reducing risk of excessive postpartum bleeding. 

I mention the connection to breastfeeding because oxytocin is also released with nipple stimulation.  Women who are into nipple stimulation during sex may enjoy it for a number of reasons, but physiologically it's because that burst of oxytocin contracts the uterus (which essentially puts interior pressure on the clitoris and, well, you get it).  In other words, if you're into nip-stim, include that in your labor-inducing sex practice.  Otherwise you can just turn on your breast pump when you're finished doin' the deed, and you will probably get a lot of the same benefits.

If a woman is having sex with a man, his stuff may play a labor-inducing role as well.  Semen contains prostaglandins, autocrine hormones that help to soften ("ripen") the cervix.  A softer cervix makes the fertilization/implantation process more likely, but these hormones work the same when a woman is already pregnant.  The low dose of prostaglandins in semen alone aren't likely to induce labor in a woman who's not yet term (which is why care providers don't warn against sex during pregnancy unless a woman is at risk for preterm labor), but the mild softening in a term mama might just be enough to tip her into labor mode.  As an added bonus, if he's, let's say, "gifted," his penis hitting against the cervix may indeed induce some mild (but not earth-shattering) uterine contractions.

Captain Obvious moment: I generally don't recommend the prostaglandin method if a mama is in a relationship where she's at risk for a sexually transmitted infection.  The last thing she needs is to be infected with an STI right before a baby comes squeezing through her vagina!  If infection is an issue, sex with a condom still contains the benefits of oxytocin and cervical pressure.  Masturbation is a safe and effective alternative for women who don't have a partner (or just simply don't want to engage in partner sex).  Again, oxytocin is stronger than prostaglandins... go team vag!

The Booze

While its use remains controversial amongst even the most alternative midwives, wine in small quantities (a glass or less) is thought to help the mother's body relax through the anxiety that often hinders the body's ability to start labor on its own.  Anxiety leads to the release of catecholamines, the "stress hormone" which interferes with the release of oxytocin.  So while the alcohol itself does not induce labor (it can, in fact, cause vasodilation, which actually hinders labor progress), a bit of wine to "take the edge off" of what ever stress a mama may be experiencing can help things along. 

The Foot Rubs

There are several pressure points in the feet and ankles that, when massaged, may induce uterine contractions.  The first is in the soft area between the achilles tendon and the medial malleolus (the "knotty" bone on the inside of the ankle).  The second is about four finger-widths above the malleolus.  Even if the massage does not actually induce contractions, a nice ankle rub may help with the ankle swelling many women experience as they get further along in pregnancy.

A midwife also once told me that the heel is a reflexology point to the cervix.  In fact, she says, you can often read how effaced (soft) a woman's cervix is by compressing her heel, and can often soften a "tough lip" by rubbing out hard points.  I have no research to back that up, just one midwife's anecdote.

And by now my May Mama has called and said that since I gave her the above information, she's been contracting steadily (but lightly) for the past little while.  So there.  Get yer freak on, doula's orders.

Moments in the Life of a Doula

Very Little Known Fact: May is International Doula Month.  2012 marks my third May as a doula, and let's just say the past few years have been nothing short of inspirational. 

I'm on call for my tenth birth.  Number ten!  Two and a half years ago I never thought I'd get here... my dedication to women's health has never been enough, and I fast learned that it's very hard to "get known" as a birth worker, especially when you've never had any babies yourself.  Still, the clients I have worked for have hired me for my presence, my energy.  And as I get more experience, more mamas are realizing that it's energy, not personal experience as a laboring person, that really matters.

Today I'm thinking about all the babies I have had the privilege to watch come into the world: Lundyn, Sara, Quinn, Aaron, Micha, Madison, Gershom, Amelia, and Sullivan.  All born to totally badass mamas with incredibly unique and wonderful birthing experiences. 

Thinking about these nine phenomenal experiences, I ran through my "stats".  Some prospective clients like to know, for example, your clients' epidural rate, though unlike your care provider's cesarean rate, a doula's epidural rate really hinges more on the way the birth progresses itself and not the actual doula.  Or so I tell myself.  But still, I'm proud of my stats.  In my nine births, I have had:

• Three boys, six girls.
• Three mamas who chose to have an epidural.
• Three mamas induced with Pitocin.
• One cesarean birth.
• Two mamas delivered at Forsyth Medical Center, one at Women's Birth and Wellness Center, and six at Women's Hospital.
• The fastest labor was an hour and a half.
• The longest was well over 20 hours.
• My favorite midwife thus far was Kate Layman, CNM at the birth center.  My least favorite was one of the faculty midwives at Women's who, fortunately, was only on for three more hours after my mama was admitted. 
• My favorite obstetrician was Dr. Grewal, my least favorite a tie between Dr. Marshall and whoever the guy was at Forsyth back in September (not worth remembering). 
• I've really loved all the nurses, but my favorite remains the pediatric nurse at Women's Hospital who helped the mama and I convince the father that circumcision has no real medical benefit.

Like any doula, I've experienced the absolute best of human love, compassion, and forgiveness simply by being there in the room.  I've heard mamas and their partners say ridiculously funny shit, sharing a good laugh between tough contractions.  I've also witnessed families make difficult decisions, seen women break down and sob when their birth plans have gone awry.  Fortunately, my birth clients have all gone on to deliver beautiful, healthy babies despite these roadblocks.  I have many favorite moments that straddle these two extremes... to name a few:

• My greatest learning moment came to me in birth number four.  The mama had been having one back-labor contraction on top of the other for a solid 90 minutes.  It had been seven hours since her last vaginal exam, at which time she was 5cm dilated.  When her contractions "stopped," I told her she was probably complete and would be feeling the urge to push soon.  After an hour of continued back pain and no urge to push, the nurse checked her and found that she was 6cm, at most.  As the baby was being born later that day (after an epidural, a nice long nap, and a marathon pushing phase), I saw that he was asyncletic.  Immediately my education flooded the forefront of my mind... it all made sense: the slow progression, the "fake" transition, the lengthy 2nd stage, even the week of prodromal labor. All textbook signs of an asyncletic presentation.  It was in this experience that I re-learned to NEVER estimate the laboring person's progress, that it's not the doula's job no matter how "clear" it seems to be at the time.
• While DONA would surely frown on this, I've been taught a few midwifery skills by midwives who needed an extra hand.  When a birth center midwife was busy stitching up a mama with a 4th degree tear, she asked me to do the fundal massage.  I'd never done it before, but she told me where to place my hand, what to do, and how hard to do it.  While it certainly went against my "doula instincts" to massage so hard, I now feel like I would be able to do hemorrhage control if I'm ever the only person present who knew how to do it.  Another midwife, during a very long 2nd stage at the hospital, gave me a refresher course in how to catch a baby if I ever had a mama deliver on the side of the road.  DONA teaches a little bit about that, but since we're really not "supposed" to do anything medical, they keep it brief.
• There's a popular one-liner amongst birth professionals about the difference between a doula and a midwife: "Midwives catch babies, doulas catch dads."  While I scoff at the obvious couple-centrism, I actually have caught a dad before.  Seeing how he was an ex-Army medic and current paramedic, no one really thought he'd have a problem with witnessing the birth.  However, the sleep deprivation, low blood sugar, and pure adrenalin of "oh my god I'm becoming a father" formed the perfect storm, and while everyone else was watching his baby crown, he was boarding the express train to the floor.  I caught him, this easily 200-pound man, inches above the ground.  Even Dr. Grewal turned from her obstetric duties to congratulate me on my quick reflexes, and hey, it bought the baby's cord some time!
• Speaking of umbilical cords, I once saw a "true knot" in one, which was awesome. The midwife and I shared a moment of "oh wow awesome!" while the new parents were admiring the new baby.  Because we're birth nerds like that.
• Some of my favorite parents have been the ones who "talk back" to care providers that aren't honoring their wishes.  At a rapid (unmedicated) birth last September, the doctor was trying to tell the woman to push when she didn't yet feel the urge.  Any decent research on an unmedicated 2nd stage will tell you this is a waste of energy, but the doctor obviously had a golf game to get to, so he continued to berate her, saying she "wasn't going to have a baby by just laying there and resting."  At this moment, she looked at him and said, "Shut the hell up, I'll push when I damn well feel like it."  Obviously the urge to push came, and within minutes she was holding her baby girl.  My favorite part about that birth was the dad talking shit about the doctor while he was on the other side of the curtain... whoops!

My favorite moments, however, are present at every single birth: the energy you can almost touch, the families being born, the immense joy in the room.  It's really indescribable, and words just cannot do justice to the experience of being present for the birth of a baby.

On another note, I also spent some time this week being the "phone doula" for a woman who was planning an abortion.  I was reminded of how similar the work is even if the outcome is obviously very different (I've discussed this before).  I gave advice, self-care suggestions, and basically was just there to listen and understand.  Without providing too much specific information about her case, I can tell her that her outlook on abortion is far different from mine.  Which is to say, she's never considered herself prochoice or "pro-life."  She was raised what she called "Super Catholic" and honestly thought she would be killing a human being.  But she was having the abortion anyway because it was her only real option.

By the end of our conversations prior to her appointment, she felt good about the choice she was making.  She had more clarity in her values, she was forgiving herself, and couldn't stop thanking me for being there for her without leading, assuming, judging, etc.

Just like at births.

I've been jokingly labeled as a "truly full-spectrum" doula by friends.  Bad Day Doula, Relationship Doula, Sleep Deprivation Doula, Headache Doula... I may end up being my mom's Hip Replacement Doula by the end of the summer.  What it comes down to isn't some certification, or even training... it comes down to who I am as a person, what I am willing to do for people, and the way I treat them.  The training informs the actions we take in response to our instincts, but someone can't simply be trained to be the kind of person a doula is.

Oh hell, I'm rambling.  I'll just let Boromir break it down for you.  Happy International Doula Month, all!!

Everything I need to know about birth, I learned from Bradley

The Bradley Method is one of the more popular childbirth education programs in the U.S.  Which is just wonderful, because Bradley has so many great lessons to teach us about the process of pregnancy and childbirth.  To name a few:

• All laboring people are heterosexual and married to a man.  Moreover, all laboring people are women.
• Your husband (what, you have one, don't you??) knows more about your process than you do.  Don't ever forget this.  
• Everything you put in your body during pregnancy makes your baby sad.
• If you utilize any medical interventions, be it an epidural or just a Foley bulb, you've failed as a woman and your body hates you.
• If you have a cesarean, you suck at life and should just go ahead and kill yourself.
• Don't listen to your HCP when she tries to give you postpartum Pitocin for excessive bleeding... she's way too medical and doesn't know anything.  
• If families really care about their birthing experience, they will find a way to shell out the big bucks for a Bradley class.  Priorities, folks.
• Teaching expectant parents about the pros and cons of medical interventions will only encourage their use.  You don't need to know how an epidural is administered... you aren't going to have one because it will kill you and your baby.
• Erythromycin is only for the babies of slutty unmarried women.  Hospitals shouldn't even mention it to married women because there is absolutely no possible way that they have gonorrhea.  Additionally, erythromycin will make you fail at breastfeeding and therefore as a person.
• The female-bodied are incapable of doing anything rad without a strong male presence overseeing their entire process.
• Miscarriage, fetal demise, and birth defects don't just "happen."  You did something wrong and should feel very, very bad for poisoning your baby like that.
• "Tough love" is the best way to ensure a woman gets the birth she hoped she'd have before labor even began.  Seriously, lock the anesthesiologist in the supply closet if you have to.  The mama is completely incapable of knowing what she wants during such a hysterical period.  (Pun totally intended.)
• Only people who support late-term abortion have amniocentesis.  How dare you would kill your baby like that.
• Even a drop of infant formula will make your child retarded.  Forget so-called "failure to thrive" and don't worry... IBCLCs are a part of the medical conspiracy and don't know shit either. 

What the doctor said, what the evidence says

This past week I attended the fastest birth I have ever (and maybe will ever) attend.  By which I mean, the mother's water broke at 7:30, and the baby arrived at 9:30.  We all got to the hospital at 9pm, and she was 8.5cm dilated.  The mother had a history of rapid labor, so this wasn't exactly a fluke.  Regardless, everyone was wonderful by the end of the night, including the mama who, while a bit shell-shocked, felt like a total rockstar for the way her body was able to work.

After a history of high-intervention preterm birth, this family was determined to have a normal birthing experience.  And normal it was, except for the sheer rapidness... of course, seeing how the labor began on its own and progressed without any medical intervention (including pain medication), it was normal.  Fast, but normal nonetheless.

The doctor, however, was not exactly an advocate for "normal birth" in many respects.  In the short 30 minutes of contact I had with him, I found him to be abrasive, paternalistic, condescending, and just plain rude.  I keep turning the story over and over in my head, and I just can't make sense of several things he said and did.

Let me be clear: this is not just some sort of wingnutty vendetta by some conspiracy theorist doula (see previous post).  My philosophy of birth is based in sound, evidence-based research.  I respect anyone who provides care according to the research, be they midwives, obstetricians, lactation consultants, nurses, doulas, or educators.  This isn't me railing against the obstetrical field just because some guy was mean to my client... this doctor displayed a clear disrespect for the evidence-based practices from which positive birthing outcomes have shown to come.

His major offenses are as follows.

1) Physician-Directed Pushing

What happened: 
The mother was completely dilated minutes after I arrived in her delivery room.  However, she did not feel an urge to push right away.  This did not stop the doctor from trying to speed things up.  Once he found her to be complete, he immediately started telling her to bear down and "hold it for 10 seconds."  The mother said she did not feel the urge to push yet, so she was going to rest.  The doctor's response was, and I quote, "Honey, you're not going to have a baby by just lying there and resting."

What the evidence says: 
Once the cervix is completely dilated, the baby's head drops into the the birth canal.  During this time, the uterus must "re-form" over the baby's buttocks.  This can take up to 1 hour, though it generally takes about 20-30 minutes.  This has been fondly named the "rest and be thankful" phase of labor.

A woman who has not had an epidural will get a strong urge to push, called the Ferguson reflex, when the uterus has completely clamped down and is ready to help her deliver her baby.  There is much research to suggest, in fact, that pushing before the urge is completely pointless; all the mother is doing is wasting much-needed energy.  This is so true, in fact, that many caregivers will advise a woman who has had an epidural to "labor down" for at least 30 minutes (rest and wait) before they begin pushing.

So really, the doctor was completely wrong... she was going to have a baby by sitting there and resting.  In fact, she was doing her body a favor. 

2) The Friggin' Lithotomy Position

What happened: 
When mama was finally ready to push, the doctor immediately began placing her legs into stirrups.  This, to me, seems like a major violation.  To place a woman's body into such a position without asking first, well, that's just wrong.  The mama cried out, "NO!!!" and quickly moved her legs back to a place that was comfortable for her.  Her husband then explained that she hadn't wanted to give birth in this position.  The doctor visibly rolled his eyes and said, "I can't deliver a baby when your legs are shut!"


What the evidence says:
Here's a "duh" moment for you: the human body is capable of a number of different positions! {gasp!}  There's really no reason to think that a laboring woman's legs can only be either in stirrups or completely shut.

In fact, lying flat on your back with the legs in stirrups increases your likelihood of tearing and decreases the elasticity of the perineum by 30%. Our Bodies, Ourselves declares this position "the single most dangerous position" for childbirth.

3) Immediate Cord Clamping

What happened:
It was the parents' wish to wait to cut the cord until it has stopped pulsating.  This is not common practice with obstetricians, though it is usually done with midwife-assisted birth.  Seconds after the baby girl was born, the obstetrician reached for the clamps.  The husband, keeping a close eye on the doctor's every move, asked, "Has it stopped pulsating?"  The doctor looked at him with a condescending glance and said, "Yeah... sure."

What the evidence says:
More and more parents are asking their care providers to delay cord clamping, and with good reason: immediately following birth, the remaining blood retained in the placenta rushes into the newborn infant.  To immediately clamp off the cord is to waste a boost of high-nutrient cord blood that could very well benefit the newborn.

The umbilical cord will usually stop pulsating on its own in about 2-3 minutes, during which time the newborn can receive up to 25% more blood than an infant whose cord was clamped within the first minute of life.  This boost has been associated, in healthy full-term infants, with higher APGAR scores, higher red blood cell counts through the third month of life, and decreased iron deficiency during the first year of life.  In preterm infants (>37 weeks gestational age), delayed cord clamping is associated with decreased risk of late-onset sepsis and better health outcomes overall. 

Why is this not a more common practice amongst American obstetricians?  Their midwife counterparts usually wait at least 2 minutes, and obstetricians in European nations delay clamping as well.  The only known risk is hyperbilirubinemia (jaundice), but such a condition generally resolves itself with early breastfeeding.

The only explanation I can come up with is that delayed cord clamping takes time, and when you're in a hospital labor and delivery unit, time is always against you.  The wam-bam-congratulations-ma'am mentality leaves countless women feeling like they are being worked through a machine instead of experiencing a joyous, empowering occasion that they can feel good about.  Such a mentality also explains why the doctor didn't want to wait for the mama to feel the urge to push.

Of course, the medical field in general just doesn't jive with the process of childbirth.  Childbirth is unpredictable, and doctors don't like unpredictable.  Hence we've seen an alarming rise in the induction rate... an alarming (and unnatural) percentage of babies being born Monday-Friday, 9am-4pm.  While medical science has indeed saved countless lives in managing births that have become problematic, normal birth should be left to take its own course.  Care providers who work with laboring folks need to take a breath and slow. It. Down.

“The woman’s body is smarter than the doctor. Time, patience, and the baby will come. Respect the woman’s rhythm."  -Dr. George Tiller

Birthing Against the Grain

 The following was originally posted at ChoiceUSA's Choice Words blog.

--------------------------------------------------

CNN featured a story today about Aneka, a woman who recently gave birth to her fourth child, vaginally and at home, after previously enduring three cesarean births. Apparently her obstetrician had told her that her pelvis was "too small" to deliver vaginally, and, after her first cesarean, she continued birthing surgically because she was told that was what she had to do.

For her forth child, the obstetrician scheduled a cesarean, but Aneka never showed. Since seven months gestation, she had been researching vaginal birth after cesarean, or VBAC. And, due to her area's hospitals not supporting VBACs and her doctor's suggestion for yet another cesarean, Aneka chose to give birth at home under the care of a midwife. The birth resulted in a healthy 9 pound baby, born vaginally after only four minutes of pushing.  (Small pelvis my ass.)

CNN offers dueling perspectives on the matter: some in the medical establishment believe Aneka's actions were "irresponsible" and dangerous, while birth advocates applaud her as a hero of the birth movement.

The home birth vs. hospital birth, VBAC vs. repeat cesarean debate is ongoing, with more and more evidence surfacing to suggest that a) home birth is as safe as hospital birth, assuming the woman does not experience major complications and is under the care of a midwife, and b) attempting a VBAC is safer than repeat cesarean, which is a major abdominal surgery that lengthens recovery time and often acts as an affront to breastfeeding.

But what concerns me about this story most is not the fact that this woman couldn't be better supported in her choices, or that she had to endure three cesareans before she found out that her body could give birth on its own, or even that it paints home birth as more dangerous than it is. What concerns me most is the public opinion surrounding Aneka's situation as evidenced by the article's comments. From the peanut gallery:

"Wow, talk about stupid. She got lucky, it really wouldn't have hurt her to go and have that c-section just to be safe. Well, I guess it's her decision. I'm just happy the baby didn't die because of her risk taking."

"I love the 'it's a woman's choice' line of thinking. What about the father (husband or not)? What about the baby?"

"This woman is a fool!"

"Who was she more concerned about, herself and her 'birth experience', or the risks to her baby?"

Never mind that this particular woman's birthing experience ended positively, or that most home birth experiences end that same way. No, Aneka was defiant and therefore is an idiot. She's irresponsible. She "could have" endangered her child's life by not listening to the doctor. In other words, women should do what they're told with their bodies, and besides, women need to stop thinking about what they want and just think about the baby (sound familiar?).

Even more troubling, many of the comments don't focus on stupidity; they focus, not surprisingly, on the number of children this Black woman has:

"I just hope she stops feeding her need to breed! Plus, she was really stupid."

"YOU HAVE 4 ALREADY! FIND THE OFF BUTTON! AND ALL YOU IDIOTS CRYING ABOUT MEXICANS AND THEIR KIDS, LOOK RIGHT HERE! THIS IS WHATS TRULY WRONG IN THIS COUNTRY TODAY, NOBODY NEEDS 5, 6 , 7 KIDS, THTS [sic] JUST NUTS...."

"Newsflash: She's an entitled black person."

So, in conclusion:

• A woman who makes an informed decision to switch to the care of a midwife after her scalpel-happy OB pushes cesarean surgery is "defiant."
• It's irresponsible to worry about having positive birthing experiences; all that matters is that the baby gets out alive.
  
• Women should never, ever have more children than the public thinks you should have, especially women of color.

My Complex Relationship with ACOG

ACOG is once again throwing its weight around on home birth, this time using shocking yet  largely meaningless language to scare women from making informed decisions about birthing options.

An ACOG position statement claims home birth "triples the neonatal death rate" and accuses home birthing women of "plac[ing] the process of giving birth over the goal of having a healthy baby."  This statement in and of itself is problematic, as surely you'd think a highly respected organization of doctors realize that processes usually dictate outcomes.  A home birthing woman who is under the care of an experienced medical professional (a midwife) is likely to experience a low intervention birth in the comfort of her home.  Because childbirth is a natural process as old as time itself, our bodies are fully capable of creating, growing, and delivering new live into the world.  In most cases, this process is going to happen on its own, and the results are going to be healthy.

Which is not to say I don't see the place of medical science in prenatal and neonatal care.  Complications arise, and it is important for home birthing women to be able to make informed decisions about when home birth is and is not a healthy option.  Additionally, the midwife needs to be able to step in and suggest a transfer when she feels the situation has gone beyond her ability.  When these complications arise, whether they're in the prenatal or neonatal period, we are fortunate enough to live in a society that can handle the problem and work diligently towards good outcomes for both mom and baby.  (Though, our track record on this isn't as good as it should be, nor is it up to par with the rest of the developed world, but that's another post.)

However, a culture that assumes there will be problems and therefore micromanages the entire process from start to finish is outright harmful to women, their babies, and their birthing experiences.  Additionally, many of these routine interventions cause more problems than they prevent, and if they weren't being carried out solely in a hospital environment, I guarantee we'd see higher neonatal mortality rates associated with them as well.  I could go on and on, but I'll let The Business Of Being Born explain:



But getting back to the statement by ACOG.  All of my work around debunking myths perpetuated by the anti-abortion camp (strangely enough with much information via ACOG) has taught me the difference between relative risk and actual risk.  When the antis say abortion increases your odds of developing breast cancer by 50%, they're talking about relative risk.  When they say the Pill increases your chances of experiencing heart attack or stroke by 50%, they're talking about relative risk.  And all of their research is coming from meta-analysis, a method of data interpretation which is not appropriate for determining cause and effect. 

ACOG knows this, but it doesn't stop them from utilizing the very same tactics as the antis, though ACOG's enemy is home birth.  Their expert statements on the purported abortion-breast cancer link debunks the claims of anti-choice researchers by specifically stating that meta-analysis is not appropriate in determining cause and effect, and relative risk is not basis for overtly issuing scare-tactics disguised as medical research.  And yet they turn right around and use research they know to be flawed in order to demonize home birth.

The American College of Nurse-Midwives issued this statement in response to ACOG's claims regarding home birth: "We are puzzled by the authors’ inclusion of older studies and studies that have been discredited because they did not sufficiently distinguish between planned and unplanned home births — a critical factor in predicting outcomes."  ACOG's language in and of itself is meant to skew the reality of home birth risk.  When they say the neonatal death rate is tripled, they are discussing a relative risk.  From Medscape writer Andrew Vickers:

In place of a "tripling in death rate," the more informative statistic is the absolute increase in neonatal death associated with home birth. On the basis of the results tables, it is possible to calculate that this turns out to be 1 neonatal death per 1000 women who choose home birth. However, the results tables show that those women would also experience some benefits, including 40 fewer premature labors, 45 fewer cesarean sections, 140 fewer vaginal lacerations, and 140 fewer epidurals.

Vickers goes on to say that, truly, weighing the cost-benefit ratio between infant mortality and maternal morbidity can seem, well, dark.  But it's something each and every pregnant family does every day when choosing birthing options, deciding on a care provider, creating a birth plan, and making decisions about where and how they will bring their children into the world.  Every obstetrician does this, too, when faced with a prenatal patient who is experiencing a complication.  Maybe that's the issue ACOG is having with home birth, that it becomes far more the family and not the doctor who is in charge. 

The reality is that birth is normal, and in the case of many women, home birth is an option that can be as healthy (if not moreso) than entering into a high-intervention hospital system where their bodies will be micromanaged.  It is up to each woman and her family, not ACOG or the government, to make informed decisions about their birthing options, and they need to be able to readily find information that is evidence-based, unbiased, and accessible.  Shock-doctrine headlines like "Home Birth Triples Neonatal Death Rate" is not any of the above.

P.S. How offensive is it for ACOG to charge that women only choose home birth because it's "trendy" and in-vogue??