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.

That moment when you learn your client's doc is a flaming antichoicer...

I have a client due in a couple of months who is under the care of an obstetrician I've yet to meet. I asked the mama-to-be a few simple questions about his philosophy, how she's felt about her care thus far, etc. But of course I like to do my own research so I know what to expect when the day arrives.

So I found the Facebook page of this doctor's medical practice. The first thing I noticed was that it's affiliated with a large, multi-state health care network that runs a few hospitals and many physician-led practices. But then I noted a prevalence of anti-abortion, anti-contraception, and even anti-LGBTIQ links. (Because having a position on gay marriage so relates to the process of pregnancy and childbirth.) Overall, I'm thinking at this point that this is highly unprofessional. Divisive social issues have no place on the professional page of a medical practice.

The furthest I go on my doula business' page is promote myself as someone who is inclusive regardless of family structure, is experienced in supporting families through all kinds of loss, and believes that quality health care is a human right. These are the least divisive ways I can think to pen it. But it translates broadly without me taking a clear and divisive position on the issues: an LGBTIQ person or a family with a non-traditional structure will know that I will respect them and want to work with them. A person who's choosing to terminate as well as a person who will experience unintended loss will know I can support them as well. There is such a thing as marketing yourself towards certain types of people without taking divisive hard-line positions on things.

And I think I'm pretty good at it. I've had doula clients tell me straight up that they are personally against abortion. Since they were planning a birth, it wasn't an issue, even when they knew I had a different view. And we worked well together with compassion and respect. I don't hide the fact that I'm pro-choice and inclusive of all individuals and family structures; my philosophy has always been that if my sociopolitical beliefs are going to turn you off from me, there's probably also some personality traits that will make me a bad fit, and I am not the right doula for you. But that doesn't mean I flaunt my beliefs to countless families that might be looking for someone to support them through the birth of their child, especially when it's completely irrelevant to their situation.

Let me say this: he's open about it, and I respect that. And honestly, he's free to run his practice in whatever way he pleases. But the affiliation with one of our state's largest, secular health care networks... that is what's getting to me.

That and the privilege. OH THE PRIVILEGE. That someone can publicize their views on the most divisive social issues all over their business page and not have to worry about it hurting their business is the definition of privilege. Like the small businesses - landscaping, towing, etc - that have Jesus fish on their logos. Can you imagine what would happen if a business put the Muslim star and crescent on their marketing materials? Forget losing customers, in some areas their business would be viciously attacked, verbally or worse.

Whatever. He'll be the guy at the foot of the bed, catching my client's baby. He's a supporter of natural childbirth, and hell, he's the one that pushed her to consider a doula in the first place. I can get past his publicly-stated conservative views so long as he treats her with respect and honors her wishes. I'm not there for him, I'm there for her.

Newsflash: It's Not Unusual To Measure Pregnancy From Two Weeks Prior To Conception

The following is a cross-post from RHRealityCheck.org
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Dear Everyone,
Please stop referring to Arizona's new abortion ban as the "Pregnancy Begins Two Weeks Before Conception Act."  It's an ill-informed statement and makes us all look like we don't know what we're talking about.  Plus, it focuses on the wrong aspects of the bill.

First of all, from a health care standpoint, pregnancy is nearly always measured from two weeks prior to when implantation (the physiological beginning of pregnancy) actually occurs.  All clinicians - doctors, midwives, the good folks at your local Planned Parenthood - measure pregnancy not from how long a person has actually been pregnant, but from their last menstrual period (LMP), which falls about two weeks prior to implantation.  This is partly because we don't always know exactly when a person actually became pregnant, but mostly because it's far more accurate to measure a person's unique gestation rate by her cycle. 

In other words, if I was pregnant and had my last menstrual period on July 23, I would be classified as "six weeks pregnant" even though I've probably only been pregnant for about four.  This is not unusual, and all clinics that provide abortions measure your pregnancy this way.

Now, let's instead focus on the real problems with this bill.  The ban on abortions after the 20th week LMP (18 weeks gestation, for those of you playing along at home) is an arbitrary marker backed up by the idea that fetuses feel pain after this point (there in fact is no evidence to support this claim).  My own state of North Carolina has had this ban in place for years, as do Alabama, Louisiana, Kansas, Idaho, Indiana, Nebraska, and Oklahoma. The Arizona bill also requires women to have an ultrasound 24 hours to having an abortion, requires clinics that provide abortions to be held to higher standards than most other outpatient surgical facilities, and states that providers must have admitting privileges in local hospitals (again not something that is generally required of practitioners operating in other kinds of outpatient surgical centers).  In other words, the Arizona bill is a major attack on abortion access, not just a bill that challenges our understanding of gestational measurement.

So really, instead of calling it the "Pregnancy Begins Two Weeks Before Conception Act," I'd like to suggest the following alternatives:

• The "Let's All Use Bunk Science To Legislate When A Fetus Feels Pain" Act
• The "Arbitrary Guidelines On Gestational Restrictions For Abortion" Act
• The "Women Are Incapable Of Making Their Own Decisions" Act
• The "State-Sanctioned Rape" Act (to borrow from the Virginia bill passed earlier this year)
• The "Let's Place So Many Restrictions On Who Can Provide Abortions That No One Can" Act

The above suggestions don't necessarily roll off the tongue, and to be sure they don't make for decent soundbites either.  But they would keep this whole mess from becoming known as the "Pro-Choice People Don't Know Anything About Pregnancy" debacle. 

Your Friendly Full-Spectrum Doula,
Lauren

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.

A Matter of Context

Trigger Warning: pregnancy loss

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

I believe I'm going to remember last week as the week of miscarriages.  Really, though, it was just the two.

The first was good news, the second not so much.  The two together provided a stark reminder that the emotions surrounding pregnancy loss are completely relative. 

The first happened to a woman who had contacted Spectrum.  She had become pregnant accidentally and had scheduled an abortion procedure around 5 or 6 weeks LMP.  Having been raised what she called "Uber-Catholic," having an abortion was, to her, the killing of a human being.  But she had no choice.  You hear this scenario played out pretty often when you work with people experiencing pregnancy loss.  Intellectually, the embryo is just that: an embryo.  But when you're supporting a person who has been raised in a certain faith or ideology, there's always this deep-seeded idea that they will be killing a human being.  What the general public needs to know is that, most times, they will still have the abortion.  No amount of belief that the embryo is human, no amount of guilt or shame they feel from their childhood upbringing, and no state-mandated scare tactics can sway them from that choice.  They will terminate the pregnancy.  The difference is, they will have more emotional trouble dealing with it.  That's where I come in.

I spent a number of hours speaking on the phone with this woman over the course of a week.  She came to trust me as a truly non-judgmental ear that didn't shame her for choosing abortion but also wouldn't correct her when she said "baby" or "kill."  She became fixated on the idea that she would feel better about the whole situation if she experienced a spontaneous abortion (the medical term for miscarriage) instead of having it induced.  I don't know whether or not she did something to herself to self-terminate (she mentioned having read the parsley + vitamin C "trick" on the internet), but regardless, she did indeed end up having a miscarriage.  The news came from her voice with absolute joy.  She truly felt like the Universe, God, or what have you worked with her to bring about the event, and in the end she was able to have the kind of pregnancy loss she could not only deal with, but be happy about.

The second miscarriage of last week happened, sadly, to one of my birth clients.  She was 18 weeks pregnant, and without sharing too much of her personal information here, I can tell you that this event was earth-shattering for her and her family.  After hearing the news, I spent the better part of the next couple of days in a kind of withdrawn daze.  The pain she must have been experiencing was unimaginable to me.  After all, 18 weeks is pretty far along: you've become attached to the idea of having a baby.  You may have even thought up some names, or even started to buy clothes.  You've already told everyone that you're pregnant.  As if the loss itself isn't enough to deal with, the fetus and other products of conception are not likely to pass on their own, meaning you'll possibly need a D&C and/or labor induction.  Your pregnancy - once this enigmatic idea of a baby - actually looks like a baby at this point... a very small baby, but a baby nonetheless. Worse still, losing a pregnancy after 16 weeks means your milk is likely to come in once your progesterone levels drop.  In other words, full breasts and empty arms.  It's really more than I care to imagine.

I have heard (mostly young) pro-choice folks scoff at the notion of having a memorial for a miscarried embryo or fetus.  Hell, I might have done it myself in my teen years; after all, if a fetus is not a baby, then you didn't lose a baby.  But listen to enough people who have lost wanted pregnancies - whether to miscarriage, stillbirth, anomaly, etc - and your opinions mature astronomically.  They are no longer as black-and-white as they were when you were a red-faced college freshman shouting at antichoice protestors in front of your local Planned Parenthood, and while you remain as staunchly pro-choice as ever, the entire idea of pregnancy loss is tangled up in a billion shades of gray. 

That's really why "the abortion war" is so damn polarizing.  Social issues are best understood and dealt with when they can be easily boiled down to a black-and-white dichotomy.  But really, no social issue whatsoever can be simplified to that end.  We try, but we fail, and in our wake we do a grave disservice to those most affected by that issue.

The antichoice camp is able to rally huge amounts of support simply because their side really does take the black-and-white approach: their arguments are one-liners and emotion-grabbing images, and they make great headlines.  The prochoice movement fails by merely trying to echo these tactics.  Our arguments are full of holes when restricted to the same style of one-liners and headlines, easily refuted when we don't get into the complexities of pregnancy and women's lives.  Our messages will not be received if we merely keep screaming them louder and louder, and we will not ever attain true reproductive justice until we begin to acknowledge that all pregnancy outcomes - birth, abortion, miscarriage, stillbirth - mean nothing without the context that surrounds them.

Just look at my two clients... one had a miscarriage, and it was wonderful.  The other had a miscarriage, and it was the worst thing possible.

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

Your Doula Training: The Cast of Characters

Note: The following blog entry is an intentionally irreverent parody of doula stereotypes.  While it is true that several characters depicted below were inspired directly by women in my doula trainings, any likeness to anyone in particular is purely coincidental.  

That being said, let's reinforce some stereotypes!!
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So you're becoming a doula! 

You've probably already decided that your personae fits within your understanding of what a doula is.  Understandable, that's what I thought as well.  Until I attended my first training.  It was then I realized that "the doula personae" is not always what you think.  In fact, there are many kinds of people (highly different from one another, as you'll find) who believe they also embody these qualities.  You might experience some serious cognitive dissonance when you meet them.  How could you be the same kind of person as her?!  Are you really that crunchy/grandmotherly/opinionated/touchy-feely? 

Don't panic.  You're probably not very much like most of them.  There are maybe hundreds of pregnant folks in your area, and they probably each have a very unique perspective on what a doula is.  That's why families interview more than one of us... heaven forbid a conservative religious woman ends up with a transgendered anarcho-feminist, or vice-versa. 

You will notice, however, that there are definite patterns in the personae of aspiring doulas, each with their own unique perspective on birth, women, and life in general.  Let's take a quick tour of the major ones, shall we?


The Experienced Mama

If her mismatched, spit-up-stained attire didn't give her away, her advanced insight into the birth process most definitely did.  The Experienced Mama is the one who has had a number of varying birth experiences.  She can speak from experience on induction, c-section, VBAC, and natural birth.  She has probably taken a variety of childbirth classes, and who knows, may be on track to becoming a childbirth educator herself.  When it comes to breastfeeding, she's experienced it all, and probably is still nursing her youngest child.  A kind, sisterly woman in her 30s, The Experienced Mama will score big on the relatability factor when she starts going to interviews.


The Religious One

You picked her out the moment she drove up in her full-sized van covered in pro-life bumper stickers.  She's not just religious; she's an unapologetic fundamentalist.  Like The Experienced Mama, The Religious One has had a variety of birth experiences... how could she not, she has 10 kids!  Of course, unlike The Experienced Mama, her birth experiences are likely to be recounted with vaguely-relative Bible passages.

Here's a woman who believes in "keeping her womb open to the will of God."  Meaning, she does not use any form of birth control (including FAM), believing that God will decide how many children she will have.  She pipes in rather often, decrying the modern age as a force that has made women forget "what their bodies were made for."  Her clinging to "the way God intended it to be" rubs the majority of the room the wrong way regardless of religious affiliation.  Look for an entertaining spat between The Religious One and The Rabid Feminist during lunch.

The Rabid Feminist

She made her entrance donning a tank top that read "FUCK PATRIARCHY." Between that and the vulva pendant hanging around her neck, The Rabid Feminist doesn't hide why she's interested in becoming a doula.

She probably has a history as a pro-choice activist or a clinic escort.  She is fascinated by the process of childbirth, the strength of laboring women, and finds it all to be political in nature.  She drives the group slightly bonkers with her constant correction of "the generic he" and her many off-kilter remarks about how not all pregnant folks identify as women.  Despite her fierce attitude, she seems rather taken with The Natural.

The Natural

Here's a woman who, before the training even begins, seems to radiate doula.  We're always told that being a doula is more about presence than experience, and in this person's case we believe it.  She has probably never attended a birth before, and while she knows childbirth basics, she in no way possesses any more trainable doula skills than any other person in the room.

The Natural has a voice that immediately calms.  It's quiet while being firm, reassuring and instantly relaxing.  When she speaks, shoulders around the room drop an inch.  Her face naturally rests in a pleasant expression, even if she is not physically smiling.  In her other life, she is probably a Reiki practitioner or a clinical herbalist.  She's adorned in loose-fitting, neutral toned garments and several pieces of under-stated turquoise jewelry.  Look for The Natural purchasing bulk herbs in your local organic co-op.

The "At My Birth, We..."

The one thing that brings the whole group together, aside from the desire to be doulas, is the growing disdain for The "At My Birth, We..."

While she means well, this is a person who can't seem to stop relating every single topic back to her own experience.  It seems literally anything said by the trainer or fellow participants can be related back to The "At My Birth, We..."  Discussing epidurals?  She thought about having one of those, but by the time the anesthesiologist got there the baby was already born.  The double-hip squeeze?  Her husband did that, and it helped for a little while but not during transition.  Turkey sandwiches for lunch?  She had one of those after the birth of her 1st child, but after the 2nd she'd had roast beef. By the end of the training, the entire group could write whole volumes on this woman's birthing experiences.

She might be the same person as The Experienced Mama.


The Conspiracy Theorist

The entire medical establishment is out to get you.  At least, that's the case if you believe The Conspiracy Theorist.

Having no medical experience herself, The Conspiracy Theorist "knows in her heart" (or possibly read somewhere on the internet) that inductions and c-sections are never actually necessary.  She pipes into the discussion rather infrequently, but every time she does, her remarks raise eyebrows around the room.  "Did you know that the postpartum eye goop has been shown to cause blindness in rats?"  "Did you know vaccines contain a chemical that brainwashes children?"  "Did you know that school lunches contain tracking devices so that the government can keep an eye on you at all times?"

The Conspiracy Theorist is the only person in the room who scoffs when the trainer discusses car seat laws and will likely be the same person who gets all doulas banned from the area hospital. 

The Traumatized

The uncontested heartbreaker of the group, The Traumatized has experienced the worst that the field of obstetrics has to offer.  Maybe she was uneducated and timidly agreed to an unnecessary induction.  Maybe she had care providers who wouldn't inform her about what was going on.  Maybe she had her first baby young, or maybe she had endured a c-section after the epidural had worn off.

Whatever it was, The Traumatized brings tears to everyone's eyes when she gently recounts her birth experience.  Her impetus for becoming a doula rests primarily in her mission to ensure no woman ever has to endure what she endured.  Or maybe she later had a beautiful birth experience with a doula and wants to share that with the world.  The Traumatized can speak to the cascade of interventions with tears in her eyes, though as a survivor she in and of herself is a healer.  She may inadvertently add fuel to the flames burning within both The Rabid Feminist and The Conspiracy Theorist.  



The Bored Housewife

This week, she wants to be a doula.  Two months from now, she might be enrolling in karate classes. The year prior, she briefly considered selling Mary Kay.

The Bored Housewife probably suffers from "Empty Nest Syndrome."  Her entire adult career has centered around being a wife and mother, and now that the kids have left the nest and her wealthy husband spends most of his days on the links, she needs to find a new cause to keep herself active.  She's sincere about her passion, but she lacks the motivation to move forward with it.  Or maybe she does and becomes the best doula ever.  Only time will tell.


The Birth Junkie

Some people jump out of airplanes.  Others shoot up heroin.  This woman gets her fix attending births.

The Birth Junkie is nothing if not passionate.  She will go on to love and connect with every mother she works with, but let's face it... at the end of the day, the reward is in the crowning.  Such an adrenalin rush lasts her several days, at which point she collapses on her bed awaiting her next client's call.  Though she may be older, The Birth Junkie never seems to get tired of the work.  Younger doulas look up to her and regard her energy as nothing short of awesome.  Her only downfall is that she tends to relive her own birth experiences vicariously through her clients.

She may be the same person as The Professional Grandmother.

The Retired Nurse

In her years of working labor and delivery, this woman has seen it all. If the doula trainer cannot answer a question about the physiology of childbirth, bet your bottom The Retired Nurse can.

She worked as a L&D nurse for a while, but the long hours and hospital wear-and-tear finally got to her.  With her nursing career behind her, The Retired Nurse is excited to be responsible for only one laboring family at a time, and better yet, she doesn't have to subject women to vaginal exams ever again!  As an added bonus, she already knows all the area's midwives and obstetricians.  Her pitfall will be her impulse to adjust fetal monitors or do a quick blood pressure check during labor, but overall, you can count on this one to be a champion doula.


The Professional Grandmother
Your first conversation with her ended with you thinking, "Well isn't she nice!"  That's her inner doula already shining through.  The Professional Grandmother is what you'd consider to be a "motherly doula."  Her kids are all grown and maybe have even had the privilege of having her at their own births.  Women will hire The Professional Grandmother first and foremost because she reminds them of their own mother (without all the maternal baggage, of course).

The Follow-Up

Today I received a birth announcement from a mama whose birth I attended last month.  It was such a beautiful card, featuring two pictures of the adorable baby girl that I had been privileged to see enter the world just six weeks earlier.  I am on call for another birth now, and have been for almost two weeks.  I hate being on call.  There is something about my mind that is never quite settled, and every on call session, I start to wonder why on earth I chose this path.

Then, of course, the mama goes into labor and I get to watch it all over again: a woman's inner strength shining through her as she brings into the world a new tiny lifeform.  There's blood.  There's sweat.  There's usually some tears.  It's amazing, and each time I kick myself for questioning my love for this work, no matter how fleeting the thought was. 

My favorite thing, honestly, is running into the family at a later date.  Sometimes they contact you with an accompanying photo, the baby that had been a mere six pounds now pulling up and taking practice steps.  Sometimes you just run into each other in the grocery store or at a yoga class.  It's all wonderful, and such a great feeling to know that they thought of you as an important part of their birth experience.

Last month I also supported a woman through an abortion.  Since we are not yet ok'ed by the clinic, I can't say I was her "doula," but I did my best with what I had: we had several conversations over the phone, I drove her to the clinic, I held her hand as she completed her paperwork, and after it was over, I drove her back home and left her with self-care instructions to go along with the instructions she had received at the clinic. 

This was a very wanted abortion, at least as wanted as it could be considering its need arose from a very unwanted pregnancy.  It was not sought due to financial restrictions, fetal anomoly, or an abusive relationship.  This woman had simply become pregnant accidentally.  She was young and not ready to be a mother.  By the time we left the clinic, all the anxiety I had read in her voice in the days prior were gone.  We barely even talked about the abortion on the half-hour drive back to town, except that she had used the breathing techniques I suggested and they worked really well.  We talked about what she was studying in college, how she was hoping to feel upbeat enough to go to a party that evening, and how she was planning on spending her summer break.  Back at her house, she hugged me and thanked me for being there for her, and I told her to give us a ring if she needed to talk about anything later on.  I haven't heard from her since.

The difference between birth doula'ing and abortion doula'ing may seem immense, but it's really the same kind of work.  You discuss options, make sure the person you're supporting can make informed decisions, support them through whatever decision they make, and are there for them every step of the way (except during the abortion procedure, for security reasons).  The major difference is, obviously, the outcome.  I could sit down and write an email to any one of my birth clients, and I'm sure I would later recieve not only an update, but a link to a Picasa album as well.  When I emailed my abortion patient the next day, just to see how she was feeling, I never heard back.  Which is fine.  And I'm sure if I did run into her at the grocery store, we would chat and things would be cheerful.  But of course, there would be very little ooh-ing and awe-ing over how not pregnant she was the way I would ooh and awe over my birth clients' babies ("Oh, he's gotten so big!"  "Oh wow, you look great!" etc). 

This makes abortion doula work rewarding in a completely different way.  At the end of the day, you don't get announcements in the mail about how not-pregnant your client is.  They don't send you pictures of their flat belly or write you telling you how not being pregnant is going for them.  From what more experienced abortion doulas have told me, you usually don't hear anything from them ever again.  Statistically, you're not even likely to get a request for a post-abortion resource. 

When you're supporting someone through an abortion, the moment that you actually connect is very fleeting.  But that's really the beauty of it.  My abortion patient told me that she was happy I was able to drive her, because her friends would have had expectations of how she should act/feel/react.  I, on the other hand, had no expectations for her: to her, I was a kind stranger with a good ear.  What I was for her was exactly what she needed, and I suppose that in and of itself is plenty for me. 

The Run Around

The collective was formed, the funds raised, and the training scheduled.  All the Spectrum Doula Collective needed, then, was a clinic to work in. 

There enlies the problem.  Although there are many abortion providers in the central-NC area, very few are willing to open their doors to our version of doula support.  One clinic manager in particular told one of our members that they "don't bring in outsiders to do [their] jobs." 

I cannot get upset by the obvious anxiety clinic workers feel when approached by someone who is, let's face it, an outsider.  Decades of threats, picketing, harassment, vandalism, anthrax attacks, bombings, arson, and shootings have shaped the way the American abortion clinic has to operate by necessity.  They can't just open up their doors to each request for volunteers: to do so could very well open a clinic up to all kinds of infiltration, breach of client confidentiality, or worse.  It makes sense that medical care providers in general would be uneasy about perfect strangers entering their most confidential areas, and the nature of abortion itself compounds these worries astronomically. 

However, I can't shake this idea that the abortion doula would be "doing the jobs" of clinic workers.  This is something that birth doulas have to face when working in a hospital environment.  Though my personal experience working with hospital staff has been overwhelmingly positive, there is a kind of unresolved idea that doulas accompany women who don't believe they would otherwise be taken care of.  Some labor and delivery nurses harbor contempt for the doula, as if the doula is there to "correct" whatever care the nurse is there to provide.  Though the duties of the labor and delivery nurse are completely out of the doula's scope of practice, this remains one of the most common myths about doulas.  (This is not to say there aren't some "bad eggs" out there who mess with the Pitocin drip, adjust and read fetal heart monitors, even perform vaginal exams!  This is indeed not the job of the doula, and any doula who performs such a task indeed be censured by her certifying organization.)

There's something to be said for the fact that both clinics that have seemed receptive to our project proposal are manged by those with a history in labor and delivery.  These are people who have worked with doulas before, and they have both had good things to say about the profession.  If only they could let their colleagues in other clinics know what we do and do not do!

Even if we did make it abundantly clear what the abortion doula does and does not do, however, I believe we would still be getting some amount of push-back from clinicians.  After all, what are we implying by offering emotional support to their clients?  Are we saying they don't do enough of it themselves?  Are we charging them with being unsympathetic?  Most of all, are we co-opting the belief of the anti-choice camp that abortion will always be an emotionally-trying experience??

Granted nothing is further from the truth.  Our core values state that we respect and value the protection of clinics and their staff members.  We have not (and will not) ever suggest that any clinic has failed to provide quality care to its patients without witnessing it firsthand.  However, even the woman who is most confident in the abilities of her obstetrician/midwife and nursing staff might desire the non-medical support of a birth doula.  Such would not be an indictment of her care provider's failure; on the contrary, this woman might simply desire something that doctors, midwives, and nurses are either not trained or unable to provide.  This is hardly a charge of neglect or bad health care: many families see birth as a process that, while decidedly medical in some respects, can run more smoothly when a trained support person accompanies the entire labor period. 

I hope we can convey to our community's clinics that volunteer abortion doulas can enhance, not replace, the care given by providers and staff members.  It truly takes a spectrum of expertise to work with the average abortion patient: there's the first contact, the options counselor, the nurses, the doctor, and anyone who provides comfort and after-care instructions in recovery.  Adding a volunteer who is specifically trained to provide support and nothing but support can only enhance the work provided by the team of clinicians.  Additionally, the unfortunate fact that many clinics in this country are under-staffed and over-worked means that the average clinic worker can only provide so much support to each individual patient.  This is not a charge of their ability to provide such support, however; it is a charge against those who have made one of the most common surgical procedures performed in the U.S. into an event riddled with silence, stigma, and shame.  And I guess really, that's the whole problem.

The Holidays and "None of Your Damn Business"

I'm a member of an online forum for doulas.  Recently, a woman posted about a scenario she and her family are dealing with and wanted advice.

Here's the deal: she and her husband have been trying to get pregnant for two years now.  They've tried everything short of IVF, which they are against for personal and moral reasons.  In the past year, she has become pregnant twice, only to miscarry at 5 weeks and again at 11 weeks.  All of her siblings (I think she has three sisters) have kids, and they always have the whole extended family gathered on Thanksgiving and Christmas.

A few weeks ago, during the family's Thanksgiving party, a number of older relatives asked her, "Now when are you two going to have a baby?"  It became so persistent that she had to excuse herself for the bulk of the afternoon.  None of the family knew she had been trying and having miscarriages.  It was so heart-breaking for her and her husband that they are considering not even joining the family this Christmas.

Now I can see a number of people thinking she's being overly-sensitive, or that we can't fault her family for upsetting her, as they didn't know about her difficulty getting and staying pregnant.  However, being the kind of person who believes that there's no right or wrong way to feel about infertility/pregnancy/pregnancy loss, I think this woman has every right to be emotionally drained from the constant reminder that she's the odd one out in the child department, and not by choice. Additionally, I can't fully excuse the family simply because they didn't know she was having trouble.

See, I'm a firm believer that the decision to have a baby is no one else's damn business.  Even if this particular woman hadn't been experiencing fertility problems, I would still find fault in the constant prying into her personal life.  They had no idea that their questioning would take such an emotional toll, true, but I don't even think we should even be asking these kinds of questions out of the blue like that.

I experience this kind of thing in my own life, though I wouldn't have the same emotional response, as I am neither having fertility problems nor am I trying to get pregnant.  It might well seem like a harmless question, "Are you planning on having a baby any time soon?"  But I just don't see it that way, and I think the knee-jerk assumption that a couple will be procreating after a few years of marriage is in and of itself problematic.

There is nothing more personal than the decision to bring a new life into the world, and you'd think the act by which pregnancy occurs would be personal enough to keep distant relatives from asking about it.  A mother or father wanting to know, in confidence, if you and your partner are planning on having a family of your own is one thing, but having an aunt or distant cousin who you only see once a year come up and ask whether or not you're having unprotected sex is a bit odd, don't you think?

And what are they expecting the answer to be?  "Oh yes, Grandma, we're planning on trying at the start of the new year."  That just seems weird to me.  You might as well be saying, "During my next cycle, I will be monitoring my cervical mucus and, when the time is right, I will be having sex with your grandson/nephew/cousin with the intention of soaking up his seed."  Not exactly the conversation you want to have over pecan pie.

If a couple wants to have a baby, it's really no one else's damn business until they choose to make it so.  The fact of the matter is, many couples experience difficulty conceiving, and many others miscarry early on.  Asking about if/when you'll be having a baby is liable to trigger difficult emotional responses, and let's face it, who really needs that during the holidays?  And if a couple doesn't ever want a kid {gasp!}, that's also no one's business.  You wouldn't ask parents why they chose to adopt, so why would you ask a woman why she's not pregnant?

I'm sure I'll hear much of it this year.  Charlie and I are "next in line" for pregnancy in his family (all the other married siblings and cousins have new babies), and everyone in my family is itching for a grandchild/great-grandchild.  I'm just thankful I'm not experiencing any sort of infertility or pregnancy issues that could make those questions loaded.  But that doesn't change the fact that my sex life is no one else's business, nor is my decision to get pregnant or remain childless.

It just seems like there's other things we could be talking about... Charlie and I both have had very big years career-wise, but I somehow doubt that will be what people want to hear about.

Birthing Against the Grain

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

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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.

Prematurity Awareness and Labor Induction

I learned from RH Reality Check that yesterday was Prematurity Awareness Day.  According to March of Dimes president Jennifer Howse, the United States has one of the highest rates of premature birth in the industrialized world, receiving a letter grade of "D" from the MoD.   The March of Dimes cites lack of access to early prenatal care and education as a main reason for the discrepancy. 

While I appreciate blogger Robin Marty for calling attention to this major problem in the United States, I must say I was shocked to find no mention of a common medical practice that contributes to premature birth: labor induction without medical indication. 

Others would call this "elective induction," but I've seen enough to know that it's usually the doctor, not the mother, that pushes for the induction, and therefore I find the term "elective" puts undue blame on the mother.  After all, we're supposed to trust our care providers.  When a doctor tells you that you "need" to be induced, we're not supposed to have to ask why.  We figure the term "need" means there's a problem.  But when it comes to induction of labor, a doctor telling you it's "needed" without providing an explanation usually means it's not needed at all.  (I always encourage my clients to ask lots of questions, even if they have a care provider that lays everything out for them.  If there's a problem, they'll usually tell you, but if they're pushing for an induction without saying why, you should know beforehand what the problem is, if any.)

Estimated due dates are just that: estimates.  In most cases, your body is the best indicator of when a baby is ready to be born, and the onset of labor is your cue.  Unless there is another complication (pre-eclampsia, placental insufficiency, gestational diabetes, etc), most babies will come when they're supposed to come.  As my dad says, "Babies are always right on time."  Inducing labor for the convenience of the doctor, the parents, or even the doula might seem okay or even preferable, but you could be cutting off valuable gestation time where the baby will be getting her/his final developmental markers.

In other words, babies born from induction can be (and sometimes are) classified as premature even if they're born at or slightly after the 38 week mark.  Again, your estimated due date is just an estimate, and different babies take different amounts of time to be "ready."  Studies show babies born at 38 weeks from a spontaneous labor have much better outcomes than babies born at 38 weeks from induction.  Babies born from induction are more likely to have jaundice, respiratory distress, lower APGAR scores, difficulty establishing a sleep cycle, increased risk for sepsis, and of course, difficulty breastfeeding.  Many induction babies need transfer to the NICU.  Being induced puts the mother at risk for cesarean, difficulty establishing a milk supply, and retained placenta (with or without cesarean surgery). 

Of course, there are good medical reasons to induce, and you should trust your care provider to help you make that call.  If there is an emergency and the baby needs to be born, good medical care and support from trained professionals can help curb these problems, but if induction is not necessary, why take the risk?  As far as the prematurity issue goes, well, you simply cannot address premature birth without addressing the medical practices that cause more babies to come too soon, and that practice is routine induction without medical indication.

Being a non-Mom

When I made the decision to pursue an IBCLC certification, I knew there would be some challenges to gaining the required clinical hours.  As a non-medical professional with no interest in becoming a registered nurse, I first questioned whether or not the IBCLC certification was even possible.  In speaking with IBLCE representatives and several lactation consultants, I learned that there are many pathways to gaining the hours needed to sit for the IBLCE exam.  Being an RN is not necessary, and in fact, many lactation consultants I spoke with at a recent conference were thrilled to meet a woman who was a) young, b) non-RN, and c) still interested in pursuing a career in lactation consulting.  They said the profession could use some "new blood," and having LCs around who come from a doula background instead of a medical one is welcome.

The recommendation I heard over and over again at the conference was, "Become a La Leche League leader!"  I had contacted my local LLL chapter, but haven't yet heard back.  So today, I went on their website to see exactly how I might best become a supporter of LLLI and possibly become a leader.

The first and foremost requirement is that you be a mother who has breastfed her children.  I can understand why this might be recommended, or even what might bring a woman to become a LLL Leader in the first place, but a requirement?  I do not wish to insult the amazing women who work with LLLI, nor do I want to discredit the invaluable work they have done to promote breastfeeding in their  communities, but this seems unfair.

One could defend LLLI: "Well, a breastfeeding mom would know what the women she serves is going through."  This is true, but any woman who has breastfed more than one child can tell you that each baby is different; I sincerely doubt an LLLI leader, regardless of how many children she's breastfed herself, can personally relate to each and every experience brought forth by a mom that needs some assistance breastfeeding. 

I have encountered the same in my work as a doula.  One of the first questions several prospective clients have asked me is, "Do you have children yourself?"  I have been rejected outright from even being granted an interview for this reason, while others have simply chosen not to hire me without saying why.  I have also heard of women not wanting a doula who has not VBAC'ed, home birthed, had a cesarean, birthed twins, etc.  While I believe firmly that it is their right to choose the doula they feel best fits their needs, the idea that non-moms make crap doulas is pervasive to a fault.

A woman at an online doula forum I read agrees that non-moms are ineffective doulas.  Her thought process: "Would you hire a fat nutritionist?"

Okay, first of all, we're talking about totally different things here.  A nutritionist who preaches good health but chooses to eat unhealthy foods is not the same thing as a woman who has chosen to not have children yet.  Eating healthy and entering into a lifetime commitment where your entire existence is consumed with taking care of another human being are completely different things.  Besides, who's to say an unhealthy nutritionist chooses to eat unhealthy foods?  And who's to say a woman who doesn't have kids has chosen not to have them?  What if this nutritionist has a thyroid problem?  What if this non-Mom is unable to get pregnant, or has had multiple miscarriages, or has lost a baby?  Or, {gasp} that she just doesn't want kids but sees value in providing support to those who do?  Saying a woman who has never had children is a bad doula is like saying a doctor who has never had brain surgery is a bad neurosurgeon. 

Secondly, as I mentioned before, each and every pregnancy and birth is different.  Even if you find a doula who has VBAC'ed, or cesarean birthed, or home birthed, or whatever, your experience is highly unlikely to be a carbon copy of hers.  Besides, doulas don't just run on their own experience; if we did, we'd only be able to support women who were having identical pregnancies, which of course would be useless.  Doulas are professionals.  We are professionally trained, and we are trained to provide support for a variety of birthing experiences.  A woman who has had twenty kids is no better at providing labor support as a woman who has, for whatever reason, had none.  (Would you hire Michelle Duggar as your doula?  Me neither.)

So back to La Leche League.  I understand that LLLI was established by breastfeeding moms, that their entire tradition was built on peer support and a sense of camaraderie.  Maybe the issue is that we need to expand our understanding of what "peer support" can be.  Maybe, instead of assuming that similar experiences makes you better able provide support, we need to understand that all women are able to support one another as a collective sisterhood.  Sisterhood, the basis for which feminism was established, crosses boundaries.  It transcends race, age, and class.  Isn't sisterhood what the founders of LLLI were looking for?  Even if I have not (yet) experienced childbirth and breastfeeding in my own life, does that make me wholly incapable of providing support to those who have?  It goes back to training, and training I have.  The LLLI motherhood requirement smacks of identity politics, an outdated movement building tool that divides instead of unites.  Solidarity should be the model for childbirth and breastfeeding support organizations, not exclusion.