Waiting for Babies

In honor of waiting for my co-writer's new baby, a few words on due dates.

First, how do we come up with a due date? There are several methods for determining the likely timeframe of delivery, including the gestation calculator wheel, Naegele's rule, lunar reckoning, Wood's method, Mittendorf's study, and ultrasound.

Naegele's Rule is probably the most common formula. It is calculated by:
Date of Last Menstrual Period + 7 days – 3 months = EDB

Naegele's rule assumes a 28-day menstrual cycle with ovulation around day 14, so it does not account for individual cycle variations from woman to woman. If a woman is fairly certain of the conception date, she can use an adjusted version of Naegle's rule:

Date of conception + 7 days – 3 months = EDB

The majority of women deliver within 10-14 days on either side of their due date, but only about 5% deliver on that exact date.

However, there are some other factors that should also be considered in determining a due date, including:

• Family gestation history
• Average menstrual cycle length
• Cycle regularity
• Characteristics of the last two periods
• Date she thinks she conceived
• When fetal movement was felt
• When heart tones could be heard

If you factor in the above questions, you may conclude that there is a more holistic way of guessing when to expect a baby than the pregnancy wheel they pull out in the OB's office at every appointment. For example, a woman who regularly has 35-day menstrual cycles likely ovulates a week later than the woman with a 28-day cycle. At the end of pregnancy, this may mean induction for being post-dates, which can lead to unnecessary cesareans (and even premature babies).

However you calculate it, and no matter how well acquainted you are with the statistics, it is HARD to wait for a baby, especially after you reach the estimated date of delivery. It's hard for Amie and me with our own babies, and it's hard when we wait for our friends and families (we try so hard not to be those people who call every day to ask if you're still pregnant).

I recommend that my clients start planning something fun every day when they get to the end of their pregnancies. Having something to look forward to can help maintain your sanity when you really hoped labor would have begun by now! Some ideas:

• Go to a movie
• Eat at a nice restaurant. You will miss tablecloths in the coming years.
• Get a pedicure or massage
• Make your postpartum pads
• Spend romantic time with your partner
• Work on a project around the house

Finally, remember that the end of pregnancy is hard, but newborns are awfully sweet and worth the wait. Good luck, Amie. I hope you don't get too far down the list before baby girl makes her debut.

Home Birth in the NYT

A great article on home birth in the New York Times today. Be sure to look at the accompanying slideshow!

If You Have 15 Minutes

Be entertained by Doc Gurley's Lost Tampon video. You will thank me.



I have a girl crush on her.

Labor Nurse's Perspective on Birth Plans

Check out this post on birth plans from the Rebirth blog. She brings up some important points about why birth plans are so often treated with derision.

What resonated most with me was this:

And then I've seen very inflexible birth plans that request things like no fetal monitoring (absolutely impossible in the hospital) which basically ask for things that are better for a home birth. These types of birth plans I have no problems with in regards to what they want or not want, but often scratch my head wondering if these couples have taken into account that they are giving birth in a hospital. As much as I feel continuous fetal monitoring or even IVs are not necessary in every birth, some hospitals have environments, protocols, etc that don't "allow" for this. I really think those who want to avoid all interventions look into alternatives to birth sites because the second you step into a hospital you give up some things, like complete control. I wish this wasn't the case, and try very hard as a nurse to let women know about informed consent and choice, but there are very few hospitals I know of that go with any request a woman has.

It's so important that women realize what is and is not realistic in hospital birth. For more on this, read You Buy the Hospital Ticket... You Go for the Hospital Ride. Giving birth in a hospital is different than giving birth at home. Wonderful, fabulous, and low-intervention births happen every day in hospitals, but they are still hospitals. Why would you go there if you basically want to have a home birth? Walking into a hospital in labor and announcing that you reject all its care is a recipe for disappointment -- and possibly a terrible birth experience, because your expectations and reality will be so different. Why set yourself up for this?

If you're planning a hospital birth, find out what the standard procedures are. Then talk to your doctor and your doula about how you are work with any aspects you want to avoid (i.e. a saline lock instead of being hooked up to an IV). Going in with realistic expectations -- and a realistic, well-researched birth plan -- will greatly improve your odds of having a satisfying experience. And isn't that what we're all looking for when we write these plans?

Interesting article about "Mommy Lit" and natural childbirth

From Mothering magazine's website.

Most compelling quote of the article:

"Even if the genre is simply reflecting what is going on in the mainstream, it is nevertheless unfortunate to see mommy lit either completely overlooking natural birth or poking fun at it.

Popular culture is not just a mirror, it also shapes who we are and how we decide to live. Mommy lit will no doubt be read by a whole slew of expectant moms and in many cases will have some impact on decisions they make about having their babies. I'd say it's time for some diversity in mommy lit's birth stories. "

The Void that is Postpartum Care in America

I just started reading a most phenomenal jewel of a book called After the Baby's Birth by Robin Lim. Two quotes just from the preface and opening chapter have struck me:

"...I came to see more clear how my sisters in the West could expect little or no postpartum care or support, either from health-care providers or from friends and family. The modern lifestyle, embraced by the West, sought after and imitated all over the world, has so fractured families that postpartum women today accept and expect to be isolated. [bolding mine] I wonder at a culture that decades ago put men on the moon, yet chooses to ignore the most significant life passage of women." (xi)

"All too often, the only postpartum care an American woman can count on is one fifteen minute appointment with her doctor, six weeks after she has given birth. This six week marker ends an arbitrary period within which she is supposed to have worked out most postpartum questions for herself. This neglect of postpartum women is not just poor healthcare, it is abusive--[bolding mine]particularly to women suffering from painful physical and/or psychological disorders following childbirth." (4-5)

In cultures across the world, newborns and postpartum mothers are viewed as sacred and in a vulnerable state of being of both body and spirit. As such, they are nurtured and cared for. I suspect that now that puerperal fever is largely a thing of the past due to a better understanding of germ theory, more sanitary practices, and antibiotics, that as we lost some of the physical vulnerability of this time period (mercifully, the vast, vast majority of women in the West survive postpartum), we also lost respect for the spiritual and emotional vulnerability.

There are many interesting, beautiful traditions for postpartum women across the world. "Warming" the mother is common to many cultures. Some bury warm coals under the postpartum woman's bed. Some women are to sit on a fire warmed rock every morning, and it is also common to place a warmed rock on the woman's abdomen. There are taboos revolving around certain foods, and it often requires that the mother consume only warm liquids like tea and soup. These practices not only warm the body, but the soul. Touch is also a familiar component to these rituals. In some cultures the responsibility falls to the midwife to come give the mother a massage or rebozo treatment designed to "bring the bones back together." In others, the mothers or grandmothers of the postpartum woman provide this life affirming touch. In America, we too have our warming ritual, if you are lucky enough for someone to bring you a warm blanket after birth. The difference is, whereas the aforementioned traditions go on for weeks, women in our culture are "cared for" (and I use that term very loosely) for a few days or less.

Today I was reading a post on a message board for moms from the mother of a 2.5 week old who was feeling overwhelmed, sleep deprived, and isolated, looking to reach out to other mothers. She got some wonderful suggestions, but what stood out to me was the comment from one poster that said "If you are feeling depressed, don't worry, there are many antidepressants compatible with breastfeeding." While this is certainly true, and I would never ever advise against someone going on such medications if they feel like they need them, it made me wonder if we are handing prescriptions out to women who are really seeking encouragement and camraderie. Much as a laboring woman asking for drugs is sometimes actually asking for more support from those around her, I can't help but feel like we are ignoring a mass of women when we hand them a pill instead of loving guidance and help.

I have been working as a hospital doula now for 2 weeks and have spent a few shifts shadowing another doula on the mother baby unit. What has been eye opening for me is how little rest these women are getting in their very brief stay at the hospital. I have seen mothers drifting off falling asleep while they try desperately to pay attention to the presentation of how to put together their breast pump. I have seen a mother who had a cesarean not 12 hours earlier whose hospital phone rang no less than 5 times in the 15 minutes we visited with her. This same mother was distraught and exhausted and told us she had had visitors all day long. These mothers are also struggling to get to know their baby, learn how to breastfeed and recover from birth which for many also means recovering from major surgery. What I have also noticed is while these rooms may be brimming with stuffed animals and flower arrangement, I have yet to see a care package for mom, a stack of magazines or her favorite food or drink. The focus is on coming to see the baby, and respect for the mother and her passage is lost. It is no wonder we have a whole generation of women suffering alone through isolation, a sudden, crushing loss of identity and postpartum depression.

What can we do to improve the state of postpartum care in America? I believe it's obvious we need better medical care including at least one home nurse visit in the first 2 weeks after birth. For a greater discussion of this, see Ina May Gaskin's article "Masking Maternal Mortality" in the March/April 2008 edition of Mothering magazine. But aside from that, what can we women, birth professionals, mothers, sisters, aunts, grandmothers, and friends of postpartum women do to help fill this void? And what can the postpartum woman herself do to create the support system that is so sorely lacking for them?

First, I believe we need to address the early visitor issue. Everyone loves to see and hold a new baby. But again, we are talking about women who are in the hospital for 24 hours, not getting to rest because the nurses are checking in on them and their babies every few hours, learning to breastfeed which can be highly challenging, and often recovering from surgery. We wouldn't expect to go see Aunt Sally 4 hours after her appendectomy, and the same respect should be given a woman who has had a cesarean. I propose that no visitors come to the hospital the first day, and if they do, be limited to immediate family and the closest friends for less than an hour. Remember, in most hospitals rooming in is standard, and these mothers are not going to get a full night of sleep. There will be plenty of time to meet and cuddle this wonderful new blessing once the new family is settled at home.

How can the postpartum mother enforce this? Some tips are quite simple. Don't call anyone while you are in labor except for those you want with you either at or immediately after the birth. When you do call to let family and friends know you've had the baby, tell them you will be happy to see them once you get home. This alerts them to the fact that you are not inviting them to the hospital. What about those who will show up anyway? Tell your nurses to mark you down as "do not announce" and they will not tell anyone you are there. Let them know you would like your visitors cleared through the nurse's station and have them place a sign on your door when you are resting/feeding and prefer not to have visitors. Please realize this is not a hardship for the nurses, they actually like to limit your visitors. It is their job for you to have a full, speedy recovery, and they realize that you resting is the best way to get that. They will not mind at all being your gatekeeper.

I realize this all probably sounds harsh. But I assure you that once you have given birth, you will understand more of what I am saying. And I will also tell you that the most crucial time to your postpartum healing is 8 days after birth. The more rest, relaxation, and general being taken care of you can arrange for, the quicker the rest of your recovery will go. You are not denying people access to your baby. You are ensuring that you are healthy enough to care for him/her in the very demanding weeks to come.

Birth professionals, I implore you to impress the importance of these 8 days on your clients prenatally and encourage them to set forth the rules I have suggested for postpartum visitors.

This post will continue with more tips on how to build your own network of postpartum care, but for now I must sign off!

Hospital Water Birthing in Syracuse, NY!

Check out Kristen Oganowski's VBAC, hypnobirthing, hospital water birth story. Hers was the first water birth at Crouse Hospital in Syracuse, New York. Her birth from the perspective of her doula, Chris Goldman follows Kristen's account. This is a wonderful, inspirational birth story, but even more encouraging are the comments following both articles that indicate hospital waterbirth is on the rise in Central New York.

One of my favorite parts of the article follows. KUDOS to Dr. N, a shining example of what OB's can and should be to birthing women today:

"And then he [Dr. N, Kristen's OB] turned to my nurse and said, "Well, it looks like you aren't getting her out of the tub!" But then he took the time to tell her the following: "Look at how beautifully she's doing. Look at how natural and normal this is. She's pushing on her own, and no one is yelling 'PUSH' in her face; no one is counting for her." And you know what? My nurse started to get really excited about this birth."

Great news for the women of Santa Fe!

An email from Julie Gorwoda, CNM and Director of Nurse-Midwifery Education at the University of New Mexico. This triumph should inspire all of you who live in areas without Nurse Midwifery care as an option in your hospitals to sharpen your pencils and write letters. Make some waves and help the women in your community to have access to safer, more personalized care.

"After 63 years of clinical nurse-midwifery presence in Santa Fe New Mexico, we are happy to announce that women in Santa Fe may soon have a CNM-attended BIRTH at St. Vincent's Hospital! The vote from the Medical Executive Committee today was groundbreaking and paves the way for full-scope nurse-midwifery care in this city, one of the last hospital-holdouts against CNM intrapartum care in New Mexico. 2008 UNM graduate Maria Theresa (Maite) Redondo-Cladera will be the first nurse-midwife at this facility after strong support from Ob/Gyn Dr. Cindi Lewis and Maite's FP employers at La Familia Medical Center, especially Dr. Gary Giblin. The three of them worked long and hard to make this a reality.

Catholic Maternity Institute was founded in 1945 in Santa Fe by CNMs who were also Medical Mission Sisters. It was one of the earliest midwifery services and also the first university-affiliated nurse-midwifery education program in the US. Midwifery leaders from CMI also incorporated the American College of Nurse-Midwives in Santa Fe in 1955 but CNMs were excluded from the only hospital in town until today. This victory for women and midwives could not have come without years of support from consumers and the midwifery community's education of thoughtful physicians.

If you know anyone on the Medical Executive Committee or St. V's administrators, please thank them and send your letters of congratulation to Maite at amniotic22@yahoo.com. Her years of intelligent, extremely capable nursing care of laboring mothers at St. Vincent's made her the logical first CNM choice for this hospital. And tell your sisters, cousins and friends from Santa Fe they don't have to go to Albuquerque or Las Alamos for a hospital birth anymore! Blessings to Laurie Holmes, CNM who attended women at home in Santa Fe for several decades and the other Santa Fe CNMs who kept the porch light on in the "City Different" for over 63 years.

Please pass on the good news!"

Recommended Reading for Your Weekend

First, I strongly suggest that you check out Linda's take on the latest ACOG nonsense. As always, they want to make sure that women are "protected" from these outlaw midwives and their dark and dangerous ways.

One of their claims, that midwives are mostly self-educated, really chaps my hide because:
1) It's untrue -- even midwives who don't attend a formal school are still trained by other midwives. And hey, isn't an internship basically an apprenticeship for an MD?
2) The autodidactic spirit of the women I know who work in birth impress me so deeply. It's a passion for learning that I simply don't see in many other professions. It's condescending to imply that you have to go to medical school to get an education about birth.

The snobbery and sexism implicit in these ACOG statements always gets me down. I wish I could say that they have no impact on me, but that would be a lie. In fact, one of the biggest reasons I had for enrolling in midwifery school is the fact that I think my education will be more respected this way. It's not the only reason (others being that I like structure in my studies, and that one of my preceptors strongly encouraged it as a condition of taking me on), but it was certainly a big one.

That said, Pam's words on this still resonate with me:
[Midwifery education] has to be personally defined. We are not all the same, nor do we all learn the same. I cannot even begin to speculate what this would look like or have to encompass for it to be "ultimate". Each family, each community, has a different need. If we all are trained the same and think the same and practice the same, where is the midwife for people who want something different for their birth?

School is the beginning, not the end, of an education.

Anyway, I also recommend that you check out the CDC's latest report on breastfeedng practices in hospitals and birth centers around the country. It's predictably frustrating. One of my favorite bloggers, Rachel from Women's Health News, has a tidy summary of the report.

The thing that is so disheartening to me about it is the pervasiveness of giving healthy, full-term infants formula supplementation, even when their mothers indicated that they were breastfeeding. Just as these facilities don't trust women's bodies to birth their babies without interference, they don't trust women's bodies to nourish those babies after birth. Routine supplementation flies in the face of everything we know about breastfeeding and the nutritional needs of the newborn. But what really eats me up is that the systematic undermining of women's confidence in their bodies. It hurts the breastfeeding relationship, it hurts the mothering relationship, and it hurts other women's confidence before they've even conceived. When is the medical profession going to stop focusing on harassing midwives and direct its attention to actually keeping mothers and babies healthy? Good breastfeeding practices would be an excellent place to start.

First International Post!

I'm spending the summer in Costa Rica with my family. Despite roughing it in the jungle, we do have high speed internet service, so I shall continue to contribute.

First, I'm late to the table with this, but I have to point out two important headlines:
Premature Births Increase Along with Cesareans Our haste to get babies our before they're ready is being recognized (at last!) as not such a good thing.

After Cesareans, Some See Higher Insurance Costs Adding insult to injury, many women are finding it difficult to find insurance after their surgical deliveries. My only glimmer of hope in response to this is that it will spark some backlash against our c-section-happy status quo. Being uninsurable is a huge deal. Of course, the insurance industry is largely responsible for the high rates of cesareans we're seeing these days -- the fear of malpractice lawsuits, not to mention insurance companies refusing coverage to OBs who support VBAC, etc, etc, got us where we are today. Now, painfully ironic though it may be, insurance carriers are complaining about the higher costs of the situation they helped create.
----
What's the birth situation in Costa Rica? Almost all women have their babies in hospitals, and many have to travel to get there. There are midwives here, but they have to practice underground to avoid prosecution (as in some states in the US, having a b`aby at home is not illegal, but practicing midwifery is). In the Talamanca region, where I am, the local indiginous population, the Bri Bri, are facing persecution for birthing at home. The government is now threatening them with prosecution for any bad outcomes of a home birth. The result is that pregnant women are sleeping in the streets as they approach their due dates, rather than facing an 8-hour walk down the mountain and into the city while they're in labor. Birth Without Boundaries is here working to change that -- I'm hoping I can help.

Decisions, decisions...

Breastfeed? Bottle feed (hey, it's organic)?

I almost feel bad posting this juxtaposition. It's like shooting fish in a barrel.

Report from Our Bodies, Ourselves co-author booksigning in Albuquerque...

I had the privilege of hearing Judy Norsigian speak last night at Bookworks about the newest book from the Boston Women's Health Collective, Our Bodies, Ourselves: Pregnancy and Birth. It was wonderful to hear someone who really gets it and is right on the political frontlines of birth in America speak about how limited women's choices are really becoming and the crises we are facing. I found it very compelling that she has observed far more fear surrounding pregnancy and birth than there even was 5 or 6 years ago. To counteract the negative messages women are hearing from each other and the media, the book focuses on giving women the confidence they need to reclaim this feminine rite of passage with an emphasis on evidence based practice. And obviously, this leads to the midwifery model of care. Birth centers are closing left and right, obstetricians are denying certified nurse midwives the right to practice in certain hospitals because of perceived "turf wars" and the well-being of women and babies is left on the sidelines in highly charged, financially fueled debate in the medical community.

I bought the book and can't wait to read it. Because of hearing Judy speak, I am now motivated to do the following. And don't worry, I will share my progress with our loyal blog-readers.

• Write letters to St. Joseph's hospital in Santa Fe and start a letter-writing campaign if there isn't one going already to fight the ban on midwives there. St. Joseph's is the only hospital in Santa Fe, so although New Mexico has a long, proud tradition of midwifery care with some of the best birth outcomes in the country, women of Santa Fe are forced into choosing homebirth if they want access to midwifery care. Find out what the story is in your area, and do the same! I'll be pressuring Elizabeth to write similar letters to the hospitals of Austin who also deny women the choice of midwifery care.


• Read the chapter about nitrous oxide used for pain relief in Our Bodies, Ourselves:Pregnancy and Birth and get educated about this topic. I've heard things about this in passing when reading British writer Sheila Kitzinger's book, but I hadn't realized the real issues behind it. There have been no studies showing any risk to mother or baby when nitrous oxide is used during labor, and yet women of the U.S. have zero access to this less invasive pain relief option. Why? No anesthesiologists necessary. Birth choices have GOT to stop being limited in this country based on profit! The well-being of mothers and babies should not be sacrified in the name of money. You can start here and here to learn more.


• Learn more about healthcare reform options. Judy strongly favors a single-payer system and in fact feels that no major strides of progress will be made for childbirth in America until such a system comes about. And in fact, all the Western countries who have more midwifery care and thus better outcomes for mothers and babies across the board than the U.S., have a single payer system. She recommends reading A Second Opinion by Dr. Arnold Relman and passing it along to any physician you know who will read it, because the pressure for change needs to come from doctors. This will certainly be making my goodreads list.
• Let everyone I know (that means you!) that Our Bodies, Our Blog accepts material from any and all writers about current issues in women's health policy and that they just might link to your article. I'm really hoping eventually we can earn a coveted spot on their list of linked blogs!
  

The VBAC debate was also discussed in the context of women being more and more frequently denied even the opportunity to choose whether to have a VBAC or not because of VBAC bans in hospitals, as well as the need for more celebrity homebirthers! The talk was really insightful and informative and I would encourage anyone who has the opportunity to go see her while she is on the book tour.

Get a Job!

Everyone at a birth needs to be employed.

No, that doesn't mean that only birth professionals should be there (sorry, Auntie May, you've gotta go!), but from my experiences as a doula, I've come to believe that anyone who's not contributing something is likely to be keeping things from progressing as they should. Too many women allow unwanted visitors to this rare and marvelous experience -- which can have consequences ranging from an annoyed birther to a stalled labor, and all that that entails.

Before inviting someone to attend your birth, consider:
- What energy does this person bring to a situation?
- Can s/he handle intense situations calmly?
- What can s/he do to help me/my partner/my children during this time?
- Do I actually want this person at my birth, or do I feel I should want them?
- Do this person want to attend my birth? Will they feel they can say no if I ask them to attend?
- Am I comfortable with this person seeing me naked? In pain?

Birth is not a spectator sport. But that doesn't mean you shouldn't have a room full of people, if that's what makes you feel safe, warm, and loved. Just think about the roles everyone in that room can play. Don't be shy about assigning duties to everyone from your doula to your mother-in-law. Remember, people are also more likely to get flustered during a long or intense labor if they don't have something to do -- they will likely be glad to know what's expected of them!

Here are some suggestions for jobs you can give your support team:
- Birth photographer or videographer
- Caterer (keep you and the rest of the team fed and hydrated)
- Massage therapist
- Doula
- Babysitter/Kids' doula (keep the kids occupied or help them understand what's going on)
- Gopher
- Reporter (keep a log of the event and write a beautiful birth story!)
- Birth tub maintenance technician
- Clean-up crew (homebirth)
- Mediator with medical staff (hospital birth)
- Hand holder (perfect for someone with a warm presence that you just want to be there for you)

I've started teaching childbirth preparation, and this is something I've covered with both my classes. It seems to be well-received, though I'm sure I'll step on someone's toes with it eventually. What do you think, gentle readers?

Yet Another Celebrity Homebirther

Melora Hardin, who plays Jan on The Office, talks about her home births, extended breastfeeding, and attachment parenting here.

I really love what she has to say about nursing both of her girls until they were 2 1/2:
I was adamant about not having to feel like I had to cover up when I was out feeding my child. We see plenty of violence in this country, and if you can't deal with a woman feeding her child, then look the other way.

She is fabulous!

Birth Spool Interview: Pamela Hines-Powell

It's our first interview!

Pamela Hines-Powell is a midwife practicing in Salem, Oregon. Her blog PamAMidwife is some of our very favorite reading here at the Birth Spool (and check out the archives here). She writes extensively about contemporary birth and "unlearning midwifery."

Pam's hands-off philosophy distinguishes her not just from the modern obstetrical world but from many other midwives as well. Her belief in the power and safety of birth inspires and humbles us.

Here's Pam:

When did you know you wanted to be a midwife?

Some people discuss midwifery as a "calling" - certainly any person in their right mind would not choose midwifery for its glamour, income, or regular schedule! In my case, it definitely felt like a calling, but I fought it tooth and nail. It started with my daughter's interventive hospital birth in 1994, which led me to become a doula. The question regarding becoming a midwife kept coming around and I kept stifling it. I think I was on the edge of knowing that my entire world would change should I take this path, and that was really scary in many ways. I eventually took a step forward and all the doors opened easily from that point on.

What educational path did you follow to become a midwife?
As a product of this culture, I believed that a "good" education came from a formal classroom environment. I have since changed my thinking on this, though it's a common misconception with midwifery (and learning in general). I started midwifery school in 1996, with a solid Anatomy & Physiology course and then midwifery studies in 1997. I ended my classroom education in 2000 and completed a four year apprenticeship in 2001.

How long have you been practicing? How many births have you attended?
I have had my own primary practice since the end of 2000. In that time I have attended about 200 births, with another 100 or so in my apprenticeship.

What are your other passions?
I love music, knitting, cleaning my house, and sleep!

Who are your midwifery mentors?
The most important mentors in my midwifery life are Michel Odent, Sarah Buckley, Gloria Lemay, Sarah Wickham, Laura Shanley, and Gail Hart. These people have influenced my beliefs and practice greatly.

You’re stuck on a desert island with one midwifery book – what do you want it to be? [Elizabeth is watching too much Lost and needs to stop thinking about the Island's obstetrical issues quite so much.]
Oh boy. Would I want a midwifery book on a deserted island? Guess I could always say one of Anne Frye's tomes which would keep me reading until I'm rescued - even if that is years away.
Any of Michel Odent's books or Sarah Buckley's Gentle Birth Gentle Mothering would be a first choice for birth-related reads. But really, I would take Middlesex by Jeffery Eugenides if I was deserted on an island!

What was your own experience giving birth like, and how did it influence you?
When I first found out I was pregnant in 1993 we didn't have medical insurance. I don't know where the exposure came from, but I called a local homebirth midwife about cost and services. I never set up an interview with her because soon after we obtained insurance and birth in the hospital would only cost us a small co-pay. I realize that at that time I thought homebirth was for people who didn't have insurance, but I have no comprehension how the concept of 'midwife' and 'homebirth' came into my thinking at all.

My daughter's birth was pretty typical. Paying too much attention to early labor contractions, arrived too soon to the hospital, Pitocin augmentation, pushing on my back, and a deep third degree episiotomy. This birth left me feeling hopeless and wounded. I started researching birth trauma and came to the idea of doulas. The first birth I attended as a doula was a homebirth - it was deeply healing for my soul.

What’s your favorite part of being a midwife? Least favorite?
My favorite part of midwifery is the challenges it has brought up in my personal life and awareness. Midwifery has really pushed me beyond my comfort zone many times - it's a lot like labor! Just when I think I have myself figured out, there's something else that comes up and pushes me further. I also enjoy the families that I am on this journey with and I love those new babies!

My least favorite is the inability to be sure of my schedule. Always being on-call is hard when you want to go out of town with friends or family. Birthdays and holidays have been interrupted by births or other client care. It never fails that if I stay up too late and crawl into bed exhausted, I will be called to a birth soon after I fall asleep.

What is your role as a midwife?
I see myself as a consultant, really. I have specific knowledge and skills that come in to play when there is a need, but this knowledge does not make me an expert on any particular motherbaby. Clients hire me for this knowledge in the rare instance that it is needed; they also hire me because of my resources and exposure to information in our community. I try to approach every client as a new version of care... each family chooses what they want done in the scope of their prenatal care (no blood pressure checks, no doppler, no testing), their birth, and postpartum. Customizing care allows me to meet the specific needs of each family without taking anything away from their experience. I trust that my clients have a stronger attachment to their health and the health of their baby than I do - and I stand by them in all their varied choices and requests.

What does being a midwife mean to you?
To me, being a midwife is a very intimate role in the childbearing journey. Because we have much more connection with women than doctors achieve, we are entrusted with more. Once a woman lets down her guard with me as a midwife, it is my job to hold that trust and respect. Midwives impact the birth experience in positive and negative ways... it is up to each midwife to separate her needs and desires from that of her client. Being a midwife offers lessons in self-reflection and huge personal growth opportunities. If I don't see those opportunities for change within myself, I am of no use to any of my clients.

Do you think birthing at home makes a difference for a mother? What about her baby?
It definitely makes a difference. We would never expect a woman to have an orgasm in a public place with strangers waiting for her climax. Yet, somehow, there is a thought that women should feel safe enough and private enough to birth in the hospital. The hormones of labor and birth mimic those involved in orgasm. If we really viewed childbirth as a sexual experience then perhaps more women would birth at home.

A woman who has safety, privacy, intimacy, and love will birth her baby easier than a woman who is under the judgmental gaze of the clock and a waiting staff. Being in her own environment offers her the familiarity of her intimate space, thereby reducing any sort of new brain (neocortex) activity (it's much easier to fall asleep in our own homes than in someone else's). In her home a woman's perception of pain is different, her feeling of control is different, and her process of labor and birth is different than in the hospital. At a hospital, there are rigorous protocols that allow for a very small window of, if any, personal desires on the part of the mother. Each woman in the hospital is another number, needing to allow certain standard procedures and interventions to be a "good" patient and "progress."

Since the baby is within the mother, they are a unit that I do not separate into two categories. If the mother's labor is hindered by observation, lack of privacy, or medications, the baby is affected. Babies need the hormones that the mother is releasing to create their own hormonal cocktail. These hormones ensure a safe trip for both of them and continue through the immediate postpartum transition to help with bonding and attachment.

What do you consider “high risk” and how do you handle those clients? Do you attend breeches, VBACs?
In my opinion, high risk applies to the obvious: complete placenta previa, pre-eclampsia, HELLP syndrome, premature births, etc. I do attend breeches, twins, and VBACs in my practice. Above all else, I can recommend that someone seek care elsewhere for their birth, but the risk that I apply to births isn't the same risk that a family may choose. For instance, I could feel fine with a labor starting at 35 weeks, but the woman in labor may not feel the same way. There are allowances on both sides and I do my best to stand up for and support the family's choice regarding continuing care.

What are the biggest challenges you face as a midwife? That midwives face in general?
The biggest risk to all midwives right now is the push to license all homebirth midwives. Mandatory licensure changes the face of midwifery - what we can and cannot do. It puts a woman's choice in the hands of a legislature, which is something I am opposed to. It also means that if a midwife chooses not to become licensed she faces criminalization. I'm strongly against criminalization of midwives. It seems that we're damned either way - in a state where midwives are illegal and being actively prosecuted, licensing seems like a logical way to end the legal battles and fear. Putting the state government (and often, the medical model) in charge of something like midwifery is risky business - the voices that make up the licensing rules and overseeing board are not always midwife friendly. It's not an easy situation to discuss with people, particularly because I live in a great state for midwifery. Oregon has only had voluntary licensure for homebirth midwives. No midwives are prosecuted in Oregon for practicing, licensed or not.

What do you predict will be the culture of birth in our country over the next 20 years? Will we ever get to a place of trusting birth?
It will have to take some huge steps towards a no-fault malpractice atmosphere and, quite possibly, socialized medicine. If we look at the countries with the best outcomes and highest rates of midwife-attended births, they are countries that have socialized medicine. If our healthcare stays privately funded then we will likely not see an improvement towards more gentle birth. I imagine that in the next ten years we are probably going to see a cesarean rate that is above 80%.


What makes your style of care different from a physician? A hospital midwife? Other home birth midwives?
I believe in women. I trust that with the attachment to their babies they have the strongest, most honest voice in choices. It's not fair to have created a relationship with a provider only to have them doubt your process and coerce you into something that you don't want because of protocols or rules. The fear of litigation is tremendous not only in hospital-based providers but also with homebirth midwives. There are a lot of "what if" stories that come into play when you talk to midwives about unhindered birth. My fear isn't in getting reamed by the system. My fear is not standing up for a woman's choice in birth. I am hired by my clients, I am not in control of their decisions.

I want to be shown that something is beneficial to motherbaby before I incorporate it into my practice. UK Midwife Sarah Wickham has a great quote:
Whether or not we do things like this as a regular part of our personal practice, why do we feel we need research evidence to support the argument for not intervening? In a model of midwifery that assumes normality, I would assume that midwives would need to see evidence that something is useful before incorporating it into their practice, not the other way around. Have we become that uncomfortable with the physiology and normality of birth that we would rather intervene than not? Are we so fearful of litigation that we feel we need to “do” rather than “be with”? And are these practices really so ingrained in us that we feel compelled to continue them on a routine basis unless – or until - they can be proven unhelpful?

This quote encompasses exactly what I believe about care in pregnancy and birth. I work hard to bring evidence to my clients so they can make the best decisions for the course of their care. The fear around stepping out into what is right is big. If we all step out together then things change, right? The time is perfect for homebirth midwives to let go of some of those old obstetric rituals and beliefs that keep women from coming into their own power.

What advice do you have for women who plan to become midwives?
Take it slow, don't rush it. If your heart is telling you to take care of your young children, put midwifery aside for awhile. Read, read, read, even if you're not actively planning on apprenticing anytime soon. New information and research comes out every day... stay on top of what is being said, being done, being learned. If you're meant to be a midwife then you will eventually be one. Pushing the goal of becoming a midwife is a lot like pushing a slow labor - it's painful and the end result can often end up being far different than what we wanted. Honor the path - sometimes we learn more on the becoming than we do the being.

Do you have an idea of what would comprise the ultimate education/knowledge for a CPM?
No, no, no. It has to be personally defined. We are not all the same, nor do we all learn the same. I cannot even begin to speculate what this would look like or have to encompass for it to be "ultimate". Each family, each community, has a different need. If we all are trained the same and think the same and practice the same, where is the midwife for people who want something different for their birth?

Since you live in a voluntary licensure state, you have written about why a midwife would choose not to be licensed. Do you see value in licensure in any circumstances? What certifications/licenses/etc. would you support, if any?
I'm still working on this one myself. I'm not sure if I have a black and white stance on it, but I do feel strongly about midwives being criminalized - in legal and illegal states. I would hope that every legislative effort to legalize midwives begins with a process that includes voluntary licensure.

Oregon and Utah are the only states that currently offer voluntary licensure of midwives. Idaho is in the process of trying to pass legislation for voluntary licensure, though midwives have been legal in that state for awhile. It is true that it's much easier to pass legislation for voluntary licensure in states where it is not downright illegal to practice, but I still think that the first legal step should always attempt to be voluntary.

If a state has mandatory licensure, midwives still run the risk of being prosecuted - either by not following state protocols or not being licensed (usually because they don't agree with or will not abide by the protocols). So in essence, even if you're 'legal' or 'licensed', you can still run the risk of prosecution just for supporting a family that chooses to go against state protocols. As a midwife, what my clients choose to do for their care and birth far exceeds any rules given to me by a state bureaucracy. If I lose my license because of standing by a family's choice then my integrity, as far as I'm concerned, is still intact.

Birth is a consumer issue, obviously. What can consumers do to change maternity care in the US?
Educate others, listen to women's stories, tell your story. Again, there are so many factors that play into the current attitudes around birth that even a consumer drive may not be enough to really change it alone. Women need to hear stories of personal empowerment through birth. All women hear is how scary and dangerous birth is. There needs to be more public voices telling women the truth about birth.

What advice do you have for pregnant mothers?
Don't overthink birth. It's not a final test that you cram for. What you need to know to birth is what you already have inside you and no amount of breathing patterns or practicing relaxation can change that inner knowledge. Listen to your body and work on gaining back the intuition that so many of us are taught to ignore. Our biggest job when pregnant is reversing the brainwashed ideas and lies about pregnancy, birth and mothering.

I know you’ve read Navelgazing Midwife’s latest post about the competency of CNMs vs. CPMs/LMs. Do you agree that nurse midwives are inherently better equipped to handle the unpredictable nature of birth? [Here is a link to that post, which has since been edited.]
Definitely not. Nurse-midwives by definition are great at hospital births. They prescribe and administer medications and procedures that work best in the safety confines of a hospital. Being a great hospital-based midwife does not mean that one is automatically a great homebirth midwife. Just as I could never walk into a hospital and assume to have knowledge about the systems there, hospital-based providers have to undergo a sort of reprogramming when attending home birth, including learning different skills.

I'm not really sure what sort of skills Barb thinks that she and other homebirth midwives should have - I don't prescribe birth control pills for women, I don't do colposcopies, I don't deal with breast lumps. I have some knowledge about them but feel these things are beyond my scope of practice - and my clients deserve a provider to refer to that does have a multitude of experience dealing with these issues firsthand. Even if I gained the knowledge, would I really use it that much? Perhaps that is the reason why it is so tricky: once given this knowledge and skills is a midwife more apt to apply it to every one of her clients? Is she more willing to be interventive because she has certain skills now? (Many naturopathic physicians in Oregon attend homebirths with a vacuum extractor!) If there are things I want to know more about or how to handle, nurse-midwifery school wouldn't be my first course of action, for sure. I don’t think I could complete nurse-midwifery school and come out with the same ideas about life and birth.

Tell us about your idea of an absolutely perfect birth culture. Where do midwives, nurses and doctors fit in? How is the care for low risk and higher risk women different? How is it the same? What are the roles of doulas and childbirth educators?
Ideally, I'd love to see women have options.

For hospital births: I believe that OB/Gyns are first and foremost surgeons (some I've talked to have admitted the same). If we're giving normal birth to surgeons then there will be a higher rate of surgery. (Which coincides with what I commented on above re: extended training outside the scope of practice/location... if skills, procedures, and rituals are learned then it's much harder to keep them from being applied across the board.) I'd much rather see OB/Gyns put to good use by overseeing high risk and surgical births. I would imagine that not too many Ob/Gyns would disagree - the struggle between keeping clinic hours, attending births and having a family of their own would ease considerably.

In hospital-based situations, I would love to see nurse-midwives as the standard of care for normal and low-risk women (though reframing what we consider 'high risk' is a necessary part of this process). I would also like women who birth in the hospital to receive at least one in-home visit before and after birth - as any midwife will tell you, in-home visits offer a distinct view of a woman's socioeconomic issues, her healthcare needs, etc. These nurses, or other professional, could offer women who are at higher risk resources and information about services in the community. Most hospital-based providers have no idea what their patient's home lives or needs are outside of clinical care. Having providers that really practiced evidence-based care would change the hospital environment towards a more positive direction.

For home births: I would love to see midwifery and homebirth as an option for every woman in every community. Currently, there are few options for a midwifery education if you do not have financial resources. This limits midwifery to women of a certain race, class, and area of the country. In essence, if you're middle to upper middle class white woman then going into midwifery could be an option for you. If you do not have these resources, and do not want to attain heavy debt along the way, then your community will not be served by homebirth midwifery. Midwifery training and midwifery access is very race and class biased. Most issues within the attachment parenting movement are racially, economically, and culturally biased - they're practices that are frequently carried out by a rather homogenous group of people.

It would be awesome if we could return to the idea that a formal, classroom education isn't the "best" or only type of midwifery education and allow for various routes of learning. I've learned so much in my career from other people and situations outside my formal education. This idea that “if you go to midwifery school and attend a certain number of births (usually quickly at a high-volume, fast-paced site) and viola! you're a midwife!” is hurting women and midwives. It is taking away from the true essence of being a midwife: learning a trade that is not easily found by memorizing words and taking tests, but by fully absorbing, being patient and present while providing women and families with continuity of care that creates an intimate relationship ready for the time of birth.

I think it's also important to look at race and class issues at high-volume birth sites - where middle to upper middle class white women go to 'get numbers', essentially practice their skills on women of color. This is an issue that most people don’t consider inappropriate…why?

In addition, we need MORE homebirth midwives. The more midwives we have, the more exposure this option gets. The more families that are interested, the more variety of midwives we need. Each family comes to homebirth with different paths and ideas - we need midwives that can suit the desires and needs of many different types of families! I'd love for there to be fewer issues around state regulations and more about community standards and peer review. While it may sound ok to say that every midwife MUST do such-and-such, talking to your peers about why your client chose NOT to do it may change the attitudes and atmosphere in the midwifery community in a positive way. There is a lot of backbiting amongst midwives about who is "safe" and who is not - and this usually revolves around being afraid of the laws, rather than supporting families.

What inspired you to start taking a hands-off role in 2nd and 3rd stage labor? What changes have you noticed since you started that approach?
Reading information from the UC community (the cbirth list was awesomely helpful during my apprenticeship and the early years of my practice) and birth writers like Michel Odent planted seeds in my head about how I wanted to practice.

We know too much about the hormones and physiologic process of labor and birth to ignore the science. Why are we still doing things that completely interrupt the process, putting motherbaby at risk? It was this dilemma that somehow pushed me further into putting into practice what I had been reading and hearing for years. I didn't want to be another midwife that did things just because it was routine or "couldn't hurt". I wanted to support the natural process as best I could.

For my practice, it started with having mothers and/or partners catch their own babies. I didn't believe in the idea that I "had to deliver" the head and then the dad could then catch the body. I wanted to dispel the myth that there were some fancy maneuvers or skill involved in catching a baby. Women never questioned their ability to receive their own babies at birth - especially in the water. They just do it. Fathers, on the other hand, were nervous. Once you explain that you just hold your hands out and receive the baby it all becomes clearer. As exciting as it is to catch a baby for me, I would imagine that feeling is a thousand times better when that baby is your baby, a product of your love.

I do not provide perineal massage or other techniques when a woman is pushing - I do not check her cervix to see if she is 'ready to push'. These two thought processes baffle me, knowing what we do about the expulsive efforts involved in pushing. Both are hindrances to the natural, instinctive flow of second stage for most women.

I cannot say that I've seen a higher rate of tears that I've needed to repair than midwives who provide hands-on 'support' during second stage, but I do not have any statistics to offer of either approach between midwives (I am in the process of slowly compiling info like this from my practice!). I rarely suture – I think at last count I had sutured 5 times in a little over 200 births. I feel that over the past couple of years I've changed the way I view tears in general, trusting the body's ability to alleviate pressure in areas that it needs to in order to avoid compromising more sensitive parts of the vagina. This idea that midwives can do all these things during pushing and at birth to prevent tears is not something that I believe in.

It seemed natural to evolve into a more hands-off third stage. Certainly with the birth of the baby the mother must be focused on that being. She is enveloped in a beautiful, blissful bubble that is protecting both her and her baby by creating a rush of beneficial hormones. These hormones will help her uterus contract, release the placenta and minimize bleeding while allowing that important bonding with the new baby that will ensure his/her survival through attachment. The last thing this loving couple needs is someone's hands on her baby, putting a hat or blanket on him, listening to the heart with a stethoscope, etc.

To assess how baby is transitioning, I am aware of baby's tone when he/she is born. It's baby’s tone that will tell us a great deal about how baby is doing - if tone is not great, but not horrible, then giving the baby some time to make the transition on his own is necessary. If some time passes with no improvement, a way to step in and assess while making verbal contact with the mother is key. We tell clients that if they do not see us come up to them or their baby after the birth then everything is fine. The gurgly breathing sounds, the color, etc., are all a normal part of the transition. We talk a lot about honoring that first 15 minutes or so - in more ways than just the attachment. We also discuss the lower risk of hemorrhage and other complications from allowing the first 15 minutes to be quiet and focused on baby. This seems to make sense to couples and they usually welcome it.

The effects? I've noticed fewer hemorrhages and more happy clients. My current apprentice got me off the thinking that every baby had to be to the breast within the first half hour. If we allow that bubble to stay intact, the baby and mother do what they need to do. Babies may not latch on right away, but they mouth the nipple and look at their mothers, which is just as beneficial for both of them. There is plenty of time for technique once she changes her attention to the outside world and things get more settled.

How do your clients react when you tell them how hands-off you are?
A few are concerned - and it usually has to do with a misunderstanding. I'm not going to stand aside and watch them hemorrhage. I'm not going to withhold support when they need it. I think the main discussions happen around the normal physiological process of labor and birth - and how I am there to be the midwife that their family needs. My role at birth changes with each family. Once we discuss their visions, their ideas and the ability to ask for what they want, people are typically fine. I am really adaptable based on what my clients want... I want a relationship built on mutual trust long before the birth so things flow smoothly and easily during that time.

I find that many people hire me specifically for my flexibility and ideas about birth. My clients are usually not the type that wants a midwife to tell them how to breathe during labor, what to do about prenatal testing, or how to feed their babies. I want my relationship with clients to be one based on equality. They have innate knowledge about their bodies and babies and I hope that I honor that knowledge above everything else I see clinically.

When was the last time you caught a baby?
It's been over a year - and it was for a client having her tenth baby and her fourth homebirth with me. But normally if anyone is going to catch a baby that isn't a family member it will be my apprentice. So there are some situations in which we do receive babies into our own hands, but not often.

What role can doulas and childbirth educators take in promoting trust of birth?
I think that doulas have gotten into the trap of doing a lot at births. Part of this is the fault of the training - all these tools, tricks, and techniques are taught and while they all have their place, many doulas want to use all of them at each birth. I think that a reasonable goal for doulas is offering support mostly for partners - and encouraging the partners with their knowledge. In the end, it would be nice if the mother felt as if the father or partner completely supported her and did all these great things rather than the doula alone.

I also think that there is a misconception that if you have a doula you'll have a birth with fewer interventions or medications. Doulas are up against too many obstacles to even think about guaranteeing that their presence will lower the rates of intervention at hospital births. If women need a doula to protect them from their care provider or birth location then they need to seriously re-evaluate where they're giving birth and with whom.

Childbirth educators also face huge obstacles. The biggest job of a childbirth educator is to help deprogram this culture and their brainwashing about birth. I feel for childbirth educators and doulas: the job that the public expects from them is momentous amidst the medicalization of childbirth. There are so many women out there that desire a natural (unmedicated) birth in a hospital setting, two things that are completely at odds with each other.

I think that exposing women to normal, unhindered birth visually as often as possible is so important. Pregnant women in general enjoy watching birth videos - if the images offer realistic, but normal views on birth, things might start to change. I would love it if all women could be exposed to unassisted childbirth stories and images... somehow the idea of an attended homebirth doesn't seem as radical when they're shown something more on the fringe. We'd also see women who felt drawn to unassisted birth have a visual, concrete example of others who have taken that path and hopefully give them direction towards their ideal birth.

Of course, all of this is dependent upon the birthworkers' own view of birth. We cannot teach women about birth trust unless we believe it with all of our heart.

What does the unassisted birth movement have to teach midwives?
What doesn't it have to teach midwives? I owe a great deal of my education and continued growth as a woman and midwife to the unassisted birth community. I'm not sure why the UC movement threatens so many midwives. We give a lot of lip service to women who birth with an attendant at home as "taking full responsibility" for their births when the act of hiring a midwife implies that both the midwife and the mother together share responsibility. Women who birth at home unattended assume full responsibility for their choices and often choose to do so because of this fact alone. As midwives we need to be aware of how just our mere presence can change a woman's labor or birth in positive and negative ways, something that I don't think many people even think about. Reading unassisted birth stories can provide midwives and midwifery students clear perspectives on what women really want and need in birth.

A UK midwife once said that they see unassisted births all the time - births where the baby is born without assistance of the midwife. She pointed out that what we call 'unassisted' here in the US is really "unattended" births. If we as midwives could really examine who we are at births, why we decide to do the things we do, and what affect that could have on the motherbaby, we might start to see more "unassisted" births.


What are some of the major and subtle effects of the changes you’ve made in your practice on mothers and newborns?
I can only really speak about the changes that have affected me. I have clients who appreciate being able to control their experience, but I don't know how much more details I could really provide than that.

For me as a woman, seeing birth work in these ways has given me tremendous faith in nature and our perfect design. Through the changes I’ve made, I actually observe births from a very different perspective... rather than being anxious when the baby comes, jumping around to do so many different things, I sit and watch. I'm aware of things, but I'm not expecting them. I am much more moved by the emotional experience of birth now than I was before I made these changes. Whereas before I would rarely feel myself getting emotional at births, I now find myself tearing up a majority of the time. Birth is so awe-inspiring, but also so ordinary. We're mammals... this is what we do.

Do mothers who trust themselves to birth trust themselves to mother? Are their babies and toddlers different in any way?
I definitely think so, but maybe I'm being too simplistic. I know that when a mother is offered the opportunity to make her own choices regarding her prenatal and birth care she seems to gain a certain level of strength that carries over into other parts of her parenting. When a couple works together during labor and births their baby essentially on their own, the foundation for parenting has been set. Together they birthed this baby - and the unity they have created at birth carries over into their parenting.

I'm not sure if their babies or toddlers are actually different in personality, but surely a less anxious, more grounded mother will help foster a more secure attachment with her baby, right?

How do we teach our children to trust birth when they, like us, are growing up in a culture of fear surrounding birth?
The first obvious, huge hurdle is to trust birth ourselves as parents. We have to re-learn what we've originally been told about birth and our bodies. Talking about birth in very normal terms is important - so is teaching our children to question what they are told, even when the information comes from us. Keeping bodily functions and health out in the open is something I found beneficial in parenting my own daughter, who is almost 14. Through my work in childbirth, her exposure to information (videos, books) and even attending some births with me, she has definitely formed her own view about birth. She still maintains that when she is pregnant, she wants an unassisted birth, with no midwife, and will call me only when she needs something. This is not because I have told her how to think; it's based on what she has been exposed to and how she feels about her body as a female in our culture.

Do you feel that trusting birth extends to trusting other physiological functions as well, like death? How can we apply trusting birth to other scenarios in our lives?
Birth and death are very similar in our culture - they are feared and they happen behind closed doors in a hospital. Speaking to a hospice care worker at a family member's death, I realized just how similar birth and dying at home are. Midwives for coming into or going out of life do the same thing: they provide options for resources, choices in care, and support. They ease pain, they offer comfort.

Trusting birth means trusting the divine nature of our body. That belief carries over into every other part of our world in terms of body image and healthcare. It affects how we deal with other healthcare providers, what course of action we take when we're ill and what type of preventative care we employ.

Is there a place for doulas at a homebirth with a midwife who trusts birth and an unhindered 2nd/3rd stage?
I don't really have any opinion one way or another regarding doulas at homebirths. My only requirement is that the woman wants the doula there and they've discussed the type of labor/birth care they want from the doula and from me. Whether or not I would want a doula at a birth isn't really important, because the decision and ability to have one should rest with the laboring mother only.

What would happen to birth statistics overall if our entire culture had a radical shift to trusting birth? Which complications would decline the most?
We'd see a more reasonable rate of maternal and infant health overall, of course. I think we'd even change some ideas that could really benefit women who are high-risk or babies that are born premature (like delayed cord clamping, more kangaroo care, increased efforts for breastfeeding, etc). The biggest decline would be cesarean sections, as we would expect, but I honestly think we'd see a lower epidural rate and more active births. In turn, we would naturally see a rise in breastfeeding and helpful breastfeeding support within communities (as opposed to paid lactation consultants).

If as a society we began to truly trust birth and were able to rely on our mothers and sisters for reliable, empowering birth information, would there be less need for professional childbirth educators and doulas?
Yes, yes, yes, yes, of course. The outside information that a woman really needs to birth her baby is small. She has all the information that she requires already within her when she is pregnant. The only obstacle is overcoming the lies that we're taught about how faulty our bodies are - once this is shifted, the door is wide open for a woman to discover her own path to birthing her baby. Each woman is different and each way of laboring varied. Honoring that and treating birth in a very no-nonsense sort of way will help women find their own journey.

Doctor, Did You Wash Your Hands?

From the NY Times:
Despite national campaigns encouraging patients to take an active role in improving hospital safety, many patients aren’t comfortable asking doctors challenging questions about their care, a new report shows.

As much as we talk about changing the culture of birth in this country, and as much fault as we sometimes find with hospitals or obstetricians, nothing will change with our healthcare in general, or birth in particular, without consumers asking for that change.

Why do we treat doctors as authority figures? Why are we afraid of making them angry or disappointed in us? Why would we rather sacrifice our own or our children's health than risk offending? They do not naturally have that power or authority -- in fact, consumers hire their care providers. We have the right to receive the information we need, as well as the care. Would you tolerate it if your mechanic was snippy or evasive if you asked a question about a recommended repair on your car? Would you keep going back to that mechanic, and recommend him to your friends?


“Patients need to feel they can ask questions that may be perceived as challenging without causing offense to those involved in their health care treatment,'’ the study authors wrote.

Women, if you have ideas about how you want to give birth, you must communicate with your doctor. If you're afraid to ask questions or make your intentions known and stand by them, it's not realistic to think you'll get the birth you want. And if your doctor does seem offended when you ask a question, isn't that an excellent sign that s/he isn't the right care provider for you?

In addition to it being part of your own health, dealing with your care team is one of our first acts of parenting. Now is an excellent time to start advocating for your baby. Start with asking questions!

April is Cesarean Awareness month!

Promote Cesarean Awareness and tell a birthing family you love about ICAN and check out their fancy new website!

A friend of mine just had a baby, and the Cesarean rate of the women in her childbirth class was 57%. These were all first time moms who now have the choice between an elective Cesarean and all its attendant risks with their next births, or a VBAC which is increasingly becoming less of an option with many mainstream care providers. Mothers attempting a VBAC face the physical barriers and restrictions in place at many hospitals, as well as the emotional hurdles that come with attempting something widely regarded as "more dangerous" by the medical community and society at large. (for more information on the REAL risk comparison of VBAC vs. repeat Cesarean look here)

This problem is epidemic and it affects us all, whether we are birthing women or not. 57% of women in this class were told they couldn't birth their babies. This is startling, and wrong. It will not stop until we do something to stop it. ACOG is telling us the rising Cesarean rate is due to more overweight and older women getting pregnant and ignoring the other major issues like their own fear of litigation. It's up to us. We cannot know the possible effects that a large Cesarean rate could have on humanity at large. What we do know is that it has the potential to obliterate the confidence and feminine wisdom of an entire generation of women. Women deserve the opportunity to give birth vaginally without fear!

Pregnant women, what can you do to help reduce your risks of Cesarean? This is a short, quick and dirty list. I'll be posting more Cesarean prevention tips throughout April.

• Consider an out of hospital birth if you are healthy and low-risk. Both birth center and homebirth midwives have dramatically lower Cesarean rates than their hospital counterparts.
• Hire a doula. A doula can help you navigate the childbirth system and teach you how to ask the right questions to decide whether intervention is appropriate or not.
• Read EMPOWERING birth stories. Don't watch "A Baby Story" or shows that focus on "baby emergencies". Try both of Ina May Gaskin's books for a start. Focus on what your body is capable of instead of what can go wrong.
• Take a GOOD childbirth class. Consider an independent instructor. These classes often cost more but they are worth it because you're not going to be fed only what the hospital wants you to know. ALACE and Birthing From Within are organizations to consider.
• Turn that breech and try to prevent the odds of back labor with a well-positioned baby. This offers no guarantees against back labor, babies move throughout labor, but it's healthy to try! Do yoga, and check out Spinning Babies for more tricks and techniques for turning both breeches and posterior babies.
• Stay home until you are in ACTIVE LABOR! Simply getting to the hospital too soon skyrockets your chances of Cesarean. More on how to know "it's time" later...
• Choose your care giver wisely. Ask good questions, and expect them to give you open, honest answers. If you feel like they are being evasive, press harder. Don't put your care giver on a pedestal: you are the ULTIMATE expert on your pregnancy and baby, and they work for you. Don't be afraid to look elsewhere for answers or second opinions. TRUST is essential for a good relationship with your care provider. Another note on care providers: if your OB is known as "THE best C-section doc in town"...there is probably a reason for that. And it is more than likely because s/he performs a lot of them. Find out why.

Risk

When I'm talking about choices in birth, I've found the subject consistently turns to risk. What are the risks of home birth? What are the risks of hospital birth? What is the safest possible way to have a baby?

The fact is that risk is an inherent part of life, and birth is no exception to that. There are situations in which being in a hospital is very desirable when you're giving birth. Isn't it wonderful that we have that option, and the benefits of all modern obstetrical technology, available to us when it's needed? On the other hand, the mainstream medical community doesn't seem eager to discuss the risks of giving birth in a hospital. It's painfully ironic to me that midwives are stereotyped as superstitious women who walk around the house burning herbs and chanting, when in fact many -- if not most -- of the procedures in your typical hospital maternity ward are based on fear, ritual, and lack of evidence.

We all have to choose the risks we're comfortable with. Personally, I'll take the risks of birthing at home, over the risks of birthing in a hospital. I feel I'm much more likely to experience the risks of unnecessary interventions in a hospital than I am to face a true emergency at home. I only wish for all women to have the option to make their own choices without bullying, superstition, or manipulation.

This lovely post from Rixa at The True Face of Birth provides a great summary of the risks of VBAC and elective repeat cesarean. What a breath of fresh air! We cannot keep disrespecting women and their babies by refusing to provide them with enough information to make the right decisions for them. If a woman has had a cesarean, her next delivery carries risks -- it's insane to pretend that repeat c-sections are risk-free.

Women are empowered when they can make their own choices, not be pushed into what ACOG would like them to do. If both choices carry risk, we need to make sure that women can choose the risks they're most comfortable with. Is that really so much to ask?



PS A more specific look at some of the risks of home vs hospital birth coming... someday. I promise!

While I'm on a linking role

I recommend that you mozy on over to Hathor the Cow Goddess and check out her reaction to this article about oxytocin and its potential protection for babies' wee brains! "Is Oxytocin Obsolete?"

"Epidurals Are For Tolerating the Hospital, Labor Is The Easy Part"

What a great quote, from this blog entry about a mom's recent second birth.

Having a natural birth in the hospital is a huge accomplishment! Women really do deserve a trophy for it. A drug-free labor at home or in an independent birth center is (comparatively) easy.

Go Minnie!

According to this article, Minnie Driver is planning a home water birth when her baby arrives. Water is awesome for labor and birth -- it's an effective, natural pain reliever and being semi-weightless helps the mom change positions with ease.

Weighty Matters

Obese Women Gain Too Much Weight During Pregnancy, Study Says

Oh, Lord. Keeping up with the ACOG theme of women being too old and fat to deliver normally, this headline really chapped my hide. Yes, obesity has health risks, and ideally we'd all begin pregnancy in perfect physical form, but really, Dr. Artal, is pregnancy really one of the leading contributors to the obesity epidemic? Women should try to limit their weight gain during pregnancy because they're too lazy to lose it postpartum?

The article harps on the fact that the current guidelines for weight gain in pregnancy state that overweight women ought to gain at least 15 pounds. Considering that that would barely cover baby, amniotic fluid, and breast growth, that hardly seems excessive. I find this especially ironic considering that the obstetrical community, with few exceptions, rarely offers anything in the way of substantive nutritional guidelines to women in its care. Those that do often offer such gems as, "Eat lots of peanut butter!" (Actual quote.) I do have a client whose OB employs a dietician on his staff, and I give major props to him.

In the words of Anne Frye, "Our culture has a tremendous loathing of large, especially fat, women." Her sensible advice is that women of size should cut out junk foods and refined carbohydrates, consume plenty of high-quality protein, vegetables, and whole grains, and walk or swim daily. Doesn't that seem more reasonable?

This attention to the weight gained by obese mothers seems, to me, to be yet another example of a reductive approach to maternity care by the medical community. Instead of "how can we help this person have the healthiest pregnancy and birth possible, given factors X, Y, and Z?" we see more of a "shame the patient who dared conceive outside our guidelines!" If nothing else, it's not an attitude that is likely to win a woman (who likely already agrees that she ought to lose weight) over to the idea of weight loss goals in the postpartum period. I'm not even going to delve into the fact that a high BMI does NOT equal an unhealthy or uneducated patient -- and neither is a low BMI evidence of a healthy, active person!

The sad thing, to me, is that focusing on one part of a woman's health and taking such an alarmist attitude towards it squanders, in my opinion, an opportunity to begin a lifelong dialogue about taking steps to improve one's health, make better choices, and embrace pregnancy as a time to implement positive, permanent health improvements. Remember, folks, this is the same community that used to advise women to smoke during pregnancy to ensure a small baby...

Homeopathy for Mamas

Homeopathy is a field of "alternative" medicine that can be wonderfully effective at treating a variety of illnesses and ailments. It's especially good for pregnant and new mothers to explore because it is safe, natural, non-addictive, and can be used in conjunction with other remedies.

As someone who is relatively new to studying the field, I won't try to write a comprehensive homeopathic guide. However, here are some common remedies for issues in pregnancy, birth, postpartum, and infants. Use these as a starting point, and consult a more detailed guide for treatment recommendations. You'll see that certain remedies (such as Arnica and Chamomilla) come up for a multitude of symptoms -- these are the ones I'd recommend buying before you need them!

As always, consult your midwife or other practitioner for guidance before taking any new remedy.

Complaint	Suggested Remedy
For pregnancy
Morning sickness	Pulsatilla, Sepia, or Nux Vomica
Anemia	Ferrum Metallicum and/or Calcarea Phosphoricum
Itching	Sulphur
Constipation	Bryonia, Sepia, or NuxVomica
Groin pain	Bellis Perrennis
For labor
Back Labor	Causticum, Gelsemium, Nux Vomica or Pulsatilla
Panic/Anxiety	Aconite
Fast labor	Aconite
Exhaustion	Kali Phosphoricum and/or Arnica
Unable to urinate	Arsenicum, Arnica, Pulsatilla or Staphysagria
Shaking	Cimicifuga
Weepy or despairing	Pulsatilla
For postpartum
Hemorrhoids	Pulsatilla or Arnica Montana
After pains and soreness	Arnica Montana or Magnesia Phosphorica
Baby Blues	Pulsatilla
For breastfeeding
Mastitis	Phytolacca, Belladonna, Pulsatilla or Lac Caninum
Engorgement	Belladonna or Bryonia
Low milk supply	Urtica Urens or Lac Caninum
Sore/cracked nipples	Phytolacca, Silica or Sulphur
For the little folks
Bumps & Bruises	Arnica Montana
Bites & stings	Apis Mellifica
Fever	Chamomilla or Belladona
Teething	Chamomilla, Calcarea Phosphorica, Hyland's Teething Tablets, or Boiron Camilia doses
Colic	Chamomilla, Dioscorea, Hyland's Colic Tablets or Boiron Cocyntal doses
Earache	Pulsatilla, Hyland's Earache Tablets/Drops, or Similisan Earache Drops

Like my table? It's my first, and simple as it is, I still had to issue an HTML SOS to my husband when the table data was floating about in space. *sigh*

Online resources for more information and purchase information.
ABC Homeopathy
Hyland's
Boiron
Similasan
Elixirs.com
Gentle Birth Archives on Homeopathy
Find a Homeopath

Books:
Everybody's Guide to Homeopathic Medicines by Stephen Cummings & Dana Ullman
Homeopathy for Pregnancy, Birth, and Your Baby's First Year by Miranda Castro

The NYT on Doulas

The Fasion & Style section(?!) of the New York Times has a piece on doulas this weekend. If you like headaches, check it out. Tempting as it is to deliver a point-by-point response to the article, I'm going to limit myself to a salient few (below), and instead focus my energies on the very valid question of what, exactly, a doula's scope might be, and offer a few thoughts on why doulas are at the receiving end of so much hostility.

Scope of practice: What the heck is a doula?
A doula provides emotional and physical support for a mother before, during, and after she gives birth. She provides knowledge, resources, comfort measures, advocacy, and suggestions to both the mother and her partner. She doesn't provide any clinical tasks or assessments, make decisions for the mother, speak for the mother, or control the outcome of the labor.

One of the biggest problems in defining the role of a doula is understanding what advocacy means in this role. I think it's vitally important that doulas discuss this with their clients well before the birth to ensure that everyone is on the same page about her role. My personal definition is that I don't speak for the mom, but I will make sure her voice is heard. No one can labor for the mom -- she has to do it herself. Likewise, I believe no one can empower the mother -- she already possesses the power to birth within herself, and all we can do is encourage her, boost her confidence, and do our best to help her feel comfortable (both physically and emotionally). One of my biggest beefs with both doulas and their clients is the very false expectation that a doula can somehow save a woman from her labor or her care provider. (And doulas, just like birth plans, are no substitute for communication with your care provider.)

An independent doula works for the laboring couple, specifically the mother, and no one else. A doula in a hospital-based program works for the hospital, meaning that she may be limited in what she can do or say in ways that an independent doula is not. For example, a hospital-based doula might be obligated by her contract to "report" a woman who eats during labor, while an independent doula would not. Ideally, I firmly believe that the doula should be a bridge between the hospital and the laboring mother, not a wall. However, if I were faced with a hostile nurse (and I never have been, seeing as how I'm awfully charming), I will always come down on the side of supporting the mother's wishes. I am most interested in the parents' satisfaction, though it's nice when everyone's happy! (So are all the other doulas whose thoughts I know on the subject.) And if a case were to arise where the parents' wishes conflicted with each other (say, the dad wants her to be on the fetal monitors continuously, but the mom wants to walk and try new positions), I will support the mother.

So, who determines the role of a doula? As the Times already pointed out, anyone can call herself a doula. ALACE, DONA, and CAPPA are three of the biggest certifying organizations, and they all pretty much define the doula's role in the same way. The differences in the organizations would take its own post to explore, but I'd say overall ALACE is the least discouraging of its doulas taking on additional roles, such as becoming a monitrice and checking dilation and fetal heart tones , as long as they understand that they need training beyond the scope of a 3-day doula workshop to do so.

Being a doula isn't rocket science, but I think that training and certifying with the above, or any other fine doula organization, is a good thing. For one thing, saying, "I'm a DONA doula," or "I'm an ALACE doula," means something. A potential client can learn what that organization stands for and make some assumptions from there. I also think that it lends credence to a doula's role as a professional to have some sort of formal training. Finally, I think clients deserve to have recourse if their doula is unsatisfactory, especially if she attempts to perform way beyond the normal boundaries of her role.

Shorter labors, fewer interventions (including cesarean), increased satisfaction... What's not to love?
Often, the doula is the scapegoat for anyone who was dissatisfied with the way a birth played out, whether it's a nurse who had to accommodate intermittent monitoring, or a mother whose birth didn't go as she had planned. Remember, having a doula doesn't guarantee a certain type of birth; also, just because a laboring mom who has a doula is declining cervical checks, that doesn't mean it's the doula's doing!

I'd be remiss in my bloggy duty if I didn't also address the fact that many doulas do step far from the cozy confines of their scope of practice. I have read things on message boards (told by the doulas themselves) that make me extremely nervous for their clients and for the fate of doulas overall. I can easily understand why an OB would feel angry towards a doula who, for example, is dosing the patient with herbs during labor or attempting to cut off conversation about options for managing a complication.

But for the most part, I think the hostility towards doulas stems from the fact that they tend to make things a little harder for doctors and nurses. Supporting women's choices, even when it goes against the standard protocol, is one of the most valuable things doulas do. So if a doula's presence gives a laboring mom the extra support to resist Pitocin, to spend time off the monitors, or the idea to try pushing upright, the good that does the mother is beyond measure. However, the hassle for other care providers may be quite quantifiable: extra hours, extra paperwork, extra explaining to higher-ups of why this labor was handled the way it was. I'd love to hear from some actual hospital L&D folks on this, though. Anyone?

---
And now, a few responses to the article. First of all, I commend the Times for pointing out that not everyone who bills themselves as a lactation consultant is an International Board Certified Lactation Consultant (IBCLC), which is a highly-trained, experienced medical professional. Folks, you don't have to have any letters after your name to give good breastfeeding advice, but if a new mother is having serious trouble, she needs to be aware that the "lactation specialist" nurse who comes to see her in the postpartum recovery room might not actually know that much about breastfeeding. Hospitals (and all care providers) must start being more transparent about their breastfeeding support.

That said...

• Using a photo of a doula seemingly palpating a pregnant client's belly for the accompanying image... Why? Not that that is terrible or outside the scope of what is appropriate for a doula to do, but it almost seems like the editors are saying, "Look, here's a doula who thinks she's a midwife or something!"
• Why throw in lactation consultants along with doulas? The fields are related, but their roles are very different. The article seems to have an agenda of "exposing" the bad behavior/advice of a small percentage of these practitioners. Which leads me to my final gripe:
  
• I think, ultimately, few hospital-based birth professionals (and certainly not the author of this piece) understand the role of a doula. They may see the doula talking a woman out of an epidural and perceive that the doula is bullying her client. But often, she is simply fulfilling the role she was hired to perform. The doula Pamela Myers hired was perfectly within her scope to recommend avoiding IV fluids (as long as the mother hydrated in another way like, say, drinking water!), and firmly recommending a shower or bath is a time-tested method of pain relief.
  
  Walking out on a client who accepts an epidural is, obviously, very poor form. However, the article admits, "In an era of nurse shortages and high Caesarean rates, doulas and lactation consultants can be godsends for many women. Indeed, multiple studies show that a doula’s presence during childbirth leads to shorter labor, less medical intervention and a happier experience." And then adds, "[F]ew women readily admit to doula discord." What, then, is the point of this article?