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.

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!

Birth plans are no substitute for...

Open and adequate communication about your needs and desires with your caregiver.

I've been mulling this one over all week, trying to pinpoint what exactly makes me so uncomfortable about ACOG stating that they encourage women to write birth plans instead of having homebirths (there are actually MANY reasons I'm uncomfortable about it...see my letter to ACOG below.)

The natural childbirth movement has raised up the Birth Plan like a revolutionary torch to reform birth in America, when in reality, Birth Plans mean quite little to birth professionals all over the country. Every childbirth author from Kitzinger to Simkin will tell expectant mothers to write one. But in all honesty, the words "birth" and "plan" really shouldn't have ever gotten mixed up with each other. Anyone who has been around birth realizes that it rarely goes as planned. Don't get me wrong, I'm not upholding the rallying cry of the "birth is an emergency" movement and saying that things often change dramatically, rapidly and drastically for the worse, rather, merely that birth is the unfolding of a process, and there are myriad different twists and turns that process can take, much of it dependent on how much unfolding is permitted to happen. Expecting the unexpected is a large part of working with birth.

My issue with Birth Plans are this: it seems that too many women put off actually discussing (or evendeciding on) their desires for birth until the time comes to present their Birth Plan. They hope to avoid verbal confrontation or resistance by showing up with a piece of paper that outlines their wishes, assuming it will be easier for the care provider to just agree to what's in writing instead of having to ask difficult questions of someone in a perceived position of authority. I know that for me personally, this is exactly what I did. I had asked questions of my care provider throughtout pregnancy and up to that point been presented with what should have been unsatisfactory, vague answers. When said care provider saw my Birth Plan, the response was less than stellar. In fact it was dismissive and sarcastic, and what inspired me to change providers and birth location at 37 weeks.

The problem with Birth Plans is that in a lot of cases, they mean virtually nothing if hospital policy is in conflict with the requested care. Too many women are writing "I want the freedom to eat and drink during labor" and "No IV unless medically necessary" without actually finding out if their hospitals even permit these practices. It's important to note here that there is practically nothing you absolutely have to consent to in the hospital, but if it is their policy, they will do what they can to get you to comply. Do you really want a fight over every item on your Birth Plan? If you are against every single policy and practice at the hospital, perhaps you should reconsider giving birth there. Just as if you are asking a homebirth midwife to perform tasks beyond her normal scope of practice, perhaps home is not the appropriate location for your birth.

Another issue that is up for interpretation is "medically necessary". Most Birth Plans start out with a paragraph that states the birthing mother will deviate from this plan if the health of her baby is in jeopardy and thus medically necessary. The mere fact that women include this paragraph illuminates clearly just how little faith our culture has in birthing women. Where exactly are these women who are putting the health and lives of their babies at risk in order to stick to the Plan? It should be assumed that women will obviously do what needs to be done in the case of a true emergency. However, instead of writing "No episiotomy unless medically necessary" or "I prefer to go into labor and avoid an induction unless medically indicated" on a Birth Plan, simply asking your care provider in what instances they perform an episiotomy or an induction yields a better and more open response. Rather than telling them how to do their job, you give them an opportunity to tell you how they practice. And regardless of what is written on your Birth Plan, that is the kind of care you are going to receive too. You owe it to yourself, and to them, to find someone whose philosophy is aligned with yours, rather than trying to change and battle for the kind of care you want from someone who doesn't offer it. Asking a highly technological OB who is quick to perform Cesareans for a non-interventive birth is no different than going to a homebirth midwife and asking to have your water broken and be induced at 39 weeks with an automatic episiotomy culminating your birth experience.

It bears repeating from a different source. Diana Korte writes in The VBAC Companion that women need to find out how their care providers generally practice because "the care you receive will be similar to what your doctor does routinely with other pregnant women in her care." Again, rather than simply coming in with a list of preferences, ask how your provider prefers to practice. This is a much more effective, open, and honest form of dialogue. Beware of anyone who says they "never" do this or that. Even the best providers use interventions, no matter how rarely, in certain circumstances. It's wonderful if your provider will agree to use intermittent vs. continous electronic fetal monitoring, but you should find out in which instances your provider feels continuous monitoring is safer and more beneficial.

What worries me about ACOG's endorsement of Birth Plans is that they could be counting on women to be taking cozy comfort in having their wishes in writing but not necessarily ever questioning their doctors in person. I hate to sound like a conspiracy theorist, but considering how condescending and paternalistic the rest of ACOG's statement on homebirths was, I'm not sure it's so far-fetched. Much of what is commonly requested on a Birth Plan has very little to do with the doctor since it often occurs long before the doctor shows up to catch the baby. A Birth Plan is not legally binding in any way. Without these important discussions with your care provider, a Birth Plan has little more value than a letter to Santa. And perhaps ACOG is banking on that.

Dear ACOG,

(I'm going to have to post my response to ACOG's latest statement on homebirths in several parts, because there's just so much to say. My first will be in letter format, thanking ACOG for all the good works they do.)

I am writing to thank you for your news release providing a statement on homebirths. Your honesty and complete willingness to come out and make a public assault on women's rights is refreshing. Most organizations who conduct business that undermines women do so quietly and with subtlety, whereas you put your complete inability to trust that women might actually know what's best for their body and their baby right out in the open. Bravo!

I'd also like to thank you for clearing up some misconceptions I've clearly had about the reason for the skyrocketing Cesarean rate. I thought maybe it was because most breech babies are now born by Cesarean because your members no longer have the skills necessary to assist a vaginal breech delivery, or because at least 300 hospitals in the U.S. have banned VBACs, and women who have had previous Cesarean deliveries are often being forced into another one. Or gosh, even maybe due to the fact that the vast majority of labors in the country are being either induced or augmented with Pitocin requiring continuous fetal monitoring which is notorious for raising the odds of a surgical delivery. But thanks to your statement, that the Cesarean rate is due to the "rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes", I now realize women are being surgically delivered because we're just too fat and old to do it the old fashioned way!

Thank you also for realizing that women are so brainless and negligent for their welfare and that of their baby that they will choose homebirth because it is "trendy". To me it appears the epidural seems to be more "fashionable" since 80% of women now opt for such pain relief while less than 1% of women are choosing homebirth, but I'm so glad you cleared up that silly theory! I'm sure you're equally concerned about women choosing elective Cesareans because of Britney Spears and Posh Spice. You know, especially since babies born via planned repeat Cesarean have a 4 times greater risk of respiratory distress. Especially since even women having their first Cesarean double their chances of having a peripartum hysterectomy, while women on their second or third have an 18 times greater risk. But I'm sure you're on top of that, and what can you do if women are just choosing to have them, right? And it's not like you can just make your OB's perform VBACs, right?

I'm glad you've clarified your position on Birth Plans. I'm sure now your members will start taking them seriously. Because you know, before this statement, a lot of OB's were reacting to Birth Plans with reactions from ridicule to outright rage. I'm sure the news will also trickle down to those OB's who pressure hospital childbirth educators not to teach pregnant couples about Birth Plans.

Lastly, I want to thank you for being so clear and open on just how important you think "the birth process" is. Selfish is the woman who dares not to let the birth process unfold just how her OB actively manages it. Ignorant is the woman who expects something out of it besides a scar and a healthy baby. The homebirth movement must include all the women who don't have that incredibly powerful instinct to protect their unborn baby the second they find out they are pregnant.

Thank you, ACOG, for exposing yourself and women for what they are. I hope you can continue to undermine women's rights in an open forum, because trust me, more women need to realize what ACOG is all about.

Fondly,
Amie

Anger Towards ACOG

I'm trying not to be angry about ACOG's (The American College of Obstetricians and Gynecologists) latest statement on home birth. I'm hoping Amie will weigh in here with some of her eloquence and humor, but in the meantime, a few quick excerpts and responses...

The American College of Obstetricians and Gynecologists (ACOG) reiterates its long-standing opposition to home births. While childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.

This reminds me of the OB in The Business of Being Born who said her problem with home birth was, "What about monitoring? Do they do fetal monitoring?" In other words, ignorance of what midwives actually do at a home birth. And which complications are they concerned with, exactly? The medical community tends to use that ominous word without delving into what they mean by it. (They also like to say, "If you'd seen what I've seen...") Midwives are highly trained professionals who know how to deal with (rare) emergencies, and who will, if necessary, transport care to a hospital setting.

ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births.

So, basically ACOG doesn't support women's rights to make informed decisions regarding her delivery and choice of provider.

Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre.

Because .5% of birth represents a fashionable trend. But I think really this is a dig at Rikki Lake.

Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades and ACOG remains committed to reducing it...Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice...

If ACOG is so interested in reducing the number of cesareans, then WHY do they keep harping on cesarean by "maternal request"? (See this great pdf from the Lamaze Institute for an excellent summary of the issue and references.) Especially when you consider the fact that most women aren't actually requesting them?

It should be emphasized that studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous. Moreover, lay or other midwives attending to home births are unable to perform live-saving emergency cesarean deliveries and other surgical and medical procedures that would best safeguard the mother and child.

And the BMJ study is what, chopped liver? I love how they use the term "lay midwife," to imply someone with little or no training. It takes time to prep an OR, even if you're in the hospital. Cesarean doesn't just happen by magic. Often a homebirth transport patient can have a cesarean as quickly as a patient in the hospital, since her midwife (a highly trained, competent professional) can alert the hospital to their impending arrival and need.

ACOG encourages all pregnant women to get prenatal care and to make a birth plan.

No one in the hospital will read your birthplan, but it's nice to know ACOG supports us having them! Oh, and midwives provide excellent prenatal (and postpartum!) care.

The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.

Wait, homebirthers don't care about healthy babies?! I chose a home delivery the second time around largely because I felt it was safer than the hospital. But the second line is what I really want to address. The "process" is important. The "process" can be magical, empowering, and beautiful. The "process" can give birth to a stronger woman, can lead to a more satisfying breastfeeding relationship, and can make bonding so instant and intense that the mother won't hesitate to advocate for her child for the rest of its life. The "process" can also belittle, abuse, and devastate both mother and baby. If ACOG doesn't see the value in birth itself, then all the rest of this is beside the point. ACOG just doesn't get it.