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!

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.

Decisions, decisions...

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

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

Birth Setting and Its Impact on Breastfeeding Initiation and Success, Part 2

Fun fact: In a completely normal, non-interventive birth, the newborn baby has the ability to crawl up its mother's abdomen, locate the nipple, and latch on all by itself. Babies are born with amazing abilities and reflexes to ensure bonding -- and their very survival -- that many people never see. Newborn self-attachment (or the "breast crawl") is a cool phenomenon, but it's not the only way to get breastfeeding off to a good start. What's another method? See a midwife for your pregnancy, birth, and postpartum needs!

What Do Midwives Do to Support Breastfeeding?
The number one thing midwives do to support breastfeeding is that they don't interfere unnecessarily in labor and birth. Midwives understand normal, physiological birth, and they respect breastfeeding as an intrinsic part of the birth process.

Immediately after a midwife-assisted birth, the baby is placed on its mother’s abdomen or in her arms. Assuming all is well (and it usually is), basic assessments, toweling off, and other immediate needs can be addressed while the baby stays right there. The first breastfeeding can take place as soon as mother and baby are both ready, often within moments of birth. Weighing, measuring, the newborn exam, vitamin K, etc. can all wait for an hour or two while the new family bonds and enjoys each other.

What's happening in these first minutes of life? A complex, amazing hormonal fiesta, for one. The star of the show is oxytocin, the "love" or "mothering" hormone. Oxytocin is secreted during sex, orgasm, labor, birth, and breastfeeding. Mother and baby also experience surges of adrenaline and endorphins (which may play a part in bonding because endorphins function similarly to opiates). Finally, prolactin, the main hormone responsible for making and secreting breastmilk, peaks at birth. In these first minutes of life, the baby adjusts to the world outside the womb. The parents get to marvel at the new person they have made. Depending on who you ask, the first minutes and hours of a baby's life may even play a large role in who that baby becomes as a person.

When mother and baby are ready to nurse, the midwife offers guidance and advice, if needed. She will also note whether there are any factors that may have an impact on breastfeeding (such as tongue-tie) and make the mother aware of them. She will also add to her prenatal education of the couple by reiterating what is normal, what isn't, and making sure the mother is comfortable in this new role.

The midwife stays with the family for several hours following birth. She returns three times in the first week of life, and is available to her clients for additional counseling, support, and home visits if needed. If a new mother experiences difficulties breastfeeding, her midwife likely has all the skills needed to help her. She can also make referrals to La Leche League leaders, lactation consultants, and pediatricians, all of whom can play a role in supporting the breastfeeding relationship.

A baby who is assisted in its entry into the world is a lucky -- and almost certainly breastfed! -- baby indeed!

Birth Setting and Its Impact on Breastfeeding Initiation and Success (Part 1)

While you may already be aware that women who birth with midwife support have higher breastfeeding initiation rates and greater long-term success, you may not know that women who birth in the hospital without the support of a midwife may have their breastfeeding relationship undermined -- often before the baby is even born.

Management of Labor and Birth
Let's take a look at some of the ways breastfeeding may be undermined in a medically managed childbirth. Any of the following factors in isolation can hinder breastfeeding; in combination, they may prove to be extremely tricky for any but the most determined mother.

Drugs for Pain Relief
Narcotics, nitrous, epidural, oh my! The potential cocktail of drugs that may make their way into a laboring woman's body (and, crossing the placental barrier, the infant) is staggering. Narcotics can make both mother and baby sleepy and uncoordinated, and they run the (rare) risk of infant respiratory distress and/or unresponsiveness, which can last several days. Every anesthesiologist has his/her own blend of drugs for epidural anesthesia, so the effects of epidural vary. However, epidural pain relief is associated with fetal distress, drowsiness, poor sucking reflexes, and other newborn complications such as jaundice, which may impact the breastfeeding relationship.

Pharmaceutical pain relief of any stripe increases the potential need for interventions such as vacuum extraction, forceps, or cesarean delivery, all of which have their own associated breastfeeding impact. Other drugs during labor that can affect breastfeeding include pitocin, diuretics, anti-histamines, and magnesium sulfate.

Drugs ingested by the mother post-delivery also affect the breastfed baby. In fact, the FDA recently warned post-op mothers taking codeine (which the body converts to morphine) to watch for sleepiness and other side effects in their infants. A significant portion of the population metabolizes this drug so quickly that high levels of morphine will be present in their breast milk. In addition to the overall worry about overdose, a sleepy baby can be difficult to interest in nursing. Less suckling leads to lowered milk supply, as the supply/demand cycle of milk production relies on regular stimulation by the baby of the mother's breast.

IV Fluids
Bag after bag of IV fluids overload the body, causing edema (swelling). This can be problematic for the new mother because it can make the tissue under and around the areola too firm, even having a somewhat flattening effect on the nipple; it can also add to existing engorgement after her milk comes in. Babies need and expect a soft, pliable nipple and areola, so the swelling can make latching on painful or difficult.

IV fluids also pose the risk of artificially excessive weight loss in the infant in the first few days after birth. Because fluid overload can affect the baby as well, its birth weight may be inflated; when he or she processes and eliminates these extra fluids in the days following birth, that weight loss may prompt a misdiagnosis of breastfeeding difficulties, leading to more interventions.

Suctioning
Although it is occasionally indicated to help clear the airway, routine suctioning of the newborn's mouth and nose has been proven unnecessary, many doctors continue the practice vigorously during every delivery. This can traumatize the baby, especially if suctioning is roughly done or causes the baby pain, and lead an aversion to anything touching or entering the mouth. In extreme cases, the infant will attempt to reject any contact with its mouth or lips following this experience. In addition to the obvious mechanical difficulties suctioning can cause for breastfeeding initiation, feelings of rejection by her infant can undermine a mother's confidence in her ability to nourish him/her at the breast. A mother who states that her baby "didn't like" the breast likely had a traumatic suctioning experience or received early supplementation from a bottle.

Maternal Discomfort
A mother who receives an episiotomy during vaginal birth, or who delivers via cesarean, is likely to be in some pain (perhaps necessitating more drugs... see above). Just finding a comfortable position in which to nurse can be a barrier. New mothers should, ideally, be able to maneuver themselves and their nurslings into different positions to alleviate sore nipples and accommodate personal positional preferences for both mother and baby. Not being able to do so can aggravate problems and frustrate the mother.

Supplementation
According to Dr. Ruth Lawrence, "comfort sucking and formation of nipple preference are genetically determined behaviors for imprinting to the mother's nipple." Though some dispute the phenomenon of "nipple preference" in babies whose first feeding comes from a bottle, research clearly indicates that these babies have to be reprogrammed for the breast. Even a pacifier can disrupt early breastfeeding efforts.

Babies considered high risk for hypoglycemia (cesarean deliveries, large babies, those born to mothers with diabetes) may be supplemented with glucose water or formula even without a diagnosis of any blood sugar issues. Unfortunately, this can make the babies' blood sugar rise and then crash later. Colostrum has plenty of lactose to help elevate baby's blood sugar, and it also has plenty of protein to stabilize it. Breastfeeding every two hours is almost always the best treatment for hypoglycemia; even just skin-to-skin contact between mother and baby helps regular infant blood sugar.

Separation of Mother and Baby
Breastfeeding early and often is the most basic and effective way to ensure success. The first nursing should take place within at hour at most; delaying that first feeding disrupts hormone levels, impacts the milk supply, and even delays mature milk's arrival. The baby may be at risk of dehydration or excessive weight loss, which can lead to formula supplementation.

Babies also need as many feedings of the first milk, colostrum, as possible to receive its full immunological benefits and protect them from hypoglycemia and jaundice. When the nursing dyad's first feeding is delayed by hours, the baby will likely receive supplementation with formula (causing nipple confusion issues as addressed above, and often resulting in many supplemental feedings in those first critical days).

Unfortunately, constant mother-baby togetherness is the exception rather than the rule in the hospital environment. Even with a normal, healthy delivery, babies are usually removed from mothers' arms for assessments. Check-ups by the on-call pediatricians, baths, weighing, and administering medication are usually performed in the hospital nursery for convenience's sake -- at the expense of bonding and breastfeeding. And despite the increasing ubiquitousness of rooming-in, many L&D nurses will still offer to take newborns to the nursery for an overnight stretch to "let mother rest."

Cesarean
With a c-section delivery, you and your baby will likely experience all of the above, and more. We've covered how pain, drugs, separation from the baby, and (likely) supplementation can affect breastfeeding. Cesarean delivery also poses an increased likelihood of long separation (sometimes several hours, making supplementation more likely). Women also lose about twice as much blood during c-section as during vaginal delivery. It is normal for a mother's milk to take an additional 1-2 days to come in following c-section. More worryingly, however, is the increased likelihood of anemia for these mothers, putting them at high risk of insufficient milk supply.

Lactation "Support" (Or Lack Thereof)
In the medical model, the language and protocols surrounding pregnancy and birth undermine women’s confidence. Women who want a natural birth are warned not to be disappointed if it doesn’t happen. They’re told that breastfeeding is best, “if it works out,” and if it’s not going well, they’re told to “stop banging their heads against the wall." Unfortunately, having this negative language surrounding these normal physiological processes leads many women to doubt their ability to perform them. And if they do encounter difficulties, they are more likely to give up.

Most doctors don’t receive any training in supporting breastfeeding mothers and some aren’t even aware of all the benefits. The “help” moms get with their first breastfeeding in the hospital from a doctor or nurse may not be all that helpful; it’s frequently very high-pressure and ignores the baby’s cues. Lactation specialists, if a hospital has them on staff, often only work 9-5 on weekdays. Sadly many women never receive any specialized assistance with breastfeeding and are left to figure out solutions on their own -- or not.

And On That Happy Note...
Obviously, many nursing dyads overcome all these obstacles and more -- or never even experience them as being obstacles to a satisfying nursing relationship. However, it's important to be aware that everything we do to a woman in labor, even if it seems innocuous, or even if it's just hospital policy, can have an impact on her ability to breastfeed her baby.

In upcoming posts, I'll address how midwifery care differs in its support for breastfeeding, and also cover some tips for overcoming the breastfeeding hurdles posed by routine hospital interventions.