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!

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.
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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.

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.

I suppose we have to address Christina Aguilera

This week, Christina Aguilera told Hello! magazine that she scheduled an elective Cesarean section out of fear of vaginal birth because she'd "heard horror stories about tearing."

Rather than addressing what I consider an impertinent debate that rages on about the validity of a women's "choice" to have an elective Cesarean, I'd like to talk about what's really important here.

Such discussions are inappropriate and useless until we start talking about the fact that little girls in this country are growing up in a culture so rife with fear of normal birth that women are choosing abdominal surgery with all of its attendant risks, a five fold increase in the risk of respiratory distress syndrome for their babies, and a higher risk of placenta accreta in later pregnancies which can result in prematurity, severe hemorrhage and hysterectomy.

Until we are working to change this culture of fear, we are not giving women choices in childbirth. We cannot judge women like Christina Aguilera until we implicate society's contribution to driving choices such as these.

By the way...there are much less invasive ways of avoiding tearing during vaginal birth. Some of the main ones include: choosing a midwife for your care provider, avoiding epidural anesthesia so you have control over your pelvic floor, NOT giving birth on your back but choosing your own comfortable, upright position, and asking your midwife to provide hot compresses on the perineum as the baby is crowning. If you do tear even with these efforts, rest assured that most tears heal far more quickly than Cesarean incisions and become infected way less frequently. With appropriate suturing and care, tearing should not cause any long term issues, which is more than can be said for an elective Cesarean.

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.