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.

Trusting birth, trusting our bodies

I met an interesting midwife on Monday who had some very thoughtful things to say about both homebirth and birth in general. Her main feelings on why women should stay home to give birth revolved around the hormone cocktail that is released during labor, and how that hormone cocktail is most effectively released when a woman feels safe. Conversely, when we don't feel safe, our sympathetic nervous system (otherwise known as "fight or flight") kicks in, and coindicentally enough, the hormones that are released under this system directly counteract the hormones necessary for women to relax and let go for labor. Since most of us feel safest and relaxed in our homes, the ideal place for birth is clear.

This is nothing new, these hormonal principles are what Michel Odent and others have used for decades to promote the idea that birth goes best when women are comfortable and either at home or at least in home-like settings. It makes a lot of sense especially when confronted with the staggeringly high statistics of artificially augmented and induced labors (Jennifer Block reports 40% of women answered that their labors were induced in the 2006 Listening to Mothers survey compiled by Childbirth Connection) in hospitals. While the reasons women are given for their induction being "medically necessary" are wide and varied, the message is clear: we don't trust your body to handle this process on its own. We don't trust it to know when your baby is prepared to arrive, we don't trust it to establish the contraction patterns we like (and what we call "normal"), and we don't trust it to expel your baby anywhere near quickly enough.

My thoughts stray to all the birth stories I've heard where the woman tells me that her uterus "conked out" or that her contractions weren't "regular" enough. The messages all imply a failure on the mother and her body. Or the mothers who have grown babies who were "too big" had pelvises that were "too small" (more than likely too small to birth in the lithotomy position"). Or the mothers whose babies overstay their welcome in the womb by a few days or weeks. All of these are candidates for induced or augmented labor.

This same midwife brought up the fact that women who give birth unassisted by anyone but themselves have remarkably good outcomes. In my quest to verify this, I obviously haven't come up with much in the way of randomized controlled trials studying the safety of giving birth unassisted. What I did find was a very much anecdotal and unverified poll from mothering.com, (it's here if you're interested) reporting a 2.1% Cesarean rate (after a transfer to the hospital, of course) compared to the national average hovering 30%, and a .72% rate of stillbirth, which is lower than or comparable to both home and hospital perinatal mortality rates. Fairly impressive considering these are births completely unattended by any medical professional. The midwife chalked this up to trust. Simple trust in the process and the body, that the day of birth is the same as any other day except you are having a baby. Now, I personally don't advocate for unassisted childbirth. My own belief is that birth is safest when quietly observed and unobtrusively monitored by a trained, experienced professional. However, I find the facts absolutely compelling. These women aren't magically growing babies that are just the right size coming on just the right date at exactly the right rate of progress during labor. The only thing that is different about these women is their intuitive trust in their bodies and their babies. I am also considerably awed that they have been able to cultivate this level of trust from within our culture of fear.

I read an article about a year ago about two doctors who delivered a baby unexpectedly on a plane. Neither doctor was a type of doctor that deals with birth on a regular basis, but they both seemed completely shocked that things had gone off without a hitch. One of the quotes that I remember most distinctly was one of the doctors saying "I wasn't sure how we were going to have enough room to deliver this baby. I mean, there wasn't even room for her to lay down!" Little did he realize that her at least semi-upright position was probably working in her favor.

Our culture has become so reliant on technology in birth that we don't even realize that it works without it. Arguably, for low-risk healthy women, it works better without it. Birth actually functions quite beautifully, even if it doesn't conform to pretty charts and graphs.

If all you have is a hammer, everything looks like a nail

Or, if all you have is a scalpel, everything looks like a surgery.

If you follow the debate about our culture of birth, you may be wondering how two sides can see the same physiological process so differently. OBs say birth is only normal in retrospect; midwives say birth is normal, period, until proven otherwise. Are women who birth at home unusually reckless or wise? Are obstetricians lying about the potential dangers of birth, or do they see scary developments in healthy women every day? Which side is right?

Here's the problem -- both sides are right. Midwives and supporters of natural birth are absolutely correct when they say birth is normal, safe, and healthy. Obstetricians and malpractice lawyers are correct when they say things often go wrong in birth, and that it often requires constant vigilance and management. When American obstetricians and midwives talk about birth, they're talking about completely different processes. In the words of Marsden Wagner,

"[W]e do not have humanized birth in many places today. Why? Because fish can’t see the water they swim in. Birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalized birth cannot see the profound effect their interventions are having on the birth. These hospital birth attendants have no idea what a birth looks like without all the interventions..."

Recently I came across an interesting New Yorker article. "The Score," by Atul Gawande, seeks to explain the industrialization of birth using the Apgar score as a template by which other outcomes, obstetric and otherwise, can be improved. Sounds great, right? After all, who doesn't want a practitioner who strives to be the best s/he can be?

But in practice, industrialization focuses not on being the best an individual can be, but on producing the best results from as large a group as possible.

"The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills... But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques... Obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section."

Basically, it's easier to teach someone to perform cesarean than to manage complications with less interventive techniques, especially since some MDs will not have the aptitude to learn those arts.

Shoulder dystocia provides a handy example in the article. He explains what it is, and lists several techniques that can be used for dealing with it, including Woods, McRoberts, Rubin, and breaking the baby's clavicles. But where is the Gaskin maneuver, a simple, extremely effective, and safe technique that simply has the mother flip over onto all fours, and which has a success rate of somewhere between 80% and 100%, depending on the study you're looking at? (For a clear and concise explanation of shoulder dystocia management techniques, see this post on The Lactivist.) Well, if you're attending a typical hospital delivery, the mother has likely had an epidural placed, and she's hooked up to various monitors, IVs, catheters, etc. In other words, even if she were capable of flipping over without serious assistance, nothing in the environment even suggests that as an option to her doctor. Apparently, it makes more sense for an obstetrician to push the baby back inside its mother and deliver it surgically (the Zavanelli maneuver) than it does to execute a simple position change. Midwives, on the other hand, are presented with a woman who may be upright, lying down, in the water, or supported in a squat by her partner, or some other variant of woman-led birthing. When the midwife is presented with shoulder dystocia, the Gaskin maneuver can be the very first thing she tries. Shoulder dystocia is shoulder dystocia... except that it's potentially very different depending on the setting and the attendant.

Gawande's article acknowledges that there is a downside to trying to regulate a human physiological process:

"And yet there’s something disquieting about the fact that childbirth is becoming so readily surgical. Some hospitals are already doing Cesarean sections in more than half of child deliveries. It is not mere nostalgia to find this disturbing. We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth. The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost...

Against the [Apgar] score for a newborn child, the mother’s pain and blood loss and length of recovery seem to count for little. We have no score for how the mother does, beyond asking whether she lived or not—no measure to prod us to improve results for her, too."

And there we have it. Variations in the course of labor are approached in such disparate ways by different groups of practitioners that we end up with two versions of birth that barely even resemble each other. An OB who sees technocratic birth every day can't imagine why someone would want to do something so difficult and dangerous at home. She isn't wrong in her assessment that the births she attends are potentially dangerous, but she is made ignorant by her education and training. Unfortunately, mothers and babies suffer the consequences of this ignorance. If only the obstetrical community would stop taking the results of their interventions for granted as normal, and start focusing on how to make birth as normal and safe as possible.

Where does this leave us? Sadly, in our current climate I don't believe we are near reconciling the polarities of our birth culture. In my ideal world, all OBs would spend part of their internship with homebirth midwives seeing what birth can be like. In the real world, activism is vitally important, whether that takes the form of lobbying your state legislature, or simply sharing positive birth stories with every woman you meet. But for practical advice on how to have a good birth, I'll once again quote Dr. Wagner, "The best thing to do if you want a humanized birth is get the hell out of the hospital!"

Big Push!

Want to protect and promote midwifery care? Get thee to the Big Push for Midwives, which launched this week.

"Increasing access to the Midwives Model of Care in all settings is essential to the health and well-being of childbearing women and their babies. The National Birth Policy Coalition supports legislative initiatives that promote the autonomous practice of Certified Professional Midwives and Certified Nurse-Midwives, and that ensure the availability of safe, evidence-based care during pregnancy, labor, birth and postpartum."

If you live in one of the states that has legislation coming up in 2008, please consider getting involved in the Push's efforts to get midwifery regulated and licensed there. Women deserve access to the gold standard of care for their reproductive health -- and that means we need midwives!

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!