Birth plans have a bad rap. They've been around for decades, initiated by women who felt technology was being misused or overused in maternity care. They were right. Dr. Marsden Wagner, MD may have been the most outspoken voice warning of inappropriate birth technology. He was a perinatologist and perinatal epidemiologist and was director of Women’s and Children’s Health in the World Health Organization for 15 years. He traveled the the world to talk about improving maternity care, including the appropriate use of technology in birth and wrote Born in the USA, Creating Your Birth Plan, and Pursuing the Birth Machine.  As women became aware that their autonomy over maternal health care decision making had been usurped, they created birth plans to try to take back their power.
I would not dare suggest that birth plans haven’t been misused on occasion, although I would suggest they've more often been misunderstood. It is oft repeated by nurses and physicians that the longer the birth plan, the greater the chance of the cesarean. What is not clear is if this is the case because it is thought that women who draft birth plans have unrealistic expectations, or whether they are treated punitively because a provider is offended that a patient would dare 'dictate practice' - a common complaint amongst obstetricians.
HypnoBirthing®  has tried to address both of these concerns. In HypnoBirthing, we recognize that birth has a fair number of unknown potential variables. Thus, we prefer the exploration of options in what we call a 'birthing preferences' document instead of a ‘plan.’ It is lengthy. This is because we've found it is unfortunately all too common for mothers to not be apprised of all of their options by some providers. When discussing these options in HypnoBirthing class, it is a regular occurrence for parents to happily exclaim 'I didn't know I could (or didn't have to) do x, y or z!' For parents coming to HypnoBirthing for a 2nd, 3rd (even 4th or 5th!) baby, the exclamation usually holds a bit of outrage as they ask, "Why was I never told this before now?"
We also suggest that this is not a list of demands; it is a communication tool that should facilitate dialog about expectations and preferences. The first time a caregiver sees this should not be in labor. It should not be produced during a prenatal and immediately filed with a dismissive, "Yes, yes... whatever you want."
Parents should go over the available options listed on their birthing preferences document and research the reasons why, or why not, each intervention may, or may not be, appropriate or desired in their unique situation. When requesting something outside of the care provider's routine, the parents should be able to intelligently articulate why this is their preference, while respectfully acknowledging that should a medical necessity arise for said procedure, informed consent will be provided.
In approaching options in this way, most HypnoBirthing parents are able to forge a reciprocal, respectful dialog about appropriate, evidence-based, individualized care.
Sometimes, however, this approach results in an outcome the parents might not have expected.
Having gone to great lengths to find a provider they feel will respect their desire to be a partner in their own care, it can come as a rude awakening to find that this attempt to reasonably discuss their care reveals their provider as someone they didn't really know.
This recently happened with some clients of mine in central Iowa, Rose and Ben. They have generously given me permission to share their story.
Rose and Ben were a loving, motivated, engaging couple. Both were working on graduate degrees and very familiar with research. Indeed, before coming to their HypnoBirthing class, they had done a great deal of research and had some ideas of what might be important to them during their birth. Their research had led them to discover that in their area, it was unlikely that they would be allowed to be partners in Rose’s care. The physicians in the area had some very antiquated and non-evidence based protocols that were firmly enforced with no room for special requests. However, they found one physician who they were certain would be respectful of their wishes, though in speaking with them it sounded as if there might have been some red flags around the issue of a doula.
They came to their HypnoBirthing class about halfway through their pregnancy. They had built a relationship with this physician. As we discussed the birthing preferences they had already researched and those included on the HypnoBirthing birthing preferences document they expected the conversations with their caregiver would go pretty well.
After the next prenatal visit, Rose called me distraught. The conversation had most definitely NOT gone well.
These parents had not asked for anything that wasn’t evidence-based. The specific requests that were denied were:
The physician then, out of the blue, asked Rose if what she was really looking for was a home birth!
The exchange in Rose's own words:
[excerpted from the longer description]
“I then asked him if he had ever worked with someone who did HypnoBirthing.
He responded, "No, and I don't want you to be the first one."
I stated, "Well, I just did the training, and I will be HypnoBirthing."
Then I asked, "Do you know what HypnoBirthing is?"
He answered, "No."
I briefly explained what it was and that it really wouldn't affect him, but I would probably look different than some of his other patients as I would be in a deep meditative state (as long as I can do it).
I then asked about delayed cord clamping.
He said, "There is no evidence for that." He also said, "I don't know how long you want me to wait? 10 seconds or what?" He said that he would not delay because he had things he had to do. He also mentioned a risk of polycythemia (I believe). I asked what that was. He said it was when a baby gets too much blood.
I then asked about wiping off the vernix and uninterrupted contact for 1-3 hours with the baby.
He told me right after the baby was born he would place the baby on my chest, but then would be taken away, wiped off, warmed, and weighed.
At this point, I was not willing to push my questioning any further. He asked me at one point, "Why don't you have a home birth?" It seems like with all you have asked me (even in the past) that is really want you want.
I have never wanted a home birth.
I responded, "I want to be in a hospital in case there is a medical emergency. I don't want a home birth."
He told me I might be better of switching doctors and that if I decided to do so he would recommend some doctors in West Des Moines who would follow what I want to a T.
I was in shock and didn't know what to say. He told me at some point that he was not going to change standard practice.
He also said, "I've been doing this for 15 years, and... that's all I'm going to say."
Imagine how these parents felt: Someone they trusted had just pulled the rug out from under them and made them feel as if their requests were unsafe…before kicking them out of his practice.
As Rose shared: “After he left, I fought tears and finally broke down in the parking lot and called my husband.” and “I have never felt more judged and stupid in my life for wanting to do what is evidence-based.”
Rose’s doula is a birth activist extraordinaire, so within about a day, with Rose’s blessing, Iowa Birth Organization  and the organization Improving Birth, both regional  and national , had been informed about this rude and unprofessional treatment. Within about 2 days, an article in the UK was written about childbirth choices that referenced this story. Within a week, other similar dismissals from physicians in Iowa were surfacing.
Outrage was sparked, conversations were started. Rose is glad that the issue they now faced was being used in a productive way.
The insistence that what she must want is a home birth, however, is what piqued my curiosity. What did this couple request that might precipitate such a response?
Support of HypnoBirthing?
This year is the 25th anniversary of the launch of HypnoBirthing: The Mongan Method. Thousands of women around the world have used HypnoBirthing with fantastic results. Labors tend to be shorter, more comfortable and require fewer interventions. The rates of surgical births are lower than average and parent satisfaction is high. Caregivers who attend HypnoBirthing births find their jobs are actually made easier. According to statistics kept by the HypnoBirthing Institute, about 80% of HypnoBirthing parents choose hospital birth, with OBs, family practitioners and CNMs. The percentage of home births is admittedly higher with HypnoBirthing parents than the national average, but the vast majority of HypnoBirthing parents are still birthing is hospitals. How does choosing HypnoBirthing suggest anyone would be looking for a home birth? Why on earth would HypnoBirthing be objectionable to anyone working, or out of, a hospital?
Presence of a doula?
The documented benefits of a doula are not new.  Even so, the number of women utilizing the services of a doula have just begun to climb as the media has picked up on just how much better outcomes can be with the help of doulas.  Doulas can reduce the duration of labor, help mothers be more comfortable, reduce the number of interventions and complications. As with HypnoBirthing, a doula can make the job of the provider much easier.
A doula can be beneficial in both home and hospital birth. Who can’t use emotional support of a caring person through the one of the most emotional events of a lifetime? Doulas comfort, advocate, act as a liaison between hospital staff and even support partners who are supporting the birthing mother.
Many hospitals actually have in-house doula programs; in Iowa, Mercy Hospital Medical Centers of Des Moines do. In fact, while women birthing at home can benefit from doula support, it would be fair to assume that most women who hire doulas are birthing in the hospital, simply because at home the mother can surround herself with all the support she needs already…those roles a doula might fill in the hospital where nurses are busy with the medical tasks of monitoring birth.
At home, the mother has complete autonomy over her birth, has spent hours cultivating a relationship with her midwife and midwife’s apprentices, and knows she will encounter nothing unfamiliar during birth. That is not to say variables do not occur in birth at home, just that the machines that go beep and the number of strangers or set-in-stone protocols are absent. Midwives take informed consent very seriously and take the time to explain when and why alterations to the plan are necessary, thus an intermediary to explain is just not usually required.
Why would this be objectionable? When patients are encouraged to ask questions and fully understand proposed intervention they can make informed decisions. They are less litigious. It would seem that the only reason to object then would be to prevent informed consumers from being partners in their own care. A provider practicing evidence-based care would welcome dialog.
Delayed Cord Clamping?
There is indeed “evidence for that.” I’ve been teaching childbirth education classes for 24 years. There was an abundance of evidence against immediate clamping of the umbilical cord back then. For years, I directed parents to a heavily cited work compiled by Dr. Morley.  In the last decade, more studies have verified what Dr. Morley said all along.  and the subject has gained traction in the news in just the last couple of years. 
As ‘The Midwife’ reports  after attending one of Karen Strange’s Neonatal Resuscitation Provider (NRP) certification workshops:
“Babies need their full blood volume. It belongs to them. Only public demand will change the length of time practitioners wait before clamping the cord. The research is already there (has already been there for years) about the benefits of delayed cord clamping, and STILL practitioners will commonly clamp and cut the cord immediately after birth, despite the research. Now the only thing left to do is to educate the public so that they will start to DEMAND delayed cord clamping. If you need more proof, look up Dr. Nicholas Fogelson on You Tube and watch his grand round presentations on this. If you need to resuscitate, keep the baby attached to the cord, keep the baby lower than the placenta so the blood can drain into the baby, and milk the cord or have the mom give a few small pushes to get even more blood into the baby. None of the concerns about polycythemia/ increased bilirubin/ jaundice with delayed cord clamping has been confirmed by research.”
An aside for childbirth professionals:
Karen Strange’s NRP classes are phenomenal! If you have a chance to attend, DO IT! 
Hm. A request with oodles of evidence to support it and no credible evidence to deny it, yet it’s denied. What’s up with that?
This one is the most perplexing. The benefits are not even disputed. There are abundant resources to support this beneficial practice. 
One is even titled “Implementing skin-to-skin contact at birth using the Iowa model: applying evidence to practice.”  (Emphasis mine.) <smh>
Now, to be fair, the last two are simply routine at a home birth. Babies aren’t typically separated from their mothers and the cord isn’t cut at along as it’s still providing oxygen to the baby. So maybe that was what put the idea into this doctor’s head that the couple actually wanted a home birth…they requested evidence-based practices of home birth midwives.
Had this doctor not simply dismissed all of their requests out of hand, Rose and Ben could have provided reference and information on the evidence to support every one of their requests, probably even the NON-request NOT made regarding the safety of home birth, although they would have needed some time to look that up since it was NOT one of the requests they had previously researched.
The question is, why should they have to? Their requests were legitimate with well-established, long-standing evidence to support them. They were not made on a whim to purposely disrupt hospital protocol. They were not made for any purpose other than the safety and well-being of mother and child. Responsible parents were making reasonable requests. Shouldn’t their doctor know at least as much as they do regarding safe birthing options? Shouldn’t HE have the latest research available to THEM? After all, how many women have heard, “Are you telling me how to practice? Which one of us has been to medical school?” I know heard of mothers getting such a response often. If you haven’t heard the many variations, just visit the My OB Said WHAT? site.  Shouldn’t parents be assured that their doctor then practices evidence-based care? AGOG admits fully 2/3 of maternity care is NOT based on solid evidence  Shouldn’t the research dictate protocol?  Or at least allow flexibility in favor of the evidence when parents request that?
In the threads on Facebook that grew from this frustrating experience, several people pointed out that at least he was honest; he didn’t lead them on and then refuse their requests at the very end. Unfortunately far too many have also experienced this betrayal. Perhaps this physician did do this couple a favor. They’ve since found one of several absolutely wonderful CNMs around. Had he not shown his true colors, they might never have even contemplated a midwife.
They will get their safe, more gentle hospital birth. However, it's only because of their courage, determination and conviction that they (and their baby) deserve better. How many people feel like Rose, but don’t know they can take a stand? How many think this bully must be looking out for there well being, even though their gut is sending them clear communication that this treatment is unwarranted and unacceptable? How many women are too shy to take a stand? Are unsupported by their partner, or worse in an abusive relationship where their personal power has been stripped from them? What about women who are trapped in this practice because of their insurance? Do they deserve to be treated this way just because they can't leave?
I can’t wait to hear Rose and Ben's wonderful birth story. I just wish they could have had it without having to fight for it.
Kim Wildner is a HypnoBirthing Childbirth Educator of 24 years childbirth experience teaching in West Des Moines. She the author of Mother’s Intention: How Belief Shapes Birth. She has been published in numerous childbirth trade journals and speaks nationally and internally regarding topical childbirth issues. For information on the current class schedule see www.kimwildner.me
© Kim Wildner, 2015
Should I bother taking a childbirth class?
This was a question recently posted on a Facebook group of mothers who are hoping to birth naturally. The consensus of mothers who responded was essentially, “Nah! You can learn everything you need from books and online.” There seems to be many variations of this question lately, so perhaps it’s time to address it in a thoughtful manner.
What I am about to explain is really important, because an independent childbirth class is one of the best investments you can make in creating the safest birth possible. Yet I see mothers looking for free on-line resources because their hospital class is too expensive at $45, or $60 or whatever the local going rate is.
I am fully supportive of mothers educating themselves anyway they can. I am an admitted bibliophile. I have a lending library of my favorite pregnancy, birthing and breastfeeding books, including one I wrote (available in paperback and eBook) that I hope everyone will read: Mother’s Intention: How Belief Shapes Birth.
I also frequently scour the internet for the latest information. I can tell you, with 23 years as a childbirth professional, there is a plethora of misinformation out there. The problem is, you don’t know what you don’t know. If you are a first time mom (or an experienced mom who has only seen conventional hospital birth) seeking out information based on the most prevalent cultural biases, you will find a lot of bad information that will not get you a natural birth if that is what you seek. This is not judgment. This is a factual statement backed up by evidence. About 4 million women give birth each year. About ¼ of those will take a childbirth class at tall. Most of those will take the cheapest class with the least amount of time investment involved.
How’s this working for women? Surgical birth rates are now more than double what the WHO has stated is optimal to save lives: Almost 33%. Induction rates are out of control leading to increases in iatrogenic (doctor causes) prematurity. Daily, the Improving Birth #BreaktheSilence campaign shares heart-wrenching stories of women who went into their births thinking they just had to show up, or thought they had informed themselves adequately, but found they were woefully ill-equipped to deal with coercion, manipulation and misinformation. The website, My OB Said What?!? shares story after story of women who are treated badly in birth by doctors and midwives who seemed really nice. Women come to my classes for second, third or fourth babies, wounded by their previous birth because they believed all they had to do was trust the ‘professionals.’
Thus, I say kudos for even looking for information. Some women just don’t bother. One woman recently wrote in The cult of natural childbirth has gone too far, “When my doctor asked me what my birthing plan was I told her I was looking at it.” Having put all her eggs in this one basket, when she went into labor during Hurricane Sandy, her (non) ‘plan’ was shot. Her labor, “…wasn't pleasant or "natural,"" unsurprisingly.
Her take-away from this experience was that anyone who would want to birth naturally must be of the ‘cult’ of natural childbirth….as if there are not legitimate psychological, physiological, anthropological, sociological or philosophical reasons for desiring a natural birth.
My take-away was that every woman should have to take a childbirth education class as soon as she starts menstruating. She should not only know precisely how the female body functions and how birth works, but how to give birth (as opposed to ‘being delivered'). Because here’s the thing: epidurals sometimes don’t work; epidurals sometimes are contraindicated; weather happens, natural disasters happen, man-made chaos happens, cars break down, traffic jams happen, precipitous births happen. There are so many reasons you may be alone without assistance to birth your baby. If you do not know what your body/baby are doing, the fear/tension/pain/ cycle is initiated and the whole process is likely to be miserable. It doesn’t have to be.
Not to mention that the sentiment of, 'No, I didn't take a childbirth class, that's why I hired my midwife/physician/doula for' is intrinsically flawed. A midwife or physician isn't there to educate you in most cases. They will tell you to take a class for that. They do not have the 12+ hours it takes in addition to monitoring the health and wellness of you and your baby which is their job, to educate you on options, informed consent, anatomy, physiology and biology, or patient rights. Hiring a doula does not absolve you from those responsibilities either. They are there to provide emotional support and in some cases act as a consumer advocate, but even then, in the throes of labor it is not their job to try to educate you, from the ground up, on what options are available to you and why. Nor is it their job to run interference for you with a caregiver with a diametrically opposed birthing paradigm or to be in an adversarial position or environment. The purpose of a childbirth class is to make sure you have laid all of the groundwork for an optimal birth experience beforehand, and to make sure you have some small grasp on how you might navigate challenges and road blocks knowledgable and without regret.
THAT is why budgeting for an independent childbirth class is important.
In the last six months or so, I have gotten five inquires regarding my HypnoBirthing® classes. Two of those inquiries asked me to shorten the class series because they figured if they didn’t take as many classes, I would charge less. (I will explain in a moment why that is not possible.) Both of these were expectant mothers in professions requiring an advanced degree from two-income households. I fully realize that perhaps that doesn't mean anything regarding financial security. I do not know anyone's story. However, neither do people know mine when they make such a request. And it's complicated. I don't judge anyone for how they must place their priorities and I don't hold it against anyone trying to budget. There are currently things I deem very important that I cannot financially contribute to financially. I get it. I'm just saying that sometimes people making these requests actually are quite a bit more financially secure than I am, so they likewise shouldn't hold it against me when I can only do so much to help them.
One inquiry also wanted to reduce the class length (because she was due soon) and because of that felt the price should be reduced. Since she was some distance from me, I offered to conduct the full series via Skype. Because I would not have to pay for a venue, account for travel time, mileage or gas, I offered this class at a price $90 less than my $250 class fee. I felt that was pretty generous. Two other inquiries were requests for military discounts, which I happily provided.
Even though I offered to do whatever I could to make sure that anyone who wanted to take a HypnoBirthing class could take one regardless of their financial situation…short of the class actually costing ME money…only the two military moms ended up taking class with me. (They had BEATUFIFUL births, BTW.)
Two of these women actually wanted detailed information on how I came up with my class fee.
I find that odd. When someone hires any other professional, do they request a detailed account of just how the professional arrived at their fee? I have never hired a plumber, contractor, electrician, doctor, dentist or physical therapist and asked them first to itemize their hourly fee in justification. I think that the reason this happens to childbirth educators is because many hospitals offer very inexpensive classes. Often these classes are not only (comparatively) inexpensive, but require just a time investment of a few hours on the part of the parents.
The reason for this is that is two-fold. I know this as I have taught in two different hospitals.
1. Hospital-based childbirth classes are subsidized by pharmaceutical companies, diaper and assorted manufacturers of baby paraphernalia. They underwrite the expense of the class in exchange for the opportunity to market directly to you. This includes being provided a mailing list with your name on it so that they may market to you in perpetuity. Your class materials are made and provided by people who want to sell you stuff. That's why your email and mail box start filling up with advertisements and coupons. Your name has been sold to an untold amount of manufacturers.
I work ONLY for YOU.
The hospital, then, has little overhead for these classes. They have the salary of the nurse teaching the class, which is likely at least $30 per hour. The venue is an existing part of their facility, purposefully. Over the years, I have been informed by three different OB nurse-managers that the birthing facility at any hospital is their best marketing tool. If they can get you to birth at their hospital, you will bring future broken arms, heart attacks and illnesses to their doors. Thus, it is very important that you be really comfortable being within their walls.
2. The material you will be offered is representative of what you will be offered at their facility, not the myriad of options actually available to you. Think about it: If you are not able to eat or drink while in labor at their facility they are going to tell you that you are not allowed to eat or drink in labor. They are not going to add that the birthing center down the street does allow that. They are not going to tell you the many ways to turn a breech if one of the two doctors at that facility automatically schedules surgery for breech. They are not going to tell you the risks of an induction if that hospital has a 70% induction rate because two of the three doctors at that facility routinely induce at 39 weeks. (Yes, these are real examples.)
Not only that, but at $30 an hour, if you had a skilled professional who could be saving lives wouldn’t you prefer to limit the amount of time that person was in a classroom with a handful of people telling them how to be good patients?
In stark contrast, I have to provide the class in the format in which it is offered. I signed an ethics agreement with the HypnoBirthing Institute, and the syllabus is 5 classes, each 2.5 hours, 1 week apart. I am allowed to offer a ‘plus’ addendum for mothers who want some postpartum/early parenting instruction, but I may not offer it as part of the series. In rare instances I may conduct the 12.5 hours of instruction in truncated form. For instance, if someone doesn’t find me until the last month of their pregnancy, or a partner works a swing shift and the only time the two parents are available at the same time is on the weekend, I may offer longer weekend classes and do it in a week or two of weekends, etc. but I must provide ALL of the material in 12 hours +/-.
This is for the protection of the parents. There is really nothing in the 5 weeks of instruction that can be left out while still providing the same level of education & experience. If someone is telling you they can provide it in less, they are in violation of their ethics agreement which should make you question what they are leaving out. This class isn't like most childbirth classes. I've had doctors and nurses take the classes and say they learned quite a bit!
Likewise, just reading the HypnoBirthing book will not teach you what you need to know. HypnoBirthing is not just teaching the technique of hypnosis and voilà! Easy birth. It’s about releasing fear, the interaction of other parents, the expertise of the educator, practicum of many hypnosis techniques, and the facilitation of effective communication techniques with care providers so that you are more likely to be able to CREATE the birth you seek. It’s not luck. I’ve had people take my class after figuring they could just buy the book or take another hypnosis for birth mail order class that was cheaper, and then find that they could not reach the level of confidence they felt they needed for it to work for them.
Birth isn't a cerebral activity.
That being said, The HypnoBirthing Institute does not regulate how much I charge. I currently charge less than others in the area, and less than the HypnoBirthing fee average across the board, but I’m also totally willing to exchange energy. I am of the opinion that if a woman really wants this experience, she should have it. I’ll work with parents, if I can. As long as I don’t end up subsidizing someone’s birth by putting more time and energy into it than they do, and it doesn’t /cost/ me to teach, I’m game.
In order for this to not be my expensive hobby I must allow for:
People may assume that this is just the 12.5 hours I am in front of them speaking. Sadly, this isn’t even close. For every hour I am actually in class, I have about an equal number of hours preparing out of class. Sometimes more. This might include (but is not limited to): Responding to email questions from clients, printing handouts, researching the latest evidence-based care in childbirth education, etc.
Yes, I have to pay myself for my time on the road, my gas, the mileage wear and tear on my car, just like any other professional. If I’m teaching from home…bonus! I don’t have to charge much for walking down my stairs and setting up my equipment. However, I still had to purchase that equipment and it does actually still take time to set up and prepare for a class. My husband is still inconvenienced in that he has to occupy himself elsewhere for a time. While I no longer have to consider this, some independent CBEs have to pay for childcare, too. If I’m traveling offsite, sometimes I drive an hour each way. That is an hour I’m not doing something else that might contribute to my household income.
If I am presenting at a venue outside of my home, that usually means that at least 20% of what I make goes to the venue off the top.
No matter where I conduct class, I try to provide food and drink, which is usually anywhere from $10-$20 per class, depending on the size of the class.
In order to remain certified through the HypnoBirthing Institute I must fulfill continuing education credits. This often requires travel to attend conferences or classes. In order to remain insured (which also costs money annually), I must be a member in good standing with the National Guild of Hypnotist, which also has a continuing education requirement apart from the HypnoBirthing CEU options. This may also require travel and/or the expense of classes or conferences. There are also dues to be a member, just like in any trade organization.
Just like any other business, I maintain a web site I must pay for, I must conduct free presentations on occasion to promote my business, which not only requires an investment of time, mileage, gas, but promotional materials such as business cards, brochures, posters, mailings, etc.
In addition to teaching aids (movies, charts, teaching baby/uterus/pelvis, etc.) HypnoBirthing class materials include a 1/2 inch binder full of handouts I must print for each couple and the official HypnoBirthing text/CD set. This set is ONLY available in a HypnoBirthing approved class and is NOT what you purchase if you get the book from a store or online.
No one pays any of these expenses for me. All of the expenses must be paid before I can even think about paying myself an hourly wage.
I usually teach 4-6x per year, with anywhere from 1-6 couples in attendance. The most I’ve ever had in a class was around 12 couples, I think. I keep the classes small intentionally. There is a tremendous amount of material to cover and discussion is usually lively. If the class is too large, the couples often cannot form the relationships that lead to comfort with such intimate discussions. However, I would absolutely teach every night of the week if I could! If I did, I would happily pass the savings on to parents as much as I could while still contributing to my household income.
As you can see, I do this because I love it, not because I’m getting rich. I do believe my 23 years of education and expertise should allow me to make a living, though. I’ve earned that right.
I’ve seen amazing births as a result of it. I’ve seen women (and families) transformed by it, and I’ve made some really great friends along the way because of it. I’ve even been told I’m really good at it! :-) So, I will work with you in anyway I can that will meet both of our needs.
Sadly, when someone decides that an independent childbirth class isn’t worth the money for their first baby, I’ll see them for a subsequent birth, but they’ll come to that class because of a hurtful first experience. This is not the place to pinch pennies. You get exactly what you pay for. After taking my class, I’ve had people in tears asking why they never learned this when they took their first, in-hospital class. I’ve also had people take both my classes and a hospital class, only to tell me they are almost teaching the hospital class because the actual instructor isn’t sharing this vital information with the other parents.
Women spend months and sometimes tens of thousands of dollars to make decisions about their wedding, yet balk at what amounts to them as $20/hour for a few hours to prepare for their birth. Nurseries are planned, remodeling is done at the expense of often hundreds or thousand of dollars. We train for our jobs. Motherhood is THE most important job. The decisions you make about your birth can have lifetime of health and financial repercussions for you, your baby and your partner. Heck just avoiding an episiotomy or unnecessary first cesarean more than pays for the investment of a really great childbirth class. Like mine!
My birth work has revolved around helping women face birth Fearlessly with a capital F.
Tokophobia is the fear of birth. This fear may be present in women who have never given birth, due to stories they've heard or cultural influences. Some of these women may choose to remain childless solely due to this fear. Some may decide to have children at some point, but will base their birthing decisions on this fear; for instance, choosing to have a surgical delivery because their fear of the process of natural birth is overwhelming. Making decisions from a place of fear, especially if the fear is based on an erroneous assumption that has become a limiting belief, means that some women might make decisions that are not in the best interest of themselves and/or their baby.
The fear may manifest in expectant women who have prior bad experiences. Sadly, too many women entering the U.S. maternity care system come out disempowered, sometimes physically damaged or both, many suffering symptoms of PTSD.
Over the years, many women have shared their fears with me, so I have an idea of what the most common fears are. However, I'd like to understand more completely so that I can try to help address fear where it originates. Please forward the following survey so that I can gather the most complete picture possible. Thanks.
NOTES ON SURVEY:
The survey is now closed. I have the data and I even had someone working on a chart representation. The data has not disappeared down the black hole that is my desktop. (Though it is circling the event horizon.) Life has intervened, but I will post it eventually.
As I'm sifting through all this old stuff, I realized that I don't think I ever did say much about my trip to Singapore to speak at the National University Hospital. This might be because I was slightly preoccupied with the economy class DVT I had to deal with upon my return, but still it's sad because it was the trip of a lifetime!
Nearing the never ending Wisconsin winter of 2011 my friend Di Bustamante of Parent Link in Singapore and I were chatting on Facebook. I was complaining about the cold and yet more snow I'd have to shovel. She was LOLing as she enjoyed the content 75-85 degree temps of sunny Singapore. Then she asked me a question that changed my life in so many ways..."Would you like to come to speak at an even in Singapore?" I said, "YES!" without thinking twice. I live by the sage advice Tina Fey said she got from an acting coach (if I recall correctly): Always say 'yes.' Then figure out how to make it happen.
Honestly, I just wanted to thaw out.
I was to fill in for a speaker who had to cancel, so the line-up was being adjusted. The topic was Kangaroo Mother Care, which I knew a little about, but would require a crash course in order to speak cogently on the topic.
I feel it is important here to provide a bit of background. I am from a little tourist town of about 9,000 people. At the time of this trip, I had moved to a Wisconsin city of about 45,000 people. Big cities freak me out. I've traveled internationally, but never to Asia. I asked around for travel advice and many people, including my own doctor, made sure to tell me to take antibiotics and digestive meds. This amused my friend Di. She said, "You do realize Singapore is a First World Country, right? You can drink the water."
I set about making plans for the trip: researching and writing about the topic (the information distilled for the presentation eventually was published in Midwifery Today) and making travel plans.
Initially, my husband was going to go with me. His work prevented that. We tried to figure out a way for my grown daughter to go, but that didn't work out. Then my dad was going to go with me, but that fell through. As the trip approached, this small town girl was realizing that she was about to travel 1/2 way around the world, alone, to a great big city.
I was terrified.
Fortunately, my friend Di was sympathetic, worldly and witty. She walked me through the entire trip, from planning to my return.
Here is might be a good idea to interrupt the story to explain that the reason there are links for all of the places I visited instead of pictures is because all of MY pictures look a lot like this:
I arrived at the stunningly beautiful Changi International Airport. Di had suggested that I just take the MRT, which is the Singapore public transit system which about put me into a full-blown panic attack. I'd never taken a city bus and my one excursion on the 'L' was scary as hell. (When the conductor says, "Oh NO! You folks don't want to get off HERE! I'll take you back a couple of stops" you don't question it.) She finally assured me that the warnings to visitors about how hard it is to get a taxi are overblown, so that's what I did. (I needn't have worried about public transport, incidentally. I visited the train station later and it was clean, safe and efficient. I was envisioning what I had seen of U.S. train and bus stations, which had been pretty darn daunting, disgusting and scary. In fact, all of Singapore was easy to navigate, safe and clean. One of the expats commented that Singapore is a great first foray into Asia because it's 'Asia light'...meaning it is easy to get around, most people speak English, and it is so safe and clean.)
I was deposited at The Chinatown Hotel. I actually do have a clear picture I can share from my room:
What do you notice about this picture? Why, yes, the commode and the sink are IN the shower!
Mind you, since it was just me, I got a small, inexpensive room. The accommodations had I traveled with my Dad (or anyone else) would have been quite different. Singapore has some of the most luxurious hotels in the world. I wouldn't have been in those either, but I made note of a nice Holiday Inn in a convenient location I'd check out next time.
The next day was a HypnoBirthing® training conducted at the Petra Hypnosis offices. Besides Singaporeans, attendees included women from Korea, Australia, Canada (some of the attendees were ex-pats living in and around Asia) and elsewhere. The first night Fauziah treated us to a delicious Indian meal, and the second we went to one of Di's favorite eateries, which was also fabulous. (And where the fuzzy picture above of my new expat friends was taken.)
Next up was the reason for the whole trip...my contribution to the National University Hospital event.
Despite being provided with a map, I got lost finding the auditorium in Tower Block because this place is HUGE!
Singapore boasts a world class healthcare system, "...being reviewed as a model by the Obama administration’s healthcare team as it explores ways to reform the US healthcare system" as it should. NUH is a certified Baby Friendly Hospital, a distinction that few U.S. hospitals can claim. (6.9% of U.S. births occur in Baby-Friendly designated facilities.) Singapore ranks much higher in infant mortality (with 2.5 infant deaths per 1,000 live births) than does the U.S. (with 5.9 infant deaths per 1,000 live births). Singapore is loses fewer mothers, with the U.S. at 21 maternal deaths per 100,000 births and Singapore at 3. THREE!
I gave my presentation, I learned much from the other presenters, and even had a bit of time for Di and her lovely daughter to show me around. We saw the Singapore Botanic Gardens and then I tried to keep up with Di as we hiked about Bukit Timah Nature Reserve. Gorgeous!
I went home, wrung out my clothes (we were hiking in a rainforest, for pity's sake!), showered and took a nap before catching my plane home.
22 hours later when I arrived in Chicago, my right leg hurt quite a bit. It had been bugging me the whole week, but I thought I had leg cramps from so much sitting. I massaged my legs, stretched and walked trying to get the kinks out. Likely, I had the clots from the first flight (which cut me off at the knees...United Airlines seats SUCK!) and didn't know it. In fact, looking back over the previous year, I have to wonder if it had been building all year with about monthly 9-12 hour car trips and a week long flu that left me dehydrated.
People have commented that I was lucky I didn't throw a clot there. I am, but not for the reason people assume. I am positive I would have received the very best care there. I just don't know how we would have paid for it! I think we're still paying for it from the care I received here and we're insured!
Anyway, I went to bed, got up and went to work the next day. I worked at a Wellness Center, and after a lunch meeting I told doc my legs hurt and asked him if I should be concerned that I had cankles. He sent me directly to the hospital for an ultrasound which showed several clots in my right leg. She didn't even look at my left, which also ached but didn't hurt, per se, and wasn't swollen.
Off to the anticoagulation center for Fragmin shots in my belly for 9 days, Warfarin, and daily INR checks. If you don't know, Warfarin is rat poison. It is very effective in thinning the blood. In that first month, I popped a blood vessel in my hand for no apparent reason, and when on this drug, these are the types of things that you have to consider:
"If that happened in my hand, it could happen in my brain."
"I wonder how long I should wait to see if I stop bleeding before I lose a finger?"
"I wonder if I should be concerned about bleeding to death?"
It's rat poison and it feels like rat poison to take it. I gained 20 lb. in a month that I never was able to lose, (which the nurses insisted was not a side-effect, but upon visiting chat groups I found was a very common problem) I needed 4-hour naps every day just to function, and I would say that would be an exaggeration of what I was actually doing.
The blood tests I had done when the clot was discovered showed that I tested heterozygous (as I understand it I have one gene mutation out of two possible) for both Factor V Leiden and Prothrombin II gene mutations. My grandma also has this problem. It was being suggested that I spend the rest of my life on Warfarin like her. She has had several heart attacks and several incidents of being hospitalized for internal bleeding because this 'therapy' is notoriously hard to manage.
As soon as I could be fairly certain that the clots were stabile, I researched other ways to manage 'thick blood' without being afraid every day of my life.
Thus ends the tale of my journey around the world! I faced my fears and did it anyway, coming away from the experience enriched, with new friends, a little less fearful, and with new knowledge about my biology. WIN!
I'd go back in a heartbeat...on a better airline with prophylactic measures taken to avoid blood clots! I still don't feel comfortable in U.S. cities, but Singapore is a city I actually enjoyed and would like to explore.
Long Lost Interview with Sheri Menelli
Pea in the Podcast download from several years ago.
Harmony Birth Fair
Real Side of Birth Interview #1
Mother's Intention can be purchased at Amazon.com
An example of one of these unsupported practices is that of routine gestational diabetes testing in the absence symptoms or risk factors. A Guide to Effective Care in Pregnancy and Childbirth states, “The available data provides no evidence to support the wide recommendation that all pregnant women should be screened for ‘gestational diabetes’...” (pp. 59), and for good reason. In Understanding Diagnostic Tests in the Childbearing Year we find that this test is not reproducible 70 out of 100 times! It’s not accurate; it’s harmful to women (in that it is a ‘fasting’ blood sugar test, requiring a pregnant woman to go without food for 8-12 hours, and then ingest pure sugar syrup despite the fact that her pregnancy physiology makes her less able to cope with this unnatural overload), yet it is the ‘standard of care.’
Another example of nonsensical thinking is the story of a friend who broke her tailbone four days past her estimated due date.
She obviously was in a great deal of pain. At the hospital, she was told all they could give her for the pain was a commonly available pain reliever because anything stronger would be bad for the baby. BUT…if she went into labor, (or if they just would let them induce her), she could have an epidural or Demerol. She responded with, “Excuse me? Why is it not OK to relieve the pain of a pathological condition that is by its very nature painful, but it is OK for a normal, physiological process that can be quite comfortable without drugs?” (More on that later!) If she went into labor in 10-minutes she could have the drug, but not now? How does the difference of 10 minutes make the drug less dangerous? The same rationale makes it not OK for a mother to have narcotics/opiates in her system if she puts it there, but it is OK if the anesthesiologist does? I am not advocating illicit drug use here. I’m simply pointing out officially an estimated 76% (Sakala & Corry, 2008) of our babies are born under the influence of epidurals. Some admit that in their hospitals, the numbers are closer to 90%. (Mothering, 2010) Epidurals are comprised of narcotics and ‘caine drugs.
We ignore the nonsensical, the lack of evidence and the disingenuousness in our maternity care system at our own peril. If we do, we make our decisions and base our behavior based on misinformation. If choosing the interventions means choosing the consequences that’s a costly mistake to make. If we aren’t willing to demand accountability those mistakes are repeated, improving nothing. I hope to help those that expect more of themselves and for their children.
So, today I'm driving to the store and I see this woman struggling as she walks down the sidewalk with a baby in a carseat. I did not see her get out of a car and there was no car nearby, though she was heading toward the same store I was going to, and there was a parking lot.
However, this struck me as incredibly funny. All I could think of was the horrible infomercials that start out, "Has this ever happened to you?" that proceed to make the easiest tasks seem impossible without the incredibly stupid featured product.
I started cracking up thinking about the infomercial that would go something like this:
Has this ever happened to you?
Do you struggle with 15 extra pounds of plastic, just to keep your baby near you? Do you spend hours at the chiropractor or suffer with debilitating back pain?
Does your kid have to wear a helmet 23 hours per day because his head is lumpy?
(Positional Plagiocephaly and carseat overuse information here: http://publichealth.lacounty.gov/ivpp/pdf_reports/Infantile%20Positional%20Occipital%20Plagiocephaly%20from%20Child%20Safety%20Seats.pdfand here: http://www.oandp.org/jpo/library/2003_03_102.asp)
Has your little one been in danger of falling to his death in unsafe situations like being precariously balanced on a shopping cart?
Have you spent money you just don't have for ridiculous products that say they'll solve these problems, like straps, special covers, or handle padding or wheels?
Well suffer no more!
Who knew? Standard issue with every baby are...
Yes, that's right! A MOTHER'S ARMS! Even better, your baby was already born portable at a very comfortable 6-10 lb. average weight! Why, babies are even bendy so they can fit into all sorts of comfortable configurations in Mom's arms, Dad's, even little sister's and grandma's!
Mother's arms otherwise engaged and grandma no where to be found?
NOT TO WORRY!
There's a wrap for that! Since the beginning of time, mothers all over the world have needed to solve the problem of using their hands while not abandoning their babies. What do to?
Ergonomically designed, weighing mere ounces, portable and doubling as a blanket, and meeting all of your baby's in-arm needs, this stylish option is even affordable!
Never let this stupidity ruin your life again! <end infomercial>
Carseats are for cars. Carseats save lives when used properly in cars. Carseats can be a useful tool if you've just spent 2 hours driving a colic-y baby around to get him to sleep and are afraid that taking him out of the carseat will mean the shrieking will commence again. A carseat can even be helpful if you haven't been able to get the baby to sleep all day, it's now 7 pm, mom hasn't eaten a bite and holding a wriggling baby while attempting to eat would mean hot spaghetti on his head.
Honestly, why does hauling a baby around in an awkward plastic bucket make sense to people? Why does it make more sense to invent things that will attempt to fix or mitigate the damage...instead of avoiding it in the first place?
And ultimately, the saddest part is what we're teaching our littles. Dolls now come with carseats that toddlers are being conditioned to believe must be part and parcel. Please.
I didn’t intend to comment on the Time magazine cover mainly because it was meant to be incendiary and I didn’t have any desire to give it energy. There are plenty of people with lots of letters after their names stepping up to explain why breastfeeding beyond infancy is natural and normal. They are doing a fine job. They are spending a great amount of time bringing the science of our mammalian biology to the masses in order to turn this into a teaching moment and initiate dialog.
However, last night I had to wonder if they are wasting their time. I have been astounded by the amount of vitriol directed toward this mother and mothers like her who follow their maternal mammalian instinct and nurse, as the World Heath Organization suggests, “...up to two years of age or beyond.” and per American Academy of Pediatrics guidelines recommending breastfeeding for “at least 12 months and for as long thereafter as mutually desired.” I am very much saddened by the harm this reaction does to mothers and babies. It is this that prompted me to share my observations.
My work for almost a decade has been to examine why certain birthing and parenting practices persist, despite the evidence that they are ineffectual at the very least, and in some cases actually known to cause harm. I believed for a long time, like those who are sharing information regarding term breastfeeding (for as long as 'is mutually desired'), that providing evidence would result in a paradigm shift for those who just hadn’t based their opinions on solid facts. After metaphorically beating my head against the wall for years in just such an endeavor, I came to the conclusion that providing facts will not change beliefs.
This was supported by a conversation I had last night on Facebook. The background is thus: A lesbian friend I know to otherwise be open-minded and compassionate commented that this cover was ‘disgusting’ and disrespectful of women. Another woman agreed and commented, “And gay marriage is wrong?! Pa...leaze!”
I only know one of the three women who partook in this exchange, but I have no reason to believe the others aren’t just as reasonable and compassionate, so my response was, “Just because you aren’t used to seeing it doesn’t mean it’s wrong. The pose was meant to be provocative and controversial, but nursing a 3 year old is healthy and normal and backed by science.”
Now, I thought that was a pretty benign response considering the disrespect being shown to women who are following a biological imperative...by other women no less. Not only that, but by women who have been disrespected by others who don’t understand them solely based on ignorance of biology. I kind of figured that was the end of it.
However, yet another poster suggested that it would be fine if the milk were pumped and given in a glass. I found that interesting considering that belief is based on the cultural (and might I add quite patriarchal) sexualization of the female body and ignores the biological fact that breasts exists to feed our offspring. I pointed that mammals posses mammary glands, and are actually classified as mammals because of this. I asked if toddlers with bottles elicited the same ‘ick’ factor. She said “no.”
In our culture, it is acceptable see toddler with a bottle or pacifier. If one stops for a moment to think about why that is, it is because we understand that mother’s milk provides sustenance to children beyond infancy, and sucking is a hardwired response to dealing with stress for babies and young children. Ok, now take the next step...why? Because before the advent of bottles and formula, the baby would be at the breast for those purposes. In many places around the world and for many people, that is still the case. Pacifiers and bottles are man-made devices meant to replace the breast...in effect to replace mothers. Anyone can do the job of feeding, nurturing and comforting once the woman’s special role is eliminated.
My response was, “I'm just wondering at the logic. A bottle doesn't ick you out because it is a cultural norm...but NOT a biological one. The parallel was provided for gay marriage. This is abnormal CULTURALLY...not naturally. Same concept. I'm not saying it's not 'strange'...as in you don't see it in a bottle feeding culture. However, naturally, it is NORMAL.” Mind you, I was not the first to bring up gay marriage, but as I said earlier, I did find the comparison appropriate for the simple reason that those who object to gay marriage do so on the grounds that they believe it is wrong. That is their belief, which is not supported by fact. The objection to nursing beyond infancy is based on belief, not fact. In my mind it made perfect sense to point this out, because I felt that perhaps the vehement response of these women was a visceral one and that once they saw we had some common ground, we’d come to an understanding.
A couple of comments that followed are what made me realize that wasn’t going to happen.
One was: “My logic is at the age of 3-6 a child is old enough to begin to understand body parts/basic anatomy. The time to wean children from breast feeding should be well before this, in my opinion, before there could be any confusion.”
Again, there is no confusion unless one has internalized that breasts are first and foremost sexual playthings. I use my hands for sex too, but that doesn’t mean I don’t use them for other purposed related to parenting my child. I haven’t heard anyone yet make the contention that hands are objectionable.
Next was: “People can write anything they want, even people with credentials.”
I’m sorry, but to me this reads as, ‘My mind is made up and I don’t want to be confused by facts from a legion of immunologist, anthropologists, neurobiologists, cellular biologists, neonatologists, perinatologists, psychologists or pediatricians.’
I brought up the WHO recommendations, which was met with, “You can throw every organization in the book at me and I still won't change my opinion. But do not sit here and draw a parallel between being gay (not a choice) and breast-feeding into toddler ages (a choice) because as far as I'm concerned you're comparing apples to oranges.”
At which point I checked out of the conversation with, “Yeah, 'cause facts never do change beliefs. I get it.” And I did. I suddenly realized that evidence is pointless in a case where someone has based their opinion on nothing more than a belief devoid of facts. Of course I knew it. I’ve written about it extensively. What surprised me in this case was it was a woman I wrongly assumed would be above shaming other women for something that’s perfectly natural.
The comparison was to people's opinions about gay marriage and people's opinions about duration of breastfeeding. So, for one, we are talking about culturally derived OPINIONS...definitely apples to apples. And both are a choice. Gay persons can and do certainly live in relationships not defined as marriage and always have. They can't always do so openly, and they are not afforded the same legal protections as couples who are 'married.' To be married and to fight for the right to be married is a choice. The same could be said for placing arbitrary limits on nursing a child that are based on nothing but beliefs about it that are not based on fact.
As far as I’m concerned, the comparison is apples to oranges only when the facts about breastfeeding are not understood. Misinformation only persists and proliferates when people refuse to educate themselves. In this case, it harms women and children to allow this to continue, and the feminist in me just can’t let it go.
Nursing into toddler years at this point in time is admittedly a choice because we have replaced (in our culture) that which is natural and normal. Thus, our children probably won’t die if we don’t breastfeed into toddlerhood. We have the ability to manufacture bottles, and glasses and mother’s milk replacements. We have exemplary sanitation and access to nutritious food (again, in the US and other developed nations, but not everywhere). Yet many women make the choice to bottle feed (or breastfeed for a limited time) because they feel pressured by culturally imposed ideas of what is ‘normal‘ and expected.
The poster seemed to assume I am not a lesbian woman in her objection to the parallel drawn between gay marriage and extended nursing. At first, I found that interesting, until I realized I assumed she was. She was correct, however. I’m not a lesbian woman. I admittedly cannot possibly understand what it is like to live as a lesbian woman. I did live and work with 400 lesbian women for a month, and 25,000 women (about 60 percent of whom were lesbian) for a week. During that time, the assumption of many people I met was that I was a lesbian or bi-sexual woman, which gave me just a taste of how women are often treated when they don’t fit the cultural norm. It also afforded me the opportunity to have many meaningful discussions with lesbian women about discrimination, cultural assumptions, patriarchal power and more. While I experienced a good deal of disapproval for many of my unconventional parenting practices and life choices, I will admit nothing compared to what I experienced during that time, or what my friends live with daily.
So when (someone I assumed to be) a lesbian woman pointed out how wrong it is for people to oppose same-sex marriage while at the same time using the same criteria to denigrate another woman for pushing societal boundaries, it made me wonder about a lot of things. For instance, how many gay and lesbian persons chose to get married to someone of the opposite sex not because it was what they knew was right for them, but because it was what was expected? Because they felt pressure to conform to some cultural idea of what was ‘normal’ that was not based in fact, but beliefs? Not their own beliefs, but those of the culture at large, no less. This is where I saw commonality.
Historically (and still in underdeveloped nations or in our own where poverty is prevalent) not nursing a child beyond infancy meant a high infant/child mortality rate. In the absence of clean water and abundant food, if another human mother wasn’t available to nourish the child, the child died. Let’s face it, before we became an agrarian culture, it’s not likely we would have tried to capture a sabertooth tiger or mastodon for their milk. While suckling from a different species does happen throughout nature, it’s not all that common. And without buckets, cups and bottles, not really all that practical for human babies.
Even with the advent of domestic animals we could constrain and containers to hold their milk, cow’s milk is made for baby cows who are born weighing 100 pounds and have 4 stomachs, not baby humans who are about 8 pounds at birth and have 1 stomach. Pediatricians warn against giving babies cow's milk because it is so bad for them. Yet guess what most formula is made of? Cow's milk! (Or soy, which is eminently worse.) And without proper understanding of the role of sanitation in wellness, many babies would still have died from such a substitution.
Today, in places where food and clean water is scarce, extended breastfeeding still saves the lives of children, not to mention the lives of women. Breastfeeding reduces the risk of breast cancer, and the longer the woman nurses, the more protected she is. The longer a child nurses, the less likely they are to become obese, which is certainly a problem for our youth today. None of this even touches on the healthy emotional development for a child that comes from having all their needs needs met in their mother’s arms. Because here’s the thing...babies who are nursed from birth have no idea that YOU think of breasts as sexual. None. To them, it’s lunch and comfort...and always has been.
Yes, today we have breast pumps and bottles and glasses. The fact remains that these things are cultural contrivances that replace Nature’s already perfect system of delivery of the perfect food. Breastmilk contains 400 substances that cannot be replicated in a laboratory, including white blood cells and other immunological factors that protect against disease in the child’s environment. (In fact, it is such a beneficial substance, it is sometimes prescribed for adult cancer patients.) Direct from the breast, it is sterile.
No mother should nurse beyond what is comfortable for both she and her infant. Neither should a mother feel shamed into weaning before she and her child both feel ready. Likewise, no woman who wants to breastfeed should endure disapproving looks or hostile comments from people who objectify women based on the erroneous belief that breasts are primarily sexual.
I find it very sad that women, especially a subset of women that are themselves misunderstood and maligned due to other peoples BELIEFS about them, devoid of facts, would be so unwilling to actually learn about why extended nursing is not only acceptable, but beneficial on so many levels. That these same women would impose the same cultural restrictions that others try to impose on them.
I know mothers who have been harassed for nursing a toddler. Women have had their 2 or 3 year old child away from them because someone in power didn’t understand that it is normal and natural to breastfeed a toddler. Women are discriminated against and harassed every single day for nursing even tiny babies in public. Further, the reasoning behind why these people who disapprove feel that women should hide themselves away in bathrooms to feed their baby, put a blanket over their baby's head, should just stay at home if they 'have' to do that, or pump and bring mother's milk in a bottle when out in public come from the EXACT same objection; that breasts are sexual and therefore seeing them used to feed a baby, even if it is the most natural thing in the world and the best for baby, makes people uncomfortable. To this I would ask, if you are gay or lesbian, have you been offended when you have heard someone proclaim that gay or lesbian affection in public is 'disgusting?' Do you think that what you know to be natural and healthy should be hidden away because someone else who is ignorant of the facts, and chooses to remain that way, might be uncomfortable? Do you feel that the discomfort of others should dictate the parameters of your relationships? Many nursing mothers pretty much feel the same way.
I actually agree that the cover is disrespectful of women, but because it pits women against each other, not because I consider nursing a toddler offensive. And as seen in the exchange that prompted my musings, it encourages women to judge other women in exactly the same manner as others have judged them. It infuriates me that women would do this to each other. It needs to stop.
This is a feminist issue. Unless and until we, as women, support each other regarding natural and healthy choices, we invite vilification of women by others who would like to control what we do with these amazing bodies we are blessed with. This is important, so I had to speak up.
by Kim Wildner
Imagine if you will, a woman who has just discovered she’s pregnant. If she lives in the United States, one of her first thoughts will likely be that she has to make an appointment with her obstetrician.
From that first appointment the woman usually acquiesces to test after prenatal test throughout the pregnancy. She will likely accept a plethora of interventions throughout her labor and birth that in many cases are, at the very least, uncomfortable or stressful (or both), and in some cases painful. She may be facing a fear of the unknown with courage henceforth unknown to her. She does so for the sake of her baby. She sacrifices privacy, and in some cases dignity, because she believes it will keep her child safe and herself healthy.
What if the vast majority of women and babies are delivered safely because birth is a reasonably safe, healthy, physiological function of the mammalian body? In other words, what if the end result could be the same in a way that focused on the joy and wonder of the process of procreation…not on every possible thing that could, but is not likely to, go wrong?
In the U.S. today, most people assume that medically managing birth makes it safer. It is widely accepted that the interventions in pregnancy and birth serve a purpose…in effect, that they are safe and effective. Does the evidence support these beliefs?
To assess whether birth is safer medically managed as opposed to expectantly managed, I believe we must first examine how obstetricians became the primary caregiver for birthing women. As an experienced childbirth educator, I’ve discussed this with parents, and without exception, the belief has been that birth originally shifted from a midwife monitored event at home to a medically managed hospital occurrence due to safety reasons. That is an erroneous assumption.
According to The Official Plan to Eliminate the Midwife: 1900-1930 (Gibson, n.d.), at the time that birth moved to the hospital, there was little doubt that midwifery was the safer option. Through early professional journals such as Transactions for the Study and Prevention of Infant Mortality (1910 – 1915), which Gibson obtained through Stanford University Medical Library, we have a unique glimpse into history. She quotes Dr. Ira Wile as saying in 1911, "In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’"(as cited in Gibson, 2006, Part I), and she attributes the following to a Dr. Levy in 1917, "Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month. These figures certainly refute the charge of high mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals" (ibid.). This, despite the fact that 80 years prior, Dr. Ignaz Philipp Semmelweis had admonished physicians for not washing their hands before attending women after handling cadavers, which he suspected was one reason for their high rate of childbed fever, and subsequently higher mortality rate (CDC, 2001). He was ridiculed.
Midwives would have had no idea their vocation was systematically being eliminated to provide “clinical material”…pregnant women…to obstetricians (as cited in Gibson, 2006, Part II). Even if they had known they couldn’t have done a thing about it. Women didn’t even have the right to vote.
Since that time, there has never been a definitive study showing medically managed birth with obstetricians to be safer than expectantly managed birth with trained midwives, though there have been those that have tried (Pang, 2002). The conclusions and methodologies, however, have been called into question (MacCorkle, 2003; Vedham, 2003; Citizens for Midwifery, 2002; Gibson, 2006; Strong, 2000, pp. 222-223). In fact, Jock Doubleday (Doubleday, 2005) has been offering progressively larger amounts of money, with $50,000 being the last offered in December of 2005, for anyone who can provide such a study. The reward has stood unclaimed since he first offered it in 1998.
Childbirth is safer than it was 100 years ago (Johanson, Newburn, & Macfarlane, 2002). Undoubtedly, it is safer to give birth in the U.S. than it is in many places throughout the world. However, to assume that if obstetricians now attend birth, then improved outcomes must be due to that development alone is a fallacy that does not take into account improved nutrition, sanitation, disease control, birth control or any number of other variables. There are many contributing factors to improved health and well-being in the childbearing year (Wagner, 1994). In fact, countries that enjoy the modern advancements mentioned above in addition to midwifery care have the best outcomes in the world (Strong, 2000), and “…there is never a doctor in the room” (Wagner, 1994, pp.124). Where exactly does modern obstetrical management place the U.S. in comparison to the rest of the world? There are 42 countries with lower infant mortality rates (Central Intelligence Agency, 2006) and 29 countries where fewer mothers die (World Health Organization, 2004, pp.23).
While this may be surprising to some, certainly, it is not to suggest that the practice of obstetrics is unnecessary. We need surgeons and experts in pathology for a small number of cases that might be deemed high risk, such as mothers who have pre-existing medical conditions or mothers with addictions. The evidence suggests that number should be a very small percentage (Johnson & Daviss, 2005; Declercq, Skala, Corry, Applebaum, & Risher, 2002).
In essence, the system under which the U.S. currently operates could be analogous to hiring a cardiologist as a personal trainer. Could heart attack deaths be reduced by having surgeons immediately available in the event that a normal, but strenuous, activity turned tragic? It’s very likely. However, would a game of tennis be imminently more difficult, if not impossible, if mobility were restricted by an assortment of electrodes and devices strapped to the player to assess every biological function and make the job of the cardiologist easier?
If this seems like an absurd analogy, consider this: the image that most of us have of birth is of a woman in bed, usually on her back, pushing out her baby, possibly with her feet in stirrups, or her legs being pulled toward her ears by herself, her partner or a nurse.
The path the baby follows is called the ‘curve of Caras’. Mothers are expected to push baby uphill in typical hospital birth. Why? Is there some physiological reason that mothers are expected to lay on their backs? No. The reason mothers are restrained to bed is so that the monitors can be hooked up and so that the doctor can sit comfortably at the end of the bed.
Women are told throughout pregnancy to avoid laying on their backs because oxygenation to the uterus can be impeded by the weight of the baby resting on the vena cava. Does the position suddenly become safe in labor? No. This position is detrimental to babies, and it creates pain for the mother because the weight of the baby rests on her tailbone (Lamaze, 2005). The position also makes the pelvic outlet considerably smaller by resting the mother’s weight on the tailbone, this flexing it inward. It makes the final stage of labor much harder than it needs to be. It almost guarantees the perineum will tear(Walsworth & French, 1998). Therefore, episiotomies are done to prevent tears. This means healthy perineal tissue is cut to prevent tears that would be unlikely to occur if the mother were not in a position that creates conditions for tears. Does it work? Think about it. If you try to rip a piece of whole fabric, it remains strong. If you first cut the fabric a tiny bit, it rips easily. The same is true of the human flesh. Fourth degree lacerations (where the perineum rips through to the rectum) happen almost exclusively with episiotomies (Goer, 1995).
All of this so the baby could be continuously monitored, and for the convenience of the provider, without any regard for how it impedes the process of birth, the danger it introduces into the process, or the comfort of the mother. It is not supported by evidence as safe, is not backed by common sense or evidence as effective for, well, anything. Yet it is a nearly universal intervention.
At this point, it might be argued that by constantly monitoring the baby, we can avert a terrible tragedy by knowing moment by moment what the state of the baby is. Except that what the evidence says is that the routine use of continuous electronic fetal monitoring does nothing but increase the rate of surgical birth without any improvement in outcomes (Goer, 1995; Wagner, 1994).
The act of giving birth becomes more difficult, and in some cases impossible, due to the assortment of wires and devices meant to assess every biological function.
Each obstetrical intervention was created for a specific medical indication for which, when used appropriately for that indication, it is effective. Unfortunately, instead of being used selectively in exclusively pathological situations, many interventions are used routinely within a healthy population, in part due to the litigious environment in which physicians must operate (Carpenter, 2004).
The following graph (Wildner, 2006) illustrates some of these. It shows the percentage of women who will experience the selected interventions under different caregivers, with no substantial difference in outcomes. (I created a chart to use as a visual comparison of the frequency of interventions used by obstetricians and midwives, but was unable to convert the format to insert on this blog. However, it showed a high rate of 6 different common interventions for doctors and nearly nonexistent rates of the same interventions by midwives.)
If we can obtain virtually the same results without performing them (and we can), why are they being done? How many of these common procedures proven safe and are they effective?
Two interventions deserve special consideration. These are procedures deemed ‘elective’, which is a bit misleading, because a woman may ‘elect’ to have them, but should she ‘elect’ to refuse them, they may be performed under court order (Irwin & Jordon, 1987).
These two procedures, induction of labor and cesarean section, while they are extremely important life-saving measures when used for medical indication, are perfect examples of obstetrical technology gone awry when used for convenience.
The World Health Organization suggests that induction is medically indicated no more than 10% of the time (as cited by The Coalition for Improving Maternity Services, 2003). Yet, according to the Listening to Mothers survey, (Declercq, et al, 2002) 55% of mothers were induced, even though there is acknowledgement that induction increases risk (Baxley, 2003; Rubin, 2006) and the chemical agents, such as Cytotec, used for elective induction are not approved by the FDA for such use (Haire, 2001; Physician’s Desk Reference, 2003). In fact, not only is Cytotec not approved for elective induction, it carries a serious warning not to use it for induction at all (U.S. Food and Drug Administration, 2005), which does not seem much of a deterrent to the American College of Obstetricians and Gynecologists (ACOG) or the American Academy of Family Physicians who “…supports the safety and effectiveness of vaginal misoprostol (Cytotec) for cervical ripening and labor induction” (Weaver, 2006) contrary to the scientific evidence.
The Centers for Disease Control, (CDC, 1993) and the World Heath Organization, (as cited by The International Cesarean Awareness Network, 2004) recommend rates of surgical birth not to exceed 12-15%. The U.S. is currently at 29.1% (Dress, 2005), meaning at least half of these surgeries are medically unjustified. Obstetricians contend (Rubins, 2003) that the increase is due to ‘maternal request’ surgeries, to avoid such things as urinary incontinence later in life, or sometimes due to fear of pain, supposedly the case with Britney Spears. Yet, vaginal birth is not a factor in urinary incontinence (Albers, 2003; ACOG, 2005), despite what some doctors may suggest (Healy, 2006). If women are requesting surgery over natural birth, which some sources doubt (Lamaze International, 2006), then one would wonder if they are being apprised of the significant risks (Thornton, 2006). Risks that are perhaps worth taking if the life of mother or baby are compromised…but not worth introducing where none previously existed.
People often say that in the end, all that really matters is that the mother and baby are okay. Is that really all that matters? What if the mother and baby could have been safe without adding insult to injury?
While some authors merely tell women they should expect care with no basis in science (Murkoff, Eisenberg, & Hathaway, 2002) others defend over-treating in order “To be sure that not even one baby will be harmed during delivery” (Tuteur, 1994; Part III-Common Obstetrical Practices). Is that a realistic goal? Is it being realized? Not as evidence by the many people who have studied obstetrical management versus midwifery attended pregnancy and birth for the last 25 years or so (CIMS, 2003; Johnson & Daviss, 2005; Enkin, Marc, Keirse, Renfrew, & Neilson, 1995; Gibson, 2003; Goer, 1995, 2002; Wagner, 1994, 2003; Stewart, 1981; Keefe, 2001; Tillett, 2005). If success is measured by results, the U.S. obstetrical system could do better. In those 25 years, infant mortality has actually worsened, (Kristof, N., 2006) and maternal mortality has remained unchanged (CDC 1998; CDC, 2003).
While this may seem an indictment of an entire system it truly isn’t. It is a call for reformation. Obstetrics have at their disposal the most advanced technology in the world. However, when you have a hammer, everything looks like a nail. By transferring care of healthy women and babies to midwives, only the actual ‘nails’ reach the ‘hammers’ through a referral from midwives, guardians of normalcy. Obstetricians are then able to use their considerable skills to benefit the women who really need their help. Under this new paradigm that views birth as a natural process, health care costs would be reduced, (Druley, 1998) maternal satisfaction would increase, (Villagran, L., 2006) outcomes would improve and obstetricians would get the recognition and respect they deserve for doing the job they were trained to do. Everyone wins.
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My name is Kim Wildner. I am the author of Mother's Intention: How Belief Shapes Birth.