Birth Matters

What do I do now?

2009-03-17T09:00:00.000-07:00

(written to a woman who transported from a homebirth and had a cesarean)

Control. Seems to be a strong theme in my life right now. Or rather, my ultimate lack of it. I may get a bit spiritual here, so reader beware.

One thing that I can guarantee is that your next pregnancy and labor will be different from your last one. Every pregnancy, every baby, every labor is unique to itself.

As I wrote in my last letter, in the end, the only responsibility we have is to plan the safest birth we can. There are lots of things we can do, techniques we can learn, knowledge we can gain, expertise we can hire, wisdom we can cultivate, trust we can give, surrender we can make....and all of these things are really important. All of these things can be something that the outcome of a birth hinges on. And every single one of them can be trumped by the universe. And the universe resolutely refuses to give us the guarantee we demand. If you believe in a deity, then you may believe that you are guaranteed an ultimate outcome to your life....but my experience has been that specific outcomes are often, quite deliberately, not revealed to me -- all I'm given is the assurance that there's a plan I'm part of and it is bigger than I can understand....if I believe my God is good, then that needs to be enough in the end (not saying this is easy or that I'm any good at it. I'm not.)

Most of the time, left alone, women have vaginal births. You have the extra burden of not having made the usual mistakes you could then blame your cesarean on. You get to face the universe not caring the same way you do a lot sooner than many. You "should" have had a vaginal birth; after all, you really did do so much "right". That's a scary place to be...what if there's something fundamentally wrong with you? Hang around ICAN long enough and you'll have the opportunity to meet some women who've had to deal with that -- planned a homebirth with a good midwife...ended up cut. Now what? What more can they do? A former president of ICAN had 3 cesarean, the third a failed homebirth...while president of ICAN. And then she had a homebirth with her fourth. Why? I don't know.

I don’t know.

I hate that phrase. Everything in me rebels against not knowing. Why was I in the 10% of clomid users to have twins? I don't know. Why was I then in the 10% with double breech twins? I don't know. Why did this happen to me, who cared SO much about not having a cesarean. I don't know. To make me stronger, bring me to ICAN, this excuse, that rationalization and so on? If any of those are true, that's not good enough. I didn't want a cesarean. Period. I don't know why I had one, not really, and I have a feeling there's no reason out there that I can understand that would make me say "oh, ok, that's why." What I do believe, because, well, that's my world view, is that there was a reason and that no matter what the reason, good or bad, for my betterment or because this world just sucks sometimes, the experience can be (and has been to a great degree) redeemed....over a lot of years with a lot of mileage between then and now.

So what? Well....chances are good that you'll never find a "reason" for your cesarean that you can "fix" and then not have to worry about another cesarean. I can tell you that you'll always have to worry about another cesarean because all pregnant women have to worry about it. Even if you do find a thing to
fix....there are other reasons to have a cesarean and we just can't control most of them (any of them? I guess we can control elective repeats by not signing up for them and we can control for failed inductions by not consenting to induction but are there any others?)

I don't like fake it till you make it. I believe it’s fundamentally dishonest to one's own self. But, sometimes we do have to keep moving even while we look back and try to figure stuff out. If you don't find something to pin your cesarean on, what will you do the next time you are pregnant? Will you plan a repeat cesarean? Or will you go ahead and plan another vaginal birth, maybe at home....and do it, even though you are scared to death you'll have another cesarean? You do have control over what you plan. So keep asking the questions, keep picking through the wreckage and know that ultimately, we all reach that moment when we have to surrender to something that's just a lot bigger than we are, whether you call it birth, universe, fate, karma, evolution, luck, random chance or god.

I've really come to believe that those women who have the sorts of births (or VBACs) where they pat themselves on the back and say "see, I did this, that and the other thing and that's why I got my VBAC" are mistaken about how much credit they can take. They may have made good choices and that may have made a difference (then again, saying "no, I won't sign up for a repeat" might be all it takes for some women to have a VBAC – heck all it takes for a lucky few is to go into precipitous labor before the scheduled cesarean – talk about the importance of plans and choices! ) but in the end, they were blessed that the universe had an outcome in mind that fit what they wanted. Don't get me wrong, bad choices can certainly change an outcome...but think about all the bad choices that end in a vaginal birth.

This is like trying to resolve free will and predestination if you believe such things...they are both true and they are both at work. I guess birth really is life. I don't know why you had a cesarean. I really wish you hadn't. And I really hope you have a VBAC next time. And I know that chances are, you will. And until you do, you won’t know whether it will really happen or not.

What If?

2009-03-16T15:07:00.000-07:00

I do not think you are kidding yourself about planning a VBAC and this is why. Your responsibility as a mother is *not* to not have a cesarean or to have a VBAC. Your responsibility is to plan the safest birth for you, your baby and your family. That's it. Now, obviously and for lots of really legitimate and important reasons, we all hope that the safest birth for everyone involved is a vaginal birth, because no matter what the circumstances, necessary or not, surgical delivery can really suck. So the question I would ask you is this -- are you planning the safest birth you can? If your physical condition does change for the worse, will you continue to plan the safest birth you can even though doing that might be incredibly painful and disappointing? Are you doing everything you can to keep as healthy as you can? Do you understand your risk factors and how they could impact the choices you have? Are your circumstances now different from what they were the previous two times? If you answer yes to these questions, then I can't see that you are fooling yourself or kidding yourself or in any way delusional.

The part of all this that is so hard to come to terms with is that there are very real factors that can make or break plans for a vaginal birth that are completely out of our control...boy, does that grind...but in the end, it is possible that your body will not stay healthy enough for a planned VBAC in spite of you doing everything you possibly can. It is also possible that the events of your last 2 pregnancies will NOT repeat, because this is a different pregnancy. Previous pregnancies can seem predictive but often they are not. Each pregnancy, each labor, each baby is different. That you CAN be sure of. You can't do anything at this point about having had 2 previous cesareans. Oh, we wish we could! But we can't. You can make plans with those 2 cesareans in mind, and you should. You do have control over all sorts of things. But what you (and anyone else -- ICAN, midwives, physicians) don't have control over is the final outcome.

Remember -- it is NOT about having a VBAC. It is about planning the safest birth you can. Period.

What did I do wrong?

2009-03-15T14:59:00.000-07:00

I have 2 good friends who’s VBACs turned to repeat cesareans for "no good reason" that anyone can figure out....yes, the babies were likely (subtly) malpositioned, even after prenatal chiropractic care and great attention to optimal fetal positioning and they hired midwives who knew many tricks to straighten out babies...and the tricks didn't work. They labored for many many hours...they did "everything right"....and still ended up back in the OR...it is heart breaking. And both have asked, many times “What did I do wrong?”

What did I do wrong?

And I have to say that the "answer" I have is two-fold....first, the baby is an independent player in the whole labor and we can't always predict or dictate what the baby will do. Second, there is a very real element of "luck". Just plain bad luck. It is SO much easier if we find something that looks like a cause. A reason gives some closure, some sense of "if I'd just" to help it NOT mean that you really don't have control over the outcome....but the truth is, for those women who make all the plans, "do everything right" and end up with a VBAC? They were lucky too. We almost automatically take credit for "doing it right" being the reason we have our VBACs but we are fooling ourselves if we think we have that kind of control. The flip side of believing you have that control is to then believe an unwanted outcome means you didn't do something you could have or should have. I'm convinced, after a decade of hearing stories, that this just isn't true. Sometimes you do everything you can and it doesn't work. I don't know why.

When the labor is done and you are in that soul searching place, the compulsion to second guess decisions made during labor is overwhelming...because we forget the intensity and immediacy of labor. My friends had good and patient midwives. There was a reason they trusted them -- with the labor and when the decision was made to transfer to the hospital. Whatever that something was that led them to decide on transfer and ultimately to agree to the repeat c/s, it was real. And since no one can recreate that inarguable something now, its compelling to say "if I'd only"....but there *was* a real reason they didn't just keep laboring, even if no one could put it into conscious thought or words then or now. It is SO tempting to think "if I'd just labored for another x hours, I would have had my VBAC" but we have no idea if that is true or not...maybe yes, they would have. Or maybe they would have transferred later. Or maybe the baby would have been in a lot of trouble by then. Or maybe the baby would have been fine but nothing else would have changed. Or maybe something else would have happened...we just have no idea.

I don’t tell women to stop asking questions or to stop trying to understand what happened. I don't think they can stop, I know I couldn't when I was trying to figure out why I made the decisions I did around my c/s. But the advice I do give is to consider that the answers you may get through your searching may have more to do with your understanding yourself rather than you understanding that birth. There are answers there but they may be to a question that you don't yet realize you are asking. They likely will come later than you hope and slower than you think you can handle, but you will.

What I did this Weekend

2008-07-27T11:20:00.001-07:00

There's a lesson in here, somewhere. Actually, it isn't too hard to find, since we humans are mammals too.

I work the day shifts this weekend and mid-day yesterday, a good Samaritan brought in a VERY pregnant stray cat with the tail of a kitten hanging out. She was obviously distressed, panting and vocalizing. She is also very sweet, not even protesting even when I had to do a vaginal exam. All I could feel was the tail of the presenting kitten. Everyone is asking "should we get surgery set up?" "Does she need oxytocin?"....the radiograph showed at least 7 skulls....I said NO. We are going to take a little blood just to make sure she doesn't have low calcium or glucose and isn't FeLV/FIV positive and then we are going to make her a nice box with fluffy blankets, give her food and water and leave her alone in a dark ward. There was much grumbling when I told them that on pain of my everlasting wrath they were NOT to check on her until we heard kittens (good natured grumbling, they all know how I "am"). This morning I came in to find *8* beautiful kittens -- all alive and all nursing beautifully. And a mom who is just a fantastic mother and still as sweet as can be. Too bad they don't give women the same sort of treatment when they are trying to have a baby. And the pictures DO make me glad that for the most part, humans don't have litters!

Won't Play Nice Anymore, Part 3

2008-07-18T21:37:00.000-07:00

This question was raised on an email list I participate in: “if OBs are constantly feeling threatened by the angry mob that is the rest of us then how will we ever be heard, and how will we ever come to a consensus?”

(Let me preface all the rest of my comments with this: as women in this culture, we are from a very early age taught in very subtle ways to be nice, act nice, play nice, keep people happy, don’t rock the boat, whatever you do don’t be a bitch…..there’s a price to be paid for not being a good girl. We want people to get along and it’s hard to know exactly what to do when there’s no chance of that happening.)

This topic gets discussed by ICAN’s Board of Directors with some frequency — are we "too extreme", "too angry", "too whatever"….how do we get listened to and become more than just a "bunch of angry women"…. A starter Blaming the Activists — the topic is size acceptance, not birth, but it did resonate with me and the notion of being "angry" or "extreme".

I’ve been involved in some form or another with ICAN for about 9 years now. As my kids have gotten older, rather than getting less involved ("moving on") I’ve gotten more involved, on a larger, more "political" level, I suppose you could say. So I’m going to ramble a bit about where I’ve ended up on this topic…. I’m not sure I can put it all in a concise and succinct form.

On a very fundamental level, I believe there will be no change until the powers involved start either losing money, or believing that they will lose money. That’s the way our system works, that’s the nature of a for-profit system. It’s why I believe that the VBACban crisis will only be solved by the courts — because it will be only when VBACbans are ruled illegal (and thus, those who have them are open to prosecution) that they stop. If it were about asking nicely or not-so-nicely, if it were about facts, if it were really even about what women want, there wouldn’t be VBAC bans now. The hospitals that have reversed bans have done so because the publicity threatened their bottom line. That doesn’t mean we stop educating but it is why we have to be realistic. And when you threaten the bottom line for a large corporation….you will be tagged "radical", "extreme", "unreasonable", "shrill", "hysterical" and any other name they can think of to discredit you.

The status quo in this country for all birth issues is not OK. But, it is the status quo. Which means, if you challenge it, you are going to, once again, be labeled "radical", "extreme", etc etc etc. It means that, since most people in the country don’t look beyond the surface when it comes to birth, anything you say that conflicts with the conventional "wisdom “about birth (which has nothing to do with being wise) will make you seem crazy. If you challenge the pervasive techno-worship that characterizes all of medicine, you look radical. You ARE radical!

We are a pain phobic society. If you talk about the emotional fall-out from birth gone bad….you will make people very uncomfortable. You will make the people participating our twisted maternity "care" feel bad…often they will think you want them to feel bad. You will trigger very unwanted emotions in women who’ve stuffed their own trauma in order to survive. People will accuse you of wanting to make other women miserable, of wanting to push your own belief system on others, of intolerance, of just about anything they can to not think about what you are actually saying. Because if you are right, then people have to do something about it. If you say things that don’t have these effects on your listeners….then you are no longer be talking about the issues we are so concerned about. Change is tough….and there’s always institutional resistance to it. If the institutions threatened by the change we want successfully describe us by framing the issue as a personal one ("all OBs are awful people who are only out to get rich and don’t give a flip about women and babies") instead of as a criticism of a broken system ("ACOG is a protectionist organization looking out for the financial interests of their members at the cost of safety for mothers and babies") then it is very simple to marginalize us as a bunch of irrational, intolerant, angry women.

We can be polite to the new president of ACOG, we can write carefully crafted letters encouraging him/her to take on the challenges of the future, blah blah blah….but let’s be realistic here. The people who run ACOG are very politically savvy….and they (think they) know darn well exactly what they can get away with, they know darn well exactly who’s pocket they need to be in….and they have the money to do it. It isn’t about facts. It’s about money. Even if you want to blame "the liability crisis", it’s still about money. Why are they suddenly talking about legislating homebirth into illegality? With less than 1% of all births out of hospital, it certainly doesn’t impact the bottom line….but….now the midwives are getting organized (The Big Push). Now the mainstream is learning about how illogical maternity care really is (BoBB). Now ICAN is telling stories about insurance companies denying medical coverage and distributing information about how to fight a VBAC ban…someone has decided that the bottom line might just be threatened after all…. if ICAN makes any difference at all on the macro level, it isn’t going to be because we are nice. It isn’t going to be because we are nasty, either. It’s going to be because we are numbers. We are the only consumer based organization in this mess….and our biggest strength is you and others who support ICAN with their money and their time. Why? Consumers. Money. Votes. Money. It will be because we do threaten the bottom line and thus, force change. I think that ACOG and AMA understand us (and the midwives) just fine. As long as we aren’t a threat, they ignore us (and until very recently, that’s pretty much what they’ve done). When we are a threat, they will fight us. They will never accept us and willingly make the changes we want. Not because they are made up of bad people (I don’t think they are) but because they are a business.

Of course I’m angry. Doesn’t mean I’m wrong. (or irrational. or mean). What activist hasn’t used anger over injustice to motivate them? I defy anyone to name a successful reformer who didn’t have anger/passion/righteous indignation working for them….political/colonial independence. abolition. suffragettes. civil rights. apartheid. And all of those reformers were crazy, angry, radical, fringe activists too….we are in very good company. The people we are in opposition to (the "OB community") should feel threatened. Because that’s exactly what we are doing. Threatening their comfort, their safety zone, their livelihood. Not because we wish ill upon them as human beings but because we can no longer sit silently as ill is visited upon a larger and larger number of women and babies. Because if we don’t speak, no one else will. If that doesn’t make you mad….well….not much more to say. And certainly, no consensus to be had.

Honesty from ACOG

2008-07-10T22:29:00.000-07:00

Sometimes you just have to wonder if someone wasn't thinking. I'm not sure who originally found this, but its a document well worth giving some time to: "Lay" Midwives and Homebirth, from ACOG State Legislative Update Year in Review (August 2007)

Its no secret to anyone that ACOG doesn't approve of midwives or homebirth. They barely tolerate CNMs and have only recently given approval to certain credentialed Independent Birth Centers (which typically restrict access to only the most narrowly defined "low risk" client possible) because of the threat they see in increased public attention to homebirth (there's no reason to think that homebirths are actually increasing, all buzz about The Business of Being Born aside). The thing that I just love about this document is that its so honest! So honest in its deliberate misrepresentation of midwifery (while I've been known to do my share of OB bashing, I don't believe they are mostly idiots -- they know exactly why the term "lay midwife" doesn't apply to most midwives these days) and so revealing in the motivations for why ACOG is opposed to midwifery. Let me share a few choice tidbits:

"Even the nurse-midwives no longer can be counted on to speak publicly against home birth or lesser trained midwives...Nurse-midwives – a fickle ally...Whereas nurse-midwives have been ACOG’s front-line defense against these bills, that’s no longer a sure thing. Today, you don’t see nursemidwives speaking with any consistency against home birth or the certified professional midwives (CPMs)." (Gotta wonder what the leadership of ACNM is feeling about this right not...since it tends to look like they continue to believe their future lies with ACOG. So much for sticking up for each other.)

"Legislators respond to the home birth “choice” message...In 2005, a midwife bill (HB 36) was championed by an unusual coalition – Republicans, including the Speaker of the House, home schooling proponents, the religious right, and the state’s Amish and Mennonite communities. The bill language was deceptive in its simplicity. It said, “Nothing in Missouri law shall encroach on a mother’s right to give birth in the setting and with any caregiver of her choice.” (I can't really see how homebirth isn't a choice. And I don't see what is so odd about the above coalition, other than they aren't usually associated with "choice" in reproductive terms. Now, when the "pro-choice" advocates finally realize that birth in all its forms is just as much a "choice" issue as abortion, THAT will be a strange coalition. Oh, and I'm unsure of what's so deceptive about the Missouri bill -- I think its pretty clear.)

"The situation with hospitals declining to do VBAC deliveries has complicated our advocacy efforts on midwives. ACOG Fellows in California, Washington and other Western and Rocky Mountain states report that women are seeking out alternatives, including home birth with midwives, in their desire for a VBAC." (Well, no kidding. After all, it is a free-market and if you don't provide the service....someone else will. When they provide a service that is exceptionally better than anything you ever offered, you are going to have trouble catching up.)

"Physician back-up for midwives and out-of-hospital deliveries is a growing concern in some states." (lack of back-up IS a problem, one which the homebirth community would love to see a solution to. Oh, wait...) "In Wisconsin, the professional medical ethics of physicians who choose to back-up CPM-trained midwives were in dispute over home birth legislation that got approved in 2006 over the objections of the Wisconsin ACOG Section, the state AAP Chapter, and the State Medical Board." (...the problem is that physicians ARE backing-up CPMs! How unethical.)

With regard to Licensure Bills in various states: "ACOG is playing defense on most of these bills. It’s the rare situation where we can defeat these bills on the merits. For example, in Missouri, ‘lay’ midwife bills get introduced year after year. These bills have been stopped – up to now – mainly by deft political maneuvering and hardball tactics employed by the State Medical Society, not by any persuasive testimony about comparative safety or quality of care." (This might be my favorite. There it is -- they can't defeat these bill based on any evidence that homebirth is less safe or poorer quality care. They have to use hardball tactics.)

There's lots more but you'll need to just go read it for yourself -- the usual "European studies of homebirth aren't relevant to the U.S.", "people just can't understand all the different types of midwives", "midwives are uneducated" drivel, laid out in clearly understood language. Send it to those people you know who think that ACOG really is speaking out for the best interests of women and babies, and not for their own best interests.

ICAN and the AMA

2008-07-01T21:40:00.000-07:00

Statement of the International Cesarean Awareness Network
Regarding the AMA/ACOG Homebirth Resolution
June 30, 2008

The International Cesarean Awareness Networks (ICAN) condemns the recent resolution passed by the American Medical Association and put forward by the American college of Obstetrics and Gynecology suggesting that homebirth is unsafe and that legislation stating such should be passed by states.

The resolution is not evidence-based and, in its apparent suggestion that homebirth ought to be outlawed, threatens long-held standards of informed consent and patient autonomy. ACOG itself maintains that maternal autonomy is almost absolute. The resolution is also a clear conflict of interest, since AMA and ACOG have much to gain in driving women away from using home-based care providers.

The resolution ignores a solid base of evidence that consistently shows homebirth is safe for low-risk women.[i] It also ignores the fact that there is no evidence to support the notion that hospital-based deliveries are superior for low-risk mothers. In fact, while the obstetric community often touts the significant drop on childbirth-related deaths in the last century, little of this improvement has any relation to obstetric care practices, but rather the advent of antibiotics, sterile practices, and safe transfusions. Approximately 95 percent of women in the U.S. give birth under the care of an obstetrician in the hospital and with this care, the U.S. has the second worst newborn death rate in the world[ii], and ranks 41^st in maternal deaths among all nations [iii]

This resolution comes at a time when the physician community increasingly fails to deliver quality, evidence-based care to women and their babies. The most basic needs of laboring women – continuous labor support, food and drink, freedom to move, freedom from routine interventions, being allowed to push in an upright position, and immediate and unbroken contact with the newborn – are routinely ignored in U.S. hospitals. Additionally, major medical interventions such as induction and cesarean section are frequently used without true medical need.

For many mothers, the hospital environment fails to meet their needs, which is why some mothers choose to deliver at home under the care of a trained professional midwife. In our volunteer-based community, ICAN regularly supports mothers who were frightened or bullied into unnecessary interventions by their care providers or were never informed of the risks of interventions. Because of concerns over legal liability and convenience, physicians have prompted over 300 hospitals to ban vaginal birth after cesarean, forcing normal healthy women into cesareans they likely do not need.

Every woman has the right to evaluate the risks and benefits of various care providers and birth settings and choose what is right for her and her baby. Whether through legislation or institutional pressures, it is unacceptable for any professional trade organization to infringe on women’s autonomous decision-making process.

[i] Johnson & Daviss, BMJ 2005;330:1416 (18 June), Fullerton et al., J Midwifery Womens Health. 2007 Jul-Aug; 52(4):323-33., Wiegers et al., BMJ. 1996 Nov 23; 313(7068):1309-13., Janssen et al., CMAJ. 2002 Feb 5; 166(3):315-23., Anderson & Murphy, J Nurse Midwifery. 1995 Nov-Dec; 40(6):483-92., Ackermann-Liebrich, et al., BMJ. 1996 Nov 23; 313(7068):1313-8., Declercq, Public Health Rep. 1984 Jan-Feb; 99(1):63-73., Duran, Am J Public Health. 1992 Mar; 82(3):450-3., Olsen, Birth. 1997 Mar; 24(1):4-13, Mehl., et al., Women Health. 1980 Summer;5(2):17-29.

[ii] State of the World’s Mothers: Save the Children.
[iii] World Health Organization, the United Nations Population Fund, the U.N. Children’s Fund, the U.N. Population Division & The World Bank.

Read ICAN’s response to criticism of maternal and infant mortality rate numbers.

Happier News

2008-05-28T17:51:00.000-07:00

I love positive updates. Anyway, those of you who might read my blog/thoughts will remember that I was pretty scathing in my denunciation of a certain “Mr. Smith” who seemed to discount any likelihood that ICAN could bring something of value to a meeting devoted to controversies in maternity care. An admirable trait of Mr. Smith’s is that he isn’t afraid of controversy and he isn’t afraid to open up dialog that could be heated. And really, isn’t that the most important thing? Anyone with any sense knows that there will always be disagreement on some things, and differences of opinion on how any given crisis should be met and challenged and what the priorities for change should be. But through some very honest communication with Pam Udy, we’ve found that indeed, we do have something to offer each other and that our common ground is something we can definitely work in. I like that. A lot. And have to say, it does say something about Mr. Smith, that he was willing to reach out as he did.

So thank you Mr. Smith. Looking forward to the next conference!

(And if you know who Mr. Smith is, then you know and if you don’t, you don’t need to. Sorry :-)

Here comes the bus...

2008-05-23T18:50:00.000-07:00

For a while now, there's been a big push to legalize CPMs (certified professional midwives) in Illinois, a state with a nasty reputation for persecuting midwives to the utmost extent possible. The women of ICAN have always had an uneasy relationship with "legalization" and licensure of CPMs....because unless the people pushing for legalization are very careful (and sometimes even when they are), usually the state requires a sacrifice to the gods of the medical association before agreeing to legalization. The big three sacrificial lambs are VBAC, breech and twins -- and sure enough, VBAC moms once again find themselves laid out on that altar, under the bus of licensure, hung out to dry while preserving homebirth for "low risk women". I think what really stings this time around is that the ICAN chapters in Illinois have been very active in supporting the efforts to get a licensure bill in front of the state legislature, writing letters, raising money and really getting out there for this cause. And now we find that for our efforts we get a pat on the back, a sympathetic "sorry about that" and a trip back to the surgical suite, since not only are homebirths after cesarean forbidden but we can't find a hospital to "let us" VBAC even if we want to go back into the lion's den. I'm sure the midwives are upset about this and I'm sure they feel like they had no choice. And maybe they didn't or maybe they did. After talking to a few people who know more about Illinois politics than I do, I realize that the situation isn't simple or even logical...so the story isn't nearly done, even if it might look like it. But I've got to say, I'm am SO tired of always being the one who gets locked out, when the women I represent need what a CPM can offer more than any other group out there. Still, while the International Cesarean Awareness Network can't support The Midwifery Licensure Act (Senate Bill 385, House Bill 385) as it is currently written, we are going to keep very close track of its progress, should it make any. Keep watching to see what you can do if the opportunity presents itself.

2008-05-22T18:27:00.000-07:00

I haven't been good about writing lately, but I did want to get this out there -- of course, its in many, many blogs, but hey, never hurts to get it out there once more. This is a great video about cesareans -- and one that would be very easy for someone with more mainstream ideas to accept, i think. Anyway, if it works to get it embedded here, here it is:

Won't play nice anymore, part 2.

2008-04-17T21:31:00.000-07:00

The President of ICAN, Pam Udy, had a conversation with a person, I’ll call him Mr. Smith (name changed to protect us, the innocent), in which he told her that ICAN would never be welcome to speak at any event he organized because “we don’t have initials behind our name and no one wants to listen to women crying about their birth experience.” He believes that it is a priority to have an event where mainstream medical professionals (OBs, etc) would attend, so as to foster dialog between them and the “activists” who are concerned about the state of maternity care in this country. Pam quite coherently explained to him why it is important for ICAN to have a voice and why we cannot continue to let the “medical experts” have the last say in what is best for mothers and babies. He responded with a series of questions, which I have included below. More importantly to me, answering his questions allowed me to think through the role that ICAN does play versus the role that ICAN MUST play, if any of the things we all agree are problems are to be solved.

What makes us believe we speak for the majority of women?

Superficially, I don’t think we do, but only because the majority of women who’ve had traumatic births (not just cesareans) do not acknowledge that — for any number of reasons, but one big one is that they think they are the only one who feels that way and they are ashamed of it. If they knew other women are also unhappy, then they wouldn’t be ashamed. We are the voice telling women it’s ok to be unhappy about something that was a bad experience and that it doesn’t make them a bad mother to be unhappy, nor does it say anything about whether they love their child.

What makes us think our experiences are representative of most women’s experience?

There are quite a few studies that look at "satisfaction" after birth and it is quite easily demonstrated that if you look out farther than 3 months, women with interventive/surgical births aren’t very happy about it. But you have to ask them, they won’t volunteer that information (for the reasons listed above). Is this "most" women’s experience? I don’t know….but as the cesarean rate climbs higher and higher, it’s getting to be more and more women’s experience….do we have to wait until it’s a big majority before we say anything?

What number of women can we say we speak for?

I’ll answer that with another question — what is the threshold at which we have a moral obligation to speak? If only 5% of women identify as traumatized, is that too small a number? Is 10% big enough? (Would we be ok with 5% of all women being abused in a domestic partnership?) Or do we need to wait until over 50% of women have traumatic births before we are obligated to speak? If the cesarean rate is 30+% and half of those women are unhappy about having one (which I believe is a conservative estimate), are those 15% not important enough to speak to and for? If we know that cesarean surgery isn’t the optimal way to have a child, do we have any obligation to speak out about that? If a woman and/or the culture she lives in don’t perceive her experience as abusive and yet it is, do we keep silent? (Some cultures think its ok for a husband to beat his wife and children, so is it ok in that culture?) What about the babies? The evidence continues to accumulate that interventive births, including elective non-medically indicated cesareans are bad for babies — who speaks for them? Do we not speak, since they aren’t indicating that they are traumatized by their birth experience?

Do we only speak for the women who identify as traumatized? Or do we speak for the women who don’t understand that they were traumatized, and yet behave in ways that show they were? (Look at the studies that show women with cesareans elect to have fewer children). Many women in the cultures that allow for wife-beating probably think its "ok" for the most part, even if they really don’t want to be beaten. So we don’t say anything about it?

Mr. Smith doesn’t get to decide what the threshold is. I suspect the notion of setting such a threshold for some other issue would be repugnant to him (female circumcision? male circumcision? domestic violence? lack of access to medical care? hunger? homelessness? child abuse?). The notion that abusive maternity care isn’t in exactly the same category as other forms of abuse is beyond offensive to me. When Mr. Smith persists in calling us "angry women" as an excuse to deny us a voice, he is actively participating in the insidiously persistent patriarchal and misogynistic culture that has in the past considered things like violence against women, lack of political voice or power, lack of property rights, unequal pay, unequal educational opportunities, perfectly reasonable and defensible, and which STILL does condone versions of all these inequalities. I’d be willing to bet a sizable sum that Mr. Smith doesn’t identify himself as a narrow-minded misogynistic fool but the more I think about his "concerns", the more I do identify him as such.

The hypocrisy and willfully close minded attitude are astounding in someone who claims to be concerned about the state of maternity care and childbirth in the U.S. He can support a session titled "Why Men Leave: The Epidemic of Disappearing Dads" that identifies a condition called "Male Postpartum Abandonment Syndrome" and then complain that if we speak out, the MD’s won’t come? What exactly is it that he thinks we want to say? Mr. Smith has bought into the lie that we are a bunch of angry, hysterical women who are only reacting out of irrational emotion. And he conveniently doesn’t notice that the MD’s aren’t coming to these forum/conferences/congresses already, and that they aren’t likely to. Mainstream medical professionals aren’t going to attend something that bears no resemblance to what they must believe is reality (that what they do is necessary and right and to do otherwise would be unethical and unsafe). A sprinkling of MD’s speaking on various birth-friendly topics at this last event certainly didn’t prove me wrong. I’d go so far as to say that my talk on uterine suturing techniques is more likely to attract an MD than any talk on water birth or male PPD. And yet, I’m sure my initials aren’t the letters Mr. Smith is looking for. It is interesting to look at a list of speakers from this last event, to see just what collection of “initials” Mr. Smith did find acceptable:

Karen H. Strange, Midwife
Barbara Harper, RN
Dianne Garland, RM
Cornelia Enning, Midwife
Laura Erickson, LM, CPM
Sarah Buckley, MD
Kathy Forrister, RN
Ellen Margles, CNM
Duncan Neilson, MD
Sandra Bardsley, RN, LCCE
Robert Newman (who’s implied Y-chromosome seems to be the right letter)
Mark Fisher (of a Prime Insurance Corporation and owner of a Y-chromosome)
Robbie Davis Floyd, PhD
Yeshi Neumann, CNM
Carol Penn, DO
Amy Gilliland, Doula Trainer and researcher
Marcy Axness, PhD
Joe Dispenza, DC
Alan Huber (Y-chromosome anyone?)
John W. Travis, MD
Susan Roberts, ND
Stephanie Cave, MD
Eneyda Spradlin-Ramos, BA, LMT, CD
Judith Rooks, CNM, MPH
Zina Bakhareva, MD
Jose Louis Grefnes, MD
Fernando Molina MD
Nils Bergman, MD
Jeanette Schwartz, RNC
Beth Genly, CNM
Zinaida Bakhareva, MD
Bianca Lepori (an architect! and no Y-chromosome — how open-mined and daring)
Nikki Lee, RN, IBCLC
Joni Nichols, BS, MS, CCE, CD (DONA), (CBI)
Jose Louis Grefnes, MD
Yves DeSmedt
Isabelle Gabriells
Veerle DePauw, MD
Sandy Williamson, CNM, MSN
Richard Morris, Administrator
Lonnie Morris, CNM
Anna Verwaal, RN, CD
Susan Jenkins, JD
Karen Strange, CPM
Anna Verwaal, RN, CD

11 MDs. And then a collection of other professional degrees/certifications that will not impress your average Fellow of ACOG in the slightest, not to mention a few that have no degree/certification that I can see. Don’t get me wrong, I’m not doubting that these presenters are very knowledgeable or even experts in the topics they are presenting (I’ve heard many of them speak and they are extremely knowledgeable in their fields of interest/expertise) but the excuse that we don’t have "initials" after our names is a smokescreen behind which Mr. Smith is hiding his prejudice and fear.

It is about time the established "birth activists" quit their vaguely masturbatory inside-crowd-only exercises in preaching to the choir and realize that they’ve been doing exactly the same thing for decades now and things are only getting worse for the women and babies they purport to care about. It is about time they realized that without the consumer, they are going to continue to cycle through a round of conferences and congresses and forums every year or two, saying the same things over and over and over and making absolutely no difference whatsoever and never registering at all on the mainstream radar screen (medical or otherwise). They actually need us a lot more than we need them, since frankly, I can’t see that they’ve helped us much with all their pontificating about safe birth and birth choices and how to have a satisfying birth experience, etc etc etc. We can offer them something new, something different, something that isn’t the same old same old ineffective inaction. We don’t have to tell our sob-story birth stories…we can speak just as knowledgeably on any number of birth topics (from the academic/scientific to the alternative and controversial) as any "doula trainer" or "LM" and thus gain both acceptance from the old guard and wider "name" recognition as an organization that is much more than a “bunch of angry women". We bring in the consumer — the women who’ll write the letters, switch providers, picket hospitals, support the struggling midwife and her independent birth center, vote with their feet. That’s something the experts haven’t managed to pull off yet and I don’t think they can. The consumer, the woman who doesn’t have any qualifications other than a scar, on her belly, perineum or heart, is the KEY, without which, all of this is just a bunch of self-proclaimed experts in an irrelevant discipline complaining about an unacknowledged crisis, to which they have no answers anyway. Women weren’t emancipated and given the right to vote by a group of trained constitutional lawyers, experts on social change and experienced activists. It happened because the women who were affected by the injustice decided to stand up and do something about it. If we ever see real change, it will be because of us, not the trained experts.

So once again, it’s time to stop being nice. Quit worrying about what people “in power” might think and just do what is right. There has NEVER been any social change for good that didn’t require regular, ordinary people to stand up and say no, no more. For me, that includes both the medical mainstream and the established birth activism community. No. No more. You can’t marginalize us anymore and you can’t accomplish anything without us. So quit blaming us for the problem on the one hand (“women just don’t bother to educate themselves/care/think for themselves) and then refusing us a place in the fight on the other (“no one wants to listen to a bunch of angry women”). You can’t have it both ways. Right now, you haven’t got anything worth a protectionist attitude anyway.

Did it again

2008-03-27T21:40:00.000-07:00

Ok, so I'm a bit obsessive-compulsive about some things. While I was certainly glad to get it done, I was almost immediately dissatisfied with my first version of 1 in 3. So, I re-edited it. And because I'm sure you are all SO dying to see the new version, it is right over there, on the right, for you to click on and watch. Or, you can go to YouTube and see it big screen here. And for those of you who've asked for copies of it in the past, now you can just download it from YouTube.

Read This!

2008-03-22T21:16:00.000-07:00

Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery

A fantastic article written by a fantastic woman. Kmom is probably the best resource for information about birth and breastfeeding for women of size, and is also just about the best resource out there for information on "Gestational Diabetes". She has a real gift in synthesizing and summarizing the research in a non-biased way -- after you read the above article (a companion piece for Our Bodies, Ourselves: Pregnancy and Birth) check out her website: Plus-sized Pregnancy (it isn't just for plus-sized women).

If it ain't broke, well, break it!

2008-03-01T06:36:00.000-08:00

One of the blogs I get regular updates on is ElementalMom. Laureen is a friend and birth activist and a generally really cool person....and she finds some of the scariest stuff. So, I present the newest entry in the "heck, who cares if we break it, we can just fix it and make more money in the process" annals of Obstetrics...

Popular Science: Compassion Cure

Just when you think they can't possibly screw it up any more. Sheesh. I suppose it is another reason for women to just luv their OBs....

Won't play nice, anymore.

2008-02-29T22:01:00.000-08:00

“Nice” isn’t a term that I am generally described with, to be honest. Yes, sometimes I am described as compassionate, caring or sympathetic. Often I am described as rational, even-tempered or reasonable. You’ll hear passionate, strong-willed and stubborn used upon occasion too but really, rarely do people describe me as “nice”. That’s ok with me, I’ve never consciously aimed at “nice” as a personal descriptor. But like most women in this culture, I still struggle with the “be a nice girl” problem – you know, wanting to be liked, not wanting to cause trouble or difficulty, wanting people to get along, not wanting to offend. Like most women, a lot of what I’m really thinking in my head doesn’t get put out there for public consumption. And in some ways, ICAN has struggled with this dynamic, I’m sure in large part because we are an organization that is almost exclusively women. It hurts us when we are characterized as “hysterical angry women”, because that’s not at all who we are. We don’t want to be controversial, not really. We are all about choices and options, really wanting more than anything for women to have both the choices and the knowledge to make them when it comes to decisions during the child-bearing years.

The problem is, being nice isn’t going to work anymore. And I think I’m going to like that, even as it catches my breath sometimes. There’s a lot going on in birth politics right now – Ricki Lake’s The Business of Being Born is making more of an impact than I ever expected it to. ACOG released an updated statement about homebirth, the really interesting part being that for the first time ever, they supported the idea of births occurring in free standing, independent credentialed birth centers (they’ve always opposed that in the past). They accused women who plan homebirths of being more concerned with fad and fashion that with the safety of their babies and themselves. ICAN countered with probably the most strongly worded Press Release I’ve ever seen from us. And the responses to our statement were wonderful. I think it’s about time someone “publicly condemned” ACOG for their misogynistic and dangerous policies. The AABC recently released a statement about why they are not going to revisit the VBAC study and why they do not recommend birth centers allow women to plan VBACs in a birth center. They determined that we aren’t exactly “high risk” but we certainly aren’t “low risk” either…and made sure they repeated several times the warning that any birth center who did allow VBACs at their facility needs to consider whether it’s worth jeopardizing “low risk” births. I can’t help but wonder about the possible connection between the two statements, especially since most birth centers affiliated with AABC are owned/staffed by Certified Nurse Midwives, who have aligned themselves with ACOG in a (probably futile) attempt to save themselves from extinction (once ACOG turns its sights on them). So, in our new “say it like it is” mode, we pointed out that AABC is sacrificing the women who need them most, the women who will support them when ACOG comes after them, and that once we’ve been picked off, they will come next. We got a lot of good feedback from that and a call from AABC too….seems maybe they want to work with us – on what I’m not sure, since they haven’t said anything about rethinking the VBAC issue.

Sometimes there is confusion about ICAN being a “homebirth” organization – we are absolutely NOT that. Do many of our members have homebirths? Yes, that’s certainly true. Do many women who want a VBAC have no real option other than a homebirth? Yes, that’s certainly true too. If we appear to be a “homebirth organization” it’s as much a result of the lack of other choices as anything. What we really are is an organization devoted to promoting a full range of birthing options for all women, regardless of history. In the process of working on the DC premier of The Business of Being Born, I had to consider and then respond to a request from ACNM for co-sponsorship or some other major degree of collaboration. And honestly, it was a no-go from the beginning. This is an organization that has systematically repudiated (and abetted in the persecution of) non-nurse midwives. Now, don’t get me wrong, I’ve met many individual CNMs who are wonderful women, who believe in birth and support their sisters the CPMs. I’m talking here about institutional biases. The whole issue of why they have such a problem with non-nurse midwives is complicated and basically not relevant to this discussion. What I’d want to encourage ACNM to consider is the big picture of the future – women are going to require attendance from midwives who are not tied to obstetrics. If ACNM really wants to promote autonomy for their members…if what they really want is the ability to be true midwives and not the handmaidens of the obstetricians….then they need to rethink their alliance with the obstetrical community. Perhaps, joining with other midwives, as scary as that seems, would be a better long-term strategy. Because really, there’s no reason to believe that ACOG will leave the CNMs alone. They already eliminate them from hospitals or actually attending births whenever they can. The Big Push might be for non-nurse midwives, but the CNMs will benefit from it too, if they just let themselves actually be midwives and stop worrying about how to preserve their place in the current dysfunctional medical system. I believe that we are approaching a moment when organizations will have to step up and take sides. The question is, whose side will you be counted on? I’d love to retire the term “medwife” and have midwife attended hospital births be something that is available to any woman who decides that’s the plan she needs to make. Really, I’d love to see medicine, even in the form of “nursing” be forever banished from the practice of midwifery. Hey, I dream big, if nothing else.

More Thoughts on The Business of Being Born

2008-02-25T22:38:00.000-08:00

More thoughts on my experience at BoBB.

Most of the showings that I’ve heard about included a panel discussion afterwards and this showing was no different. It was a pretty diverse group of caregivers – a midwife who works out of an independent birth center, a midwife who works out of one of the local hospitals, a midwife who works as a homebirth midwife and an OBGYN who works out of the big teaching hospital in town. There were quite a number of young, as yet childless women in the audience; I hope that they did get something from the movie and discussion. There were a couple of moments that really struck me – first, the homebirth midwife said something that I’d never thought of quite this way – somehow the discussion had moved to how a transport from home to hospital is handled and how providing seamless care with the OB and midwife working together rather than as adversaries is what we need to work toward but don’t in fact have in most circumstances. Those of us who do a lot of work in homebirth often hear from hospital based caregivers that they know homebirth is unsafe because of the “disasters” they see when a woman transfers in. Of course, the obvious response to that is that they never see what the majority of homebirths look like, since those women never go to the hospital and of course the transfers are complicated or difficult – that’s why they are transfers! But this midwife made the point that as homebirth supporters, we only see the messes from the hospital – and it’s true. We don’t see women planning homebirths who loved their hospital experiences. We see the women who were unhappy, traumatized, discounted, injured in the hospital….it behooves both “camps” to realize that we don’t see each other’s successes very often, if at all.

But the really telling conversation surrounded a statement made by the OBGYN. Now mind you, I do believe that this woman is fairly supportive of unmedicated, uninterfered with birth – I can’t imagine she’d agree to participate in this sort of event if she were a “section everyone of them and be done with it” sort of OB. Early in the discussion, she made the statement that “unmedicated labor and birth are the safest choice for all women and babies”. That’s pretty bold. But one of the younger women called her on it – if you took an oath to do no harm and you believe this, how then can you support women demanding an epidural at 1 cm or demanding a cesarean for no medical reason? And the OB gave the standard blame the woman response – “oh, it’s not because I push for the medication/surgery, it’s the women who are driving this. The women are demanding the epidural in the parking lot, the cesarean on demand. Of course I tell them the risks to having that epidural at 1 cm but they don’t want to hear it.” Given the esteem with which most women hold their OBGYNs, I fully believe that if the OBGYN community (or even individual doctors) were truly committed to reducing the intervention rate, it would come down. And I hear too much from doctors and nurses, read too much on their message boards, to really believe that they “love it” when a woman comes in wanting a natural birth and want to do everything they can to help her achieve one. More than anything, I got the feeling that she was like my 4 year old daughter – she wasn’t lying because she wanted to tell an untruth, she was lying because she really wanted what she was saying to be true.

I was impressed by the honesty of some of the panel members when I asked about the cesarean rate and the difficulties women face when they don’t want to have another cesarean and what they were doing about it. After the short but awkward pause that followed my question, the midwife who works out of the independent birth center pretty much laid it on the line – in this state, if you want a VBAC, you have to stay out of the hospital. The VBAC rate in 2006 in this state was 1%. (I’d bet the majority of those were out-of-hospital, to be honest.) She’s helping by attending VBACs at her birth center. The homebirth midwife is helping by attending VBACs at home. Interestingly enough, the midwife who works out of the hospital and the OBGYN didn’t answer the question. I suppose that is a good indication of what they are doing to help. I can cut the hospital based midwife some slack, she’s probably more than eager to attend VBACs but she may well be constrained by hospital policy – she did talk to me quite a bit afterwards and took my information and was very excited that ICAN had a presence in the community. The OB didn’t stick around to talk to me.

I made some good contacts – a couple of local ones who have pledged some support to the DC BoBB showing and a contact with someone from MANA, who was also very excited about the DC BoBB showing. All asked that I keep them in the loop. Believe me, I will.

Finally saw The Business of Being Born

2008-02-24T22:29:00.000-08:00

I finally had a chance to see The Business of Being Born, Ricki Lake’s documentary about birth and midwifery care in the U.S. I’d heard a lot about it and I’ll be the first to confess that initially, I was very cynical about the whole thing – it seemed like more of the same preaching to the choir was going to be about all we could expect. Well, it turns out that I was wrong, much to my delight – it seems that a lot of people have seen it and it seems that some people are a bit rattled by it (If anyone doubts that, just read ACOG’s latest statement on homebirth and their supposition that it is a choice made to be “trendy and fashionable” – they never quite mention Ricki or the movie by name but I can’t think of anything else that would provoke that sort of language.) Anyway, one of the criticisms that I’d heard from various sources was that the movie ended on a bad note, with the director Abby (who was unexpectedly pregnant during the filming and thus became a subject of the film as well) ending up with a cesarean, instead of the homebirth she’d planned. There has been some discussion of how she talked about “maybe this was just the way he needed to come” as if she were totally fine with the outcome and this was in direct contradiction to the message of the film. Maybe it’s just because I see her with the eyes of a woman who has shared the experience of an unwanted cesarean completely derailing plans, maybe it’s because I’ve spent so much of my life listening to and walking alongside other women as they journey through life post-cesarean, but it was incredibly obvious to me that Abby was NOT ok with the cesarean at all, and that at 8 months post-cesarean (not very long at all) she was still wrestling with trying to make sense of the experience. Even though her cesarean probably was the best choice for her baby, even though her cesarean wasn’t a doctor convenience or institutional protocol cesarean, but in fact, her baby was sick and needed to be born quickly, her grief and loss were real and understandable. I was sad with her while also being thankful that her boy was healthy and thriving 8 months later. Her experience actually illustrates how safe homebirth really is, because her midwife knew when they needed to go to the hospital, because the prenatal care she got might have been the reason her baby did survive, because planning a homebirth doesn’t mean refusing to change plans when it becomes in the best interest of mom and baby to do so. It is very common (and very wrong) to assume that those of us who work against the rising tide of cesarean surgery are opposed to any cesareans at all – nothing could be farther from the truth. Obviously there are times when a cesarean is life saving and we are happy that they are available and reasonably safe. More than anything, I think what I oppose is the normalization of cesarean surgery – and the refusal to acknowledge the loss that having a cesarean entails (I’d argue the loss is there even if the woman doesn’t perceive it) even when it does save the life of the mother and baby.

So I hope the next movie is about VBAC and the struggles that we post-cesarean moms face when we try to plan a normal, non-surgical birth the next time. And I hope, if and when Abby does get pregnant again, she is able to plan and have the birth of her dreams. The birth that is both what she wants AND the best birth for her and her baby.

Ask Dr. Amy

2008-02-15T19:03:00.000-08:00

Dear Dr. Amy -

I'm writing you here because I'm pretty sure you wouldn't publish anything that I write on your blog, since it seems that you pretty ruthlessly censor opinions that don't fall in line with your own. I suppose maybe somewhere in your blog lie the answers to some of my questions but to be very honest, I have no desire to go read your blog, so I'll just ask here. I have to wonder - why you are so vehemently anti-homebirth? Some people think you are an ACOG plant, stirring up the internet so that when women search "homebirth" they'll find your "information" before they find something more balanced. I think that's probably pretty unlikely. Since you don't actually practice medicine (and since it appears you aren't even licensed) I know it isn't because of things you see in practice (did you even ever practice anything related to maternity care?). Did you or someone you care about have a bad experience with a planned homebirth? Are you conflicted about the choices you've made in childbirth? A lot of women are, you know. Usually the sort of rabidly biased information that you present about homebirth comes from an emotional base(or a financial one, like ACOG's but I don't think you are losing money when women plan homebirths), not an intellectual one . I have to assume that there's some irrational basis to your hatred of homebirth for you to so willingly ignore the body of research about homebirth, for you to depend on intellectually feeble arguments against the safety of homebirth, because I'd like to assume that you are, in fact, a reasonably intelligent person. Do you really believe research done in Europe isn't legitimate? Of course a lot of the research on homebirth has been done outside of the U.S., with such a low homebirth rate here, its very difficult to do studies on it in the U.S. (not to mention pretty much impossible to get a study on homebirth published in one of the obstetrical journals!) I'd guess the Dutch and other European countries would be saddened to hear that their research and medical care is so substandard (I suppose the editors of The Lancet and the British Journal of Medicine would also be surprised to learn that their selection process for papers is so flawed), since we can't really admit their homebirth studies into the discussion. I wonder how you'd respond to the argument that midwives aren't capable of knowing pathology when they see it because they aren't trained in how to treat pathology if the argument was turned against physicians -- its irresponsible to see a Family Practitioner, rather than a Cardiologist because we all know that Family Practitioners don't have the training to treat something like heart disease. Of course, that's ridiculous -- Family Practitioners specialize in basic medical care -- well-care visits and minor illnesses and injuries and they know very well when to refer to a specialist (at least that's my experience with them, and I have always used a Family Practitioner as my primary care-giver). If you can think about it logically, it actually makes a lot of sense that a trained midwife (if a midwife is CPM qualified, she is very well trained, maybe you might want to go look and see what's involved with NARM credentialing) would be very good at seeing when a pregnancy or birth is deviating from normal -- and she would have no real incentive to ignore that. I've never quite understood the argument against homebirth based on "what we see when they transfer from home" because I'd expect the transfers to not be normal births anymore...if they weren't complicated, then they'd never be seen at the hospital in the first place! I have to assume that you've never actually met a midwife or a woman who's chosen homebirth because you seem to have a very odd notion of what we are like. I'm certainly not hippy and I'm definitely well-educated (I'm also a doctor, though a Doctor of Veterinary Medicine, with a Master's of Science as well. I am currently licensed to practice and actually do practice in Emergency Medicine/Critical Care) . I'm not a religious fanatic, nor am I likely to follow some trendy craze blindly and most people I know plan hospital births. I could care less what some celebrity is doing, and rarely know what they *are* doing. Heck, I thought homebirth was something crazy women did until I started meeting real women who planned them. Turned out they weren't anything like I assumed. I wouldn't have had that much dreaded primary cesarean if I hadn't been persuaded that it was the safest choice to make for my babies because all of my planning for my births was based on the safest choice for myself, my baby and my family. I definitely didn't plan homebirths for some nebulous selfish experience. I haven't yet met a midwife who is desperate for more clients, so I know there isn't some grand push to "steal" patients from the OBs. The midwives I know would love to have a truly collaborative relationship with an OB, because it would allow them to provide even better care for their clients. I know I'd be furious if someone told me my professional standards of practice were going to be determined by some group other than my profession, and I'm going to assume that you'd feel the same way, if you were practicing. Why in the world then would it make any sense at all to not expect midwives to determine their standards of practice? AFtger all, no one knows better what a midwife is and isn't capable of than a midwife. Sure, there are fringe fanatics in the "homebirth" world...just like there are obstetricians who think a 50+% cesarean rate is ideal. I'd consider them to be pretty fringe fanatic too. But most people understand that a fanatic is just that -- and certainly doesn't accurately represent the group. Same can be said about "bad" midwives -- sure, they exist. So do "bad" obstetricians. Doesn't mean the whole group is incompetent or negligent. Maybe you are right and the maternal mortality rate in the U.S. isn't really going up, the increase really is just a product of better reporting. The problem is, even if you're right, it doesn't explain why our maternal mortality rate is so much higher than other developed countries (and a number of developing countries). That can't really be explained by a change in reporting, since its been a consistent finding for decades. Maybe it doesn't have much to do with the fact that the countries with the lowest rates of maternal mortality use a lot more midwives and have a lot more planned homebirths, but you've got to admit, it sure looks like there's a correlation there. No one has come up with a different explanation. I've yet to hear a homebirther say that planning a homebirth should be mandatory for all women, or even for all low-risk women. We all know that homebirth isn't going to be for every woman or even a significant number of them. Honestly, the vast majority of women I know who plan homebirths just want the choice to be one that is accepted and understood, and to not find themselves faced with increasingly onerous obstacles to something that really isn't anyone's business but theirs. So I don't know, Dr. Amy, you just don't make much sense to me. Which leads me to believe that perhaps, you just don't have much sense, not when it comes to birth choices. And that's a sad thing.

New Website for the International Cesarean Awareness Network

2008-02-08T09:17:00.000-08:00

Contact: Laureen Hudson
Publications@ican-online.org
(707) 237-5253

Melissa Collins
Melissa@ican-online.org
(951) 973-1028

For Immediate Release

Advocacy Group Unveils New Web site
Site features easy navigation, community resources

REDONDO BEACH, CA, February 7, 2008 – The International Cesarean Awareness Network launches a new, user-friendly Web site today in an effort to further the group’s outreach efforts.

“The new Web site will make an impact in the battle against the growing cesarean statistics by providing information to moms, challenging them to take responsibility for their births and providing a safe community for moms to heal” ICAN President Pam Udy said. “This will give women the tools they need to make educated decisions about their births – because this isn’t about statistics. It’s about every mom and every baby getting the safest birth possible.”

Easy navigation is a key feature of this Web site, which has been in the works since July when ICAN Board Members recognized the need for a more user-friendly Web site. (The Web site can be found at http://www.ican-online.org/) Site viewers will find information separated into five categories: Pregnancy, Recovery, VBAC, Advocacy and Community.

“In our daily advocacy work, we saw a clear mandate for a site that was simple to navigate, simple to understand and full of easy-to-access information for the woman avoiding a cesarean, recovering from a cesarean or on her journey to VBAC (vaginal birth after cesarean),” Laureen Hudson, ICAN Publications Director said. “ICAN interacts with women on very different journeys -- the messages a pregnant woman needs to hear to avoid a cesarean are not the same messages a woman on the journey to VBAC needs to hear. We like to think that this site addresses those two complimentary, yet divergent, needs.”

The Web site lets women research the VBAC policies of hospitals near them; learn how to correct problems (such as malposition or pre-eclampsia) that commonly lead to cesareans; get quick physical recovery tips to help after a cesarean; and stay up-to-date on medical research on pregnancy and birth. New community features include user birth blogs, videos and images; and the capability for users to create their own homepage on the ICAN site to share with friends and family. ICAN leadership also can connect more easily via the Web site with the women ICAN serves. Further, the Web site features a new logo – the logo, and all of the Web work, were completed entirely by volunteers.

“We wanted our site to be easy for the average woman recovering from surgery and caring for a newborn to find the info they needed quickly and easily,” Webmaster Melissa Collins said. “One of my favorite features is the online social community that is safe for moms planning a VBAC or just wanting to avoid. I’m really excited to watch this new community grow.”

This new Web site comes after research in 2007 by the National Center for Health Statistics showed the cesarean rate reaching a record high of 31.1 percent. Further, a CDC report indicated the maternal death rate rose for the first time in decades and Consumer Reports includes a cesarean in its list of “10 overused tests and treatments.” Other research from 2007 cites a VBAC continues to be a reasonably safe birthing choice for mothers. And while studies indicate a VBAC is a viable option, women often have difficulty finding a health care provider who encourages a VBAC – which is where one of the site’s new features comes into play.

“The most useful tool for women is probably the Hospital VBAC Ban information,” Collins said. “Women can look up the hospitals near them and find out their VBAC policy and if any doctors are actually available to attend them. It is getting difficult for so many women to find a VBAC supportive provider and this is one way to make that a little easier for them.”

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are more than 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

Twisting in the Wind....

2008-02-04T20:57:00.000-08:00

If you happen to think that using a Birth Center for your VBAC is a good option, you might have to reconsider. This was just released. An important note -- the original study (Nov. 2004) concluded that VBAC resulted in a significantly higher rate of adverse outcomes but they drew that conclusion by including poor outcomes that had nothing to do with the VBAC status of the laboring woman (much like the Hannah Breech Trial did, to kill off vaginal breech delivery). This is part of the reason there was a push to "redo" the study, because the conclusions drawn were so fishy.

**************

The Board of Directors of the American Association of Birth Centers has issued a statement regarding the feasibility of another AABC VBAC Study.

After long and extensive review of the feasibility of the American Association of Birth Centers conducting another study on VBAC in birth centers, the AABC Board of Directors has determined it is not possible for the Association conduct such a study at this time and will instead continue to advocate to policymakers for access to VBAC. The AABC Board has struggled for some time with how this small organization can respond to the very large VBAC issue. "It is hard to say that we are not going to do a VBAC study from an emotional point of view, but practically we need to." says AABC President Cynthia Flynn, CNM, PhD.
For some this may seem like an abrupt change and the Board has anguished over this decision for months now. Here is a brief history of how arrived at this decision. . .

AABC conducted the National Study of Vaginal Birth After Cesarean in Birth Centers over a ten year period and the study was published in Obstetrics & Gynecology (November 2004). The study authors concluded, "Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs."

In response to this study the Commission for the Accreditation of Birth Centers (CABC) advised that CABC accredited birth centers may not do VBACs in the birth center unless they are participating in a national research study, with strict inclusion criteria, on VBACs.

The idea for another AABC VBAC study was presented and first discussed at the AABC Board Meeting in April 2005 (and most meetings since). At the AABC Annual Meeting in September 2006, we announced that we were going to do a VBAC study.

The following month ACOG published a new statement of policy on "Out-of-Hospital Birth in the United States" which had the potential to have a tremendously adverse effect on birth centers in America. The statement was not based on the evidence, and AABC advocated for ACOG to reconsider their statement based on the evidence. The AABC Board decided wait for the dust to settle before proceeding with a VBAC Study.

In February of 2006 we conducted a survey of birth centers to gauge how many centers would participate and how long it would take to generate a sample size that would yield reliable data. We determined that it could take up to 15 years. This was evidence of how much the climate about VBAC's had changed since the initial VBAC study was conducted.

We proposed the idea of including the VBAC study as a subset of the National Study of Optimal Birth that we were launching. We added the necessary fields for VBAC research to the AABC Uniform Data Set (UDS). At the AABC Birth Institute in October 2007 we solicited birth centers to participate in these studies.

After the conference, we sought consultation from respected researchers on the advisability of AABC conducting another VBAC study. Everyone we consulted told us not to do it. These consultants were all experienced researchers who have consistently demonstrated strong support for and a good understanding of birth centers over many years. It seemed clear that, while they were also sensitive to the growing limits of access of women to VBAC's, they also were clear about what was in thebest interests of AABC. And clear about the importance of AABC remaining a credible resource for normal birth. We could not determine how to design a VBAC study that meets Independent Review Board (IRB) criteria for informed consent, that is statistically sound, and that wouldn't be political suicide for such a small group.

Many Board members practicing in birth centers felt conflicted about their desire to provide access to care for VBAC women in their birth centers and the risks for the Association in undertaking such a study at this time. There is a health care crisis in America and midwives and birth centers have an important role to play in structuring solutions. As an association AABC must focus its strategic capital on our mission: the promotion of the rights of healthy women and their families, in all communities, to birth their children in an environment which is safe, sensitive and economical with minimal intervention.

Whether or not to do VBACs in your birth center is a decision for individual providers. The AABC Standards for Birth Centers state that birth centers are appropriate for low-risk women. The National Study of VBACs in Birth Centers found that VBAC is not low-risk, although it is not defined as high risk either. All of the research on birth centers demonstrating our quality, safety and cost-effectiveness has been on low-risk women.

The ability of your birth center do VBACs depends on several variables:

Your state regulations for birth centers.
The risk criteria you have developed in consultation with your collaborating physician.
Your timely access to acute care that will be prepared for emergency transfer.
Your willingness to take on the potentially increased liability of doing VBACs in light of the current research.
Your willingness to put at risk access to birth center care for all women if there is a bad VBAC outcome.
A birth center's decision to do VBACs does not preclude them from membership in the American Association of Birth Centers.

AABC will continue to advocate for access to care for VBAC women. We have developed the AABC Uniform Data Set, an online data registry, which will be used in collecting data for the American Association of Birth Centers' new research project "The National Study of Optimal Birth". The instrument for the study, in development over the past ten years, is designed to uniformly collect comprehensive data on both the process and outcomes of the midwifery model of care - including VBACs. It is anticipated that a large set of prospective data collected simultaneously from all providers in all settings - hospital, birth center and home will make an important contribution to our ability to evaluate and improve the delivery of care to childbearing women and families. We invite you to enroll your birth center or practice in this study.

Sincerely,

Kate E. Bauer, Executive Director
American Association of Birth Centers
3123 Gottschall Road - Perkiomenville, PA 18074
Tel (215) 234-8068 - Fax (215) 234-8829
KateBauer@BirthCenters.org http://www.birthcenters.org/

*******************

A few things strike me -- So VBAC isn't low risk but it isn't high risk either. But it certainly isn't "normal" because AABC feels it is necessary to leave the VBAC women out in the cold to preserve Birth Centers for "normal birth". I don't know, both my VBACs felt pretty damn normal to me. I particularly like the way they re-emphasize that in the several variables they list...."Your willingness to put at risk access to birth center care for all women if there is a bad VBAC outcome." really doesn't pull any punches does it?

As a good friend of mine said: "We were marginalized just as the Birth centers have been marginalized and rather than sticking with those of us who have supported them, we're being left out to be picked off. I hope they know they are next..they are on the AMA hitlist, too." If you don't know what she's referring to, see here. If we don't hang together....

Happiness

2008-02-03T17:31:00.000-08:00

I had an AHA moment today. We are currently in the midst of a teaching series at my church about happiness – the ancient wisdom of happiness, to be specific. A lot of the teaching comes from Proverbs and Psalms and the basic gist of it is that the ancients had a much better idea of what brings happiness than we do. The tie in to us moderns is that fairly recently, the scientific study of the psychology of happiness has come into its own….and the psychologists are finding that the things they’ve discovered that create happiness just happen to be the same things ancient writings recommend. Today, we looked deeper at “acts of kindness”. The basic lesson was that people who give sacrificially (and we aren’t just talking money, not at all) are just plain happier. AND that in our modern world, to really give and make a difference, we often have to join together with other people in our acts of kindness. (The environment was the example used – the things that we can do as individuals can seem totally insignificant but if we as a group start treating our environment with kindness, you can see a real difference being made). So, what was the AHA?

ICAN. Of course :-) I’ve recently changed my role with ICAN somewhat – I’ve stepped down from my job as the email list administrator and am concentrating solely on my advocacy work. And while I’m in no way minimizing how important the email list is (it’s a life line for many women) I’ve never been happier in my ICAN work than I am right now. Because I can see, as I work with the other dedicated women who are really giving sacrificially to ICAN (and the women and babies we serve) that we can make a difference, we ARE making a difference. But it wasn’t without sacrifice that I got to this point – in a very real way, giving up the email list was a personal sacrifice for me…the time I spend on line and on the phone and at meetings….that’s a sacrifice. And of course, it’s the sacrifice that brings the happiness. This isn’t just some spiritual/religious thing – this is supported by actual scientific research. Giving makes you happy, sure. But giving enough that you *notice* -- enough that something is given up in return, that’s one ticket to true happiness. It combats depression, it motivates good self care, it just does all sorts of really good stuff. Giving sacrificially with a group creates a community, a bond, a purpose that nothing else will.

The other part of the AHA was basically the same realization about my job – I’m working more hours and giving more of myself but its so completely different from my last job – I’m part of a team that’s completely committed to providing the best Veterinary care possible, to making a real difference, better than anyone else. That feels good. I suppose the combination of my job and ICAN are why, right now, I feel happier than I have in a very long time, in spite of the other things in my life that do anything but create happiness.

So – want to be happier? Want that happiness to last? Want to be in community and make a difference? It really isn’t that hard…but it does require sacrifice….money, time, energy….but the payoff is SO worth it. I’d love for ICAN to be the recipient of your sacrifice but heck, at least give it somewhere – to the homeless, to working with at-risk kids, to environmental causes, Heifer Project, Katrina relief, Habitat for Humanity, HIV/AIDs. Give up something to get back something you can’t have any other way.

Cesareans and Private Insurance

2008-02-02T01:25:00.000-08:00

I'd started to work on this project but then life happened and it got put on the back burner. But then it happened to a good friend. So its not on the back burner anymore.

Turns out, if you are looking to get private insurance (you know, the kind that isn't provided by your employer, or the govt., the kind that some politicos want to give you tax breaks or special savings plans to buy) you might well be denied coverage if you've had a cesarean within the past 5 years. Why? Well, because there are too many complications in that time, after that surgery. Interesting. But its just another way, a better way, to have a baby. Even better, if you do agree to surgical sterilization, they'll go ahead and cover you. (So basically, I think the complications they are worried about are future pregnancies and the repeat cesarean that they know you'll likely have, whether you need one or not). Because its so politically risky, insurance companies are not allowed to mandate a TOL (trial of labor) or VBAC, and understandably, they don't want to pay for a bunch of expensive repeat surgeries that aren't necessary most of the time. So, because this is a market economy at times, they just don't provide their service to women with previous cesareans. I don't blame them.

But I have to wonder if anyone is warning women about this unforseen longterm complication of having a cesarean? Oh, it doesn't really matter if you don't have to have private insurance. But depending on the outcome of the current bickering about health care, that might be just exactly what a lot of people have to get. Except a pretty good number of them won't qualify....unless they are willing to undergo surgical sterilization, of course. Is that offensive to anyone other than me?

The great part is, I'm not just ranting about this. I already have one very motivated woman who is really pissed off about this. I need a few more. Who would be willing to talk to the media. It is distinctly possible that this could become a national story...if we find at least 3 women, with good documentation of the insurance policies and the refusal, who are willing to talk about it. And if its spun well, it'll really highlight what a disaster the 30+% cesarean rate really is, in ways that most people haven't even contemplated. So, if you are one of these women, please contact me. Ask around, see if you know anyone who's had this happen, who'd talk to me. Email me, please!

From the Horse's Mouth

2008-02-01T21:46:00.000-08:00

A story, a really true story.

I was talking to a good friend of mine this morning, we've known each other for about 17 years now (yikes!). Her sister is pregnant for the first time. Her sister is a recovering anorectic (this pertains to one of the horses in this story). So my friend, we'll call her A (we'll call her sister L) says to me "L has decided that she's unhappy with her OB group. She knows there's no guarentee that she'll even know the OB who's on when she goes into labor and she's trying to not let that bother her but it really does. L really really really doesn't want a cesarean and she's afraid she's going to end up with one. I told her that if she was unhappy, she'd better switch because she needed to listen to her instincts." (A has listened to me rant over the years, plus she's experienced a couple of pretty different births herself). I asked "so what happened?" I'll give the horses some credit for being honest....

L was VERY up front with the OB group she was seeing about the fact that she was a recovering anorectic. She told them "do not make comments about my weight, do not say anything about my weight, this is difficult but I'm committed to being healthy, etc etc etc". So, at her 5 month appt, the OB (a mare) says "oh, you've gained too much weight". I'm going to assume that she didn't bother to read the record, not that she's that callous and stupid to boot.

At her 6 month appointment, she sees the senior partner, a stallion, who she really doesn't like at all. She says to him "when can I see the CNM?" (turns out there's a CNM attached to this practice). He says "You don't want to see the CNM, she's really not into delivering babies." HUH? Certified Nurse MIDWIFE isn't into catching babies? Or not allowed to....anyway, he continues: "Actually, none of us are interested in delivering babies. We don't want to get up at 2 am and come in while you have your baby."

::jaw drops::

Like I said, I'll give 'em credit for being honest. Honest horses' asses. Who no doubt belong to the American College of OBSTETRICIANS and Gynecologists, good old ACOG.

Merriam Webster has the following definition:
ob·stet·rics
Pronunciation:
\əb-ˈste-triks, äb-\
Function:
noun plural but singular or plural in construction
Date: circa 1819
: a branch of medical science that deals with birth and with its antecedents and sequels

Oh, wait, but not at 2 am.

At 7 mos, L is interviewing an independent CNM practice, with 4 midwives. I'm sure she's going to be shocked at the difference in her care. I also recommended a doula and I hope she does find one she clicks with. Here's hoping.

VBAC ban

2008-01-26T13:58:00.000-08:00

The VBAC ban project is finally up and running! What is this you ask? Well, simply put, we are going to call every hospital in the U.S. and find out what their policy is on VBAC. The International Cesarean Awareness Network did this a few years back and found out that over 300 hospitals officially "ban" VBAC (even though this is patently illegal). Needless to say, we are sure the situation is much worse now. But, the cool thing is that ICAN is about to launch a fantastic new website and included on that website is a map of the U.S. upon which every one of the hospitals we call will appear....with information about that hospital and its policies on VBAC. AND, there will be a way for anyone to leave feedback about that hospital, so you can see what other women experienced there. But, in order for this to happen, we need people to call! So if you are interested in helping out, please email me and I'll get you set up and going.

Help ICAN shine the light into the oppression that so many hospitals are inflicting on women.

I wish I'd written this!

2007-12-21T18:50:00.001-08:00

This is one of the best bits of birth writing I've come across in a while. So check out Looking glass Alice examines birth and parenting in our culture. Her other stuff is good too -- I like the fact that she's not afraid to "offend" and seems to have a good handle on why we shouldn't be afraid of "offending".

After all, which one of us ever changes if we aren't offended to begin with?

Cesarean Rate Rises. Again.

2007-12-08T09:52:00.000-08:00

So I'm a bit behind in the blogging (what's new?). But I will add my voice to all the others expressing our outrage and grief (though not surprise) that the National cesarean rate for 2006 was reported by the CDC to be 31.1%, a 3% rise from 2005. Given what I see in the stories from just the women who join the ICAN email list, I'm not surprised at all. What with VBAC bans, early inductions and cesarean surgery becoming the "treatment of choice" for suspected macrosomia....I knew the numbers would be bad.

You want to know what's really bad? These numbers are very likely lower than the reality. Why? Well, because some states (Florida is one) exclude "high risk" cesareans from their data -- so if a woman has a cesarean and she was carrying muliples, or the baby was breech or the baby was premature....that doesn't "count". I'm trying to wrap my brain around why this would be a reasonable thing to do....and honestly, the only reason I can come up with is that it keeps the "official" number lower. The argument that these are "necessary and unavoidable" cesareans doesn't make sense to me (and isn't true anyway since all of those pregnancies can end with a vaginal birth)...and excluding breech alone has to raise the cesarean rate by at least 3%...what I am sure has not had any real effect on the numbers are the "patient choice cesareans"....because they really are very rare. You wouldn't know it from the popular press but anytime anyone has tried to get a handle on how many non-medically indicated cesareans are done by maternal request....a very small number is generated. Add to that the fact that most likely, some proportion of hospitals are just plain lying about their cesarean rates (we have a few cases where we know for sure it happens, I'd assume its not limited to those few hospitals) and you get a number that's higher than 31.1%.

So in my state, Michigan, the cesarean rate was 29.8%. About the only good thing I can say about that is that it isn't 37.4%, which is where New Jersey, the state that cuts more women than any other, falls. You know things are getting bad when you see a rate below 25% and want to celebrate (or move to that state). Look up your state -- and then look at the Press Release from ICAN...and then send it to all the media outlets in your area you can find, and to your state and national legislators. Let them know that you are tired of your healthcare and tax dollars being pocketed by the medical and insurance industries, while the U.S. suffers one of the worst maternal and infant mortality rates in the developed world. Let them know that you are tired of women's legal rights to informed consent and refusal being systematically trampled on.

And then, put your money where your mouth is. Join ICAN. If that doesn't appeal, join Lamaze Intl., or CIMS, or Citizens for Midwifery or birthNETWORK or ANY organization that's trying to make a difference.

If you want to get personally involved, email me -- I've got a big project just about ready to launch and I'll need people who are willing to donate time and phone minutes. The problem is huge....but you know what else? If even a quarter of the women who've been through the medical establishment while having a baby got involved....we could make a big difference. So how about it?

NATURAL* spells....

2007-12-04T10:47:00.000-08:00

vaginal? boy, I thought new math was strange, this new spelling is WAY out there. I'm getting really old....

Seriously, though...it seems (I've noticed this myself, I'm not just hearing it from other women) that "natural birth" is the new way to say "vaginal birth". Well....ok? Yes, a baby coming out of your vagina is an integral part of a natural birth...and admittedly, having a baby come out of your vagina is a HUGE accomplishment in this day and age....but natural?

So how do we decide to define a word....strictly, as in by the dictionary or by traditional usage? By current cultural usage? What are the consequences of allowing (either actively or tacitly) definitions to shift? How important is a word, anyway....I'd say words are very important, even more so because most people don't recognize how important they are!

Let's use the word "choice" for example. I could very accurately be described as someone who is pro-choice when it comes to birth options (what did you immediately think of when you read that? My stance on the "other" choice issue? Now you are probably wondering). The minute I use the phrase "pro-choice", the minute an organization like ICAN uses the phrase "pro-choice", even if we are clearly using it in the context of birth options, not abortion...people assume that we are "PRO-CHOICE". That phrase has gained a certain specific cultural definition that then restricts how I can use it in a different context.

So, if a "natural birth" has come to mean a "vaginal birth" and has no relationship at all to the circumstances of the labor with regard to drugs and other interventions...so what? Why in the world do we care? Are we truly "natural birth nazis" out to make any woman who has any intervention feel guilty, forcing women to suffer needlessly in childbirth through the strength of our criticism, reveling in our obvious moral and physical superiority because we pushed a baby out our vaginas without drugs or assistance? Given the diversity of humans, I'm sure there are some women who feel like that, I've experienced my share of birth elitism when the fact that I've had a cesarean becomes known...but honestly, most women who plan a drug-free birth aren't like that at all. And certainly, the women I know who plan drug-free births don't do it to prove anything...they just want to maximize their chances for a safe vaginal birth and its clear that using as little technology as is safely possible is the way to do that.

There was a time when "natural birth" absolutely meant drug-free and implied free of other interventions too. It was certainly something that many women strived for, and I don't think they wanted a natural birth in order to get their natural birth merit badge. I mean really, if the majority of women would like to have a natural birth, meaning no drugs, realistically it just doesn't mean that the majority of women think they are superior to other women. It means that there's an underlying cultural assumption that a drug-free birth is a good idea. But now we have this situation where its really hard to know what women truly want (and the benefits of a drug-free birth are no longer understood) -- there's the "epidural in the parking lot" crowd (who I think might say that as much because they think its trendy? funny? inevitable?), there's the "oh, nobody gets a badge for not using drugs" group (which I suspect is more about personal "failure issues" than anything) and of course, there's the "let me tell you how bad it really is" group (which I think is human nature -- we like to top each other's stories and talking a lot about something does take the mystery out of it....its just too bad we are replacing the mystery of "what's it going to be like" with false "facts" about what its going to be like). A pregnant woman surrounded by these statements is going to have a hard time believing she's capable of a drug-free birth and she's going to wonder why she should bother?

I don't know. I can't help but think about a study done in Brazil. Its been common belief that a big part of the reason the cesarean rate in Brazil is something like 80% is because women want to have cesareans (to save their vaginas I've been told). Well gee, someone actually went and ASKED...and guess what? The vast majority of pregnant women in Brazil say they want a vaginal birth, when asked at the beginning of their prenatal care. Look at that....we were wrong, it doesn't seem like its the women who are driving the cesarean rate after all! So, I have to wonder if we are wrong about women just not wanting a natural (drug-free) birth anymore....I think a lot of women do. Its just that by the time they get to the end of the pregnancy, they've been pounded with horror stories of how torturous labor is, they've been told (at least implicitly) that they are crazy or elitist to plan a drug-free birth, they've been told quite explicitly that they can't do it and they might as well not bother (you don't have to be a martyr, after all, you wouldn't get a filling without anesthesia. Actually, I would and have but that's neither here nor there since its an apples to oranges statement anyway) and they certainly haven't gotten a bit of support from their OB. If you set someone up to fail, well, most of the time they fail.

Ah, failure. A word that is very loaded in the context of labor and birth. But see, I don't have to tell a woman she's "failed". I really don't think of it in those terms anyway, to be honest. I know women are failed by those around them all the time when it comes to pregnancy and birth. That's where my criticism falls. Women tell themselves that they've failed, all the time about all sorts of things. I think that's where a lot of the stuff about not being a martyr comes from....because we DO judge ourselves based on what other women do (not just in pregnancy and birth). I don't think its a conscious effort to make another woman feel bad in order to feel better....but I do think that's some of it. Some of it is probably a (misplaced) desire to save your friend/sister/sister-in-law/cousin from the feelings of failure that you struggle with. It does make for a pretty damn touchy topic, especially when we are talking about "natural birth", a thing that most women "fail" at.

The question of whether one should "correct" the definition of "natural birth" when used to mean "vaginal birth" came up on the ICAN list. Boy oh boy, that was heated (though polite). It also showed up the limitations of email for discussing something that is going to be extremely nuanced and depend strongly on the context of the conversation that might need to be "corrected". For the record, I don't like the term "corrected" here -- birth is a tender topic...corrected implies "did it wrong" and honestly, there's a difference between the wrong use of a term and a "wrong birth". Do I believe that we need to fight against the trend making natural equivalent to vaginal? Yeah, I do. Its yet another erosion in safe birth....because it takes the very idea of a drug-free birth out of common language. If you don't hear it talked about, you don't think about it, you assume it doesn't happen. But for me, that doesn't mean stopping a woman in the midst of her telling her birth story for the first time and correcting her, when she says she had a natural birth with an epidural. It might mean asking some questions...if she's part of a group and everyone is swapping stories around, I might say something like "hey, that's so cool you had a vaginal birth, they are getting rarer and rarer, especially with all the stuff they do to you in the hospital these days" or depending, I might just ask "hey, did you say natural or did you say vaginal, I missed that part" or any number of more indirect ways to point out what I see as a disconnect. As long as they aren't threatened, for the most part, women LIKE to talk about their experiences. I like women to talk to me about birth because then I can share my experiences too. And then we can all think harder about pregnancy and birth and the state of things and what it should be like rather than what it is like. Because ultimately, that's what it is all about -- helping women fully understand what choices they have and what those choices mean -- giving women all the tools to make safe choices for their babies and themselves, something that most women just don't have the knowledge or confidence to do. And I believe that the vast majority of pregnant women will do whatever it takes to have the safest birth they can...they just don't know what a really safe birth looks like, and the only people telling them are us -- the crazy, hysterical natural birth nazis....

So yeah, let's make sure we are clear on terminology. But let's mix that with a healthy dose of empathy and compassion for the women who've never had a chance to hear about a really natural birth.

Nobody Wins

2007-11-29T23:21:00.000-08:00

I'll preface this post with the statement that while OF COURSE any allegation of child neglect or abuse must be investigated, it is obviously too much to ask that such investigations be done with even an iota of common sense, much less responsibility to the legal rights of the children involved, not to mention anyone else.

I had an experience the other day I hope NEVER to repeat. I suppose it could be considered "enlightening" if that word can even be used when talking about the mindless, heartless monster that is "social services" (to be fair, I should say "social services in my state" since maybe its better elsewhere? Right next to that bridge for sale....). I have a friend, I've known her for years. She's a smart woman, loves her kids and has had a really hard time for awhile now. She's not perfect (I've yet to meet that person) but she's sure as heck not stupid or lazy or criminal....she's just a mom struggling to keep a roof over her kids' heads and food on the table.

So one day, CPS shows up at her door, demanding to be allowed into her house. A complaint has been filed. The nature of the complaint pretty much proves that it has to be a malicious in nature. Sadly, my friend knows that there are several people who could and would do such a thing. So, she does what she is legally entitled to do -- she refused to allow the CPS agent into her house and instead required them to follow the formalities. Perhaps this particular agent had never before dealt with an educated parent, willing to advocate for herself and her kids....because she sure acted like someone had just pissed on her hydrant....it would be amusing if it hadn't ended up causing a lot of distress to my friend and her kids and costing ME, the taxpayer, a bunch of money that could be better spent, oh, finding kids that are actually being abused? Or perhaps, if that's too much to ask, funding schools, since my state is pretty much bankrupt at this point, with no relief in sight and the schools are taking the brunt of the budget cuts.

So this whole farce drags out....and earlier this week, I found myself sitting in the lobby of the local Welfare office (oh, there's some nice sounding name they call it now -- I can't for the life of me remember what it is -- Family Assistance something? Health and Human Services? Bend Over and Smile? I dunno....it was the welfare office.) I got there early so I had a chance to sit and watch. I'm not sure I've ever before been in a place that so sucked any life, any dignity, any hope out of a person. People coming in, with varying degrees of frustration or futility in their eyes. People who I would bet are just trying to make ends meet. Yeah, I'm sure some of them are there because they made stupid decisions but as is said, there but by the grace of God go I.....fluorescent lights, humming just below hearing, cheap plastic chairs that look like they came from a bus station 15 years ago (you know the kind, they sorta but not really are formed to fit your butt -- which means they really don't fit anything), broken toys over in a corner for the kids to play with, clerks who are more robot than anything, unless you don't stand in the right line or fill out the right form or sign the right sheet....anyway, there I sit, waiting to wait with my friend while CPS interviews her kids, which supposedly will be the end of this unless they find something (which they won't). Again, my friend knows her legal rights (and more importantly, her children's legal rights) and so she has a lawyer present, to sit in on the interviews. Oh my goodness, if the agent's hydrant got pissed on before, this was chest thumping I'd expect from chimpanzees, not government employees.

I think it took almost an HOUR for CPS to figure out that they weren't going to find a copy of the law stating that they didn't have to allow the lawyer to be present (since it didn't exist) but they did get to say "the prosecutor" a lot (which is amusing in a sick way -- if they actually DO get the prosecutor involved, then the presence of a lawyer is more than guarenteed!). They did try to get the lawyer excluded on the grounds that they are allowed to interview a child without the suspected abuser present. I realize that lawyers are generally unpopular but this was not at all fair to the very nice woman who was representing the children as I must say I didn't see anything about her interactions with the children I'd consider abusive.

Finally someone figured out that if they weren't willing to just say "oops we were wrong, we're so sorry for wasting your time, have a nice day" then they needed to come up with an alternative. (In the meantime I'm getting creative in the "visitation room" with its own collection of broken toys, keeping a bunch of kids occupied as best I can -- imagine what it would have been like if they'd actually refused to let me in, the way they first wanted!) So, it turns out if they do a different sort of interview THEN the lawyer can be present (in the process of this compromise they got to say prosecutor a few more times)....so that's what they did. Including trying to interview the barely verbal baby who's in that special separation anxiety stage....I'm sure there was some box on some form that had to get checked off and heck, the kid got a piece of gum (bribery) out of the deal.

So finally, oh, about 2 hours later, we all traipse out to a chorus of "thank-you-so-much-we'll-be-in-touch-have-a-nice-day (if they just could have said that, oh, about 2 hours earlier it might have been a nice day) and run the gauntlet of the hopeless to get the heck out of there.

So now I get why hospitals like to threaten difficult parents with CPS -- they've sprung from the loins of the same cursed mother! And I suppose, ACOG's members would be their multi-headed evil triplet. I know the answer to this institutionalized paternalistic bullying with its implicit misogyny IS knowing one's rights and standing firm (at least the immediate short-term answer, I'm at a complete loss as to the long term solution). I can also now very clearly see the conflict -- you know you need to do what's right but in doing that, your kids have to suffer to some degree or another -- be it something as (hopefully) slight as spending the morning in a decidely unpleasant place with decidedly unpleasant people who want to separate you from your parent (though I'm sure it didn't seem slight to the younger kids) to something as horrifying as the fear that your children could end up in foster care while the whole thing is "sorted out" -- the temptation to just do what they want and get it over would be overwhelming. Principles only get you so far.

And you know, I'd say that the people (mostly women) who work for the system are ultimately victims too -- because I believe that the majority of these people go into the job really wanting to make a difference, really wanting to save abused children, or help struggling families....and somehow they too get the passion, the fire, the life sucked out of them. So what is it? Is it Western culture? Human nature? What is it that makes it impossible to know when to sit still, when to reach out to assist and when to rescue? Sounds an awful lot like obstetrics, doesn't it? Humans just don't do institutional compassion very well, do we....

Howling At an Uncaring Moon (ADULT language follows)

2007-11-26T18:24:00.000-08:00

Here's the obligatory warning. I'm gonna drop a number of F-bombs and equivalent offensivenesses so if that's a problem, stop reading now.

I'm so FUCKING sick and tired.

I FUCKING tired of people being surprised at my hurt. I'm FUCKING tired of being nice, political, detached, dispassionate, reasonable.

Today I had someone (who I like and respect) express surprise that I would call a midwife (who answered a query in a public forum) on the fact that she thinks women who express their birth trauma in terms of rape are just crazy, basically. Oh, she phrased it in terms of prior experience, bad expectations blah blah blah. Its bullshit. Unadulterated BULLSHIT.

You know what? My cesarean felt just like a rape. Because I've BEEN raped, I can pretty accurately make the comparison. But you know what? I don't think a prior experience of sexual assault is necessary for a woman to KNOW she's been raped. Of course, the fact that something like 1 in 3 women in the U.S. have experienced a non-consensual sexual contact before the age of 18 means that there's a whole bunch of women who DO know what they are comparing to. So pretty much all I have to say to those who aren't happy with my comparison of my "good" cesarean with my rape is FUCK YOU. How dare you. How fucking dare you.

My cesarean was 9 1/2 years ago. It wasn't even a "bad" one compared to the horrors that most women endure. And I CRIED tonight on the way home about it. THAT'S what happens when I let myself think about it. Me -- controlled, professional, even-tempered, fair-minded, appropriately detached, 2 VBACs later, well on the way to being healed ME. Also the me who since the cesarean has had to deal with anxiety disorder, depression and substance abuse...oh, the cesarean certainly isn't the only "reason" for these problems but it sure as hell didn't help, now did it?

And you know what? I'm FUCKING tired of the Business of Being Born (Ricki Lake's movie). Why? Because everyone who cares is all about how wonderful it is and how profound it is and blah blah blah...it isn't going to make one stinking bit of difference. Because the women who NEED to see it wouldn't GET it even if they did see it. They are so fucking brainwashed that the very thought that their precious OB might not have the same dreams they do is impossible for them to fathom. I'm also really really sick and tired of the fucking choir. I'm tired of midwives carrying on about how important they are. Oh I get how they have to protect their living, their licences, etc. I get that, really I do -- the prosecutions (persecutions) against midwives are nothing less than immoral and maliciously hateful to boot....but frankly, most of them are so fucking full of what a great job they are doing that they won't see the slaughter and if they do, they have to blame it on the women who run so willingly to it. And ok, I can't be that mad at them, after all, part of the reason I'm ranting here is because the slaughter is so damn depressing and overwhelming.

And I'm really really tired of women not getting it. Who do I blame for that? What the hell has happened that women are OK with getting their genitals mutilated for no good reason? What the hell has happened that women ARE abused during birth, more often than not, and they don't care? It pisses me off that women don't care. It pisses me off that somehow, they've been so manipulated from the time of their own births that they think it really is ok to be sexually abused (in all sorts of ways, having a baby only being part of it). Because that's exactly what it is, sexual abuse (aka rape -- oh, I can't believe she said that! whatever). Except part of me KNOWS that every single woman does KNOW that what happened to her was wrong. Most of the time, she just shuts up, stuffs it and acts like the good little girl that she's supposed to be, to the degree that she'll rip you a new asshole if you DARE imply that she might have reason to be hurt....whatever. I'm fucking tired of that woman too. Fighting with each other when really, we are the only hope we have. Why is it ok for a virtual stranger(s) to stick his (her?) hands up your vagina for no good reason on any number of occasions and then require you to submit to conditions that are pretty much the same as bondage/torture leading to nasty drugs, deliberate cutting of your vagina (and anus, if you are really lucky), or your stomach, muscles and uterus, putting you at risk of serious and life threatening complications for THE REST OF YOUR LIFE. Oh, and did I mention the fact that IT ISN'T GOOD FOR YOUR BABY EITHER????? Your Obstetrician LIED to you. Gasp.

Oh wait. I'm just an angry woman, probably unstable, certainly hysterical, projecting my own mental illness on poor innocent you. Well, that's ok, I'm well acquainted with the finer points of denial so I get it.

Catch me as I fall
Say you're here and it's all over now
Speaking to the atmosphere
No one's here and I fall into myself
This truth drives me
Into madness
I know I can stop the pain
If I will it all away
Don't turn away
(Don't give in to the pain)
Don't try to hide
(Though they're screaming your name)
Don't close your eyes
(God knows what lies behind them)
Don't turn out the light
(Never sleep never die)
I'm frightened by what I see
But somehow I know
That there's much more to come
Immobilized by my fear
And soon to be
Blinded by tears
I can stop the pain
If I will it all away
Don't turn away
(Don't give in to the pain)
Don't try to hide
(Though they're screaming your name)
Don't close your eyes
(God knows what lies behind them)
Don't turn out the light
(Never sleep never die)
Fallen angels at my feet
Whispered voices at my ear
Death before my eyes
Lying next to me I fear
She beckons me
Shall I give in
Upon my end shall I begin
Forsaking all I've fallen for
I rise to meet the end
"whisper" -- amy lee and ben moody

right now, that song describes what it feels like to me to get cut open and then told it doesn't matter. yeah, even 9 1/2 years later....I wish more women didn't close their eyes.....

Ok, so I'm winding down now. I really don't even know exactly what to do with all this....I'll gather myself together and keep plugging away, at least for the sake of my kids, if not for any real change now.

Ramblings of a bored Veterinarian

2007-11-18T15:11:00.000-08:00

Funny the things I can figure out when its actually not the middle of the night (which is usually when I have time to even contemplate writing). I figured out how to make the screens smaller with the embedded youtube videos. Yay! So I now have 2 videos prominently displayed on my sidebar....and links to several others that I hope you will check out.

I also added a bunch of blogs and websites to my lists...there's a lot of action right now. We'll see if it lasts. Everyone is all excited about Ricki Lake's movie...I haven't seen it yet, though I'd like to. But honestly....how many women are actually going to see it? Who aren't at least halfway in our choir anyway? And how many women are actually going to make the jump OUT of the hospital....no, they'll just persist in believing that a good birth plan and a doula will guarantee the birth they want...and sadly, in many (most?) cases, hospital staff are very good at getting around both those things.

I try really hard not to get too depressed about the state of things. I think I must be in a "down" phase right now....it seems like its the same old thing over and over and over....I want to have a VBAC but...my hospital banned them....my OB won't do them....my husband doesn't want me to....there are no midwives in my area....we can't afford a homebirth....or....I planned a VBAC but....my OB told me it isn't as safe as we thought....the baby looked big and they wouldn't induce me....I went to 42 weeks and the baby had to come out.....the ultrasound showed my placenta was getting old....my fluid getting low....I didn't want another cesarean but.....

Which leads to a fairly controversial topic, I suppose. The "godly submissive wife". I don't know enough about other faiths to know for sure if this bit of doctrine exists elsewhere -- I suspect it does in some form or another in both Islam and Judaism but I'm familiar with it as an expression of Christian belief. It is a wildly debated topic, since the Bible actually doesn't define it very well....and certainly doesn't define it in terms of modern society and culture. First, the disclosure -- I am an evangelical Christian (by a more traditional and non-political definition -- you can't call me fundamentalist or right wing) and I do believe that a wife should be properly "submitted" to her husband (of course, all believers are to be submitted to each other, too. And, it always pays to remember that the same scripture that urges wives to submit to their husbands instructs husbands to *die* for their wives. Personally, I think I got the better end of that deal). Anyway, the rub is "properly". There are some groups that believe this means the wife has to get her husband's permission for any decision of import. There are some groups that mean this gives a husband complete veto power over any choice his wife might make. There are some groups that believe this means a wife has to do anything her husband demands of her. And I suppose, if a husband were also properly laying his life down for his wife, all the potential abuses inherent in this sort of extreme interpretation probably wouldn't be an issue. But, guess what....humans pretty much will screw anything up. And so, we screw this one up. I have heard too many times "I'm a (Godly/Biblically) submissive wife and my husband doesn't want me to have a VBAC. (or home birth. or midwife. or something of that sort) Unless God changes his mind, I have to have another cesarean because I'm submitted to him." My response to that is "if your husband said any of the following, would you do it? 'I want you to watch porn with me.' 'I think car seats aren't that important and I'm not going to pay for one, you can drive without one.' 'I want you to sign this tax form, even though I haven't been honest on it.' 'I want you to tell your mother we are busy this Thanksgiving.' 'I don't want you talking to your sister, I think she's a bad influence on you.' 'I don't want you going to that Bible study, you need to be home.' 'I want you to have a boob job/tummy tuck/other elective surgery so that you are more sexually attractive to me.'" The fact is, the Bible *never* provides justification for immoral behavior. Lying, cheating, sexual sin, withholding oneself from the body of Christ, endangering children, frivolously endangering oneself....there's never a good reason for any of those things. It doesn't matter if the husband "thinks" any of those things are ok. If I know that what my husband is demanding of me is contrary to God's plan and purpose...I'm not obligated to do it. I'd say I'm obligated to NOT do it, rather the issue is my attitude toward my husband as I choose to obey God. What does this have to do with birth? Well....if a woman truly believes that a given choice is the safest one for her baby, then I'd argue is it immoral to then choose to do otherwise. The fact that the overall risk of something bad happening to mom or the baby is small regardless of the actual choice doesn't matter. The fact that most people might disagree with the conclusion a woman comes to doesn't matter (after all, most people would probably disagree with the overbearing interpretation of submission but she chooses to live that way). A husband has no right to demand immoral behavior from his wife, even if it is "his child too". But, you say, its different. Is it? Is how our children enter this world not that important? If that's what you truly believe, then why are you bemoaning the fact that your husband says you have to have a repeat cesarean. If it isn't important then it really shouldn't matter. (For the record, in my marriage, wifely submission means that in a situation where we disagree on the path we should take, as long as both choices are morally acceptable choices, he gets to choose. IF we absolutely can not come to an agreement. We never rush to this conclusion. This has happened exactly 2 times in over 16 years.)

I'll end with another potentially hot opinion. All of the excuses for why a woman can't have a VBAC or home birth or whatever are just that -- excuses. Women hide behind "my husband would never agree to it" or "we just don't have the money" or "neither of the hospitals in my town allow it" or "there aren't any midwives in my city" or "it's my husband's baby too" or "I don't want to ruin my marriage fighting about this" when in fact, the issue is that while they think they *should* plan a VBAC or home birth or whatever, they actually don't want to. Not really. I know this will be unpopular....but too often I've seen that where there is a will, a way is found, too often I've seen it to believe that a woman can't get what she wants for her baby if she really wants it.

I suppose I sound rather cynical right now. In some ways, I suppose I am. It just seems like we are going round and round and round in the very same circle while most women quietly run toward slaughter and then spend the rest of their lives telling themselves its ok.

2007-10-28T17:30:00.000-07:00

Again, not nearly enough time to write like I'd like but...I came across this and I really like it. I dunno...it seems SO obvious...why don't more women get this?

http://naturalmomstalkradio.com/blog/are-women-weak/

When you think about how much many women (at least educated women) WON'T put up with...the things that they find inexcusable...the things that they do allow (certainly educated women are even MORE likely to allow birth abuse) are mind-boggling.

So what does it take to open eyes?

Gretchen

My Video

2007-10-19T10:43:00.000-07:00

Ok, I'm gonna try to do this...my video is embedded at the bottom of my blog (when I put it as a sidebar, it got cut off) but I doubt most people will go look for it there....of course, when this disappears, they won't look for it here either -- not quite sure how to get around that :-)

Anyway, I made this video. And when I have a bit more time, I'll explain why I did (or didn't do) some of the things in it.

Gretchen

Fox in the Hen House hunting Witches

2007-10-12T05:21:00.000-07:00

I recently learned about something very disturbing...the American Medical Association formed a group called the Scope of Practice Partnership (SOPP), whose mission is to launch investigations of unlicensed “midlevel providers” and to support initiatives to fight legislation expanding the current scope of practice for licensed “midlevel providers”. If you search "Scope of Practice Partnership" you'll find some interesting and really scary stuff -- unlicensed "midlevel providers" would include non-Certified Nurse Midwives ("lay" or "direct entry" midwives) in states where licensure isn't available, even if those midwives were CPMs and thus, license "ready". If you read between the lines (and on top of them too) you can see that "investigations" is a nice way of saying prosecution and of course, they also oppose legislation introducing licensure to these sorts of health care providers. Licensed "midlevel providers" include the following: chiropractors, advanced practice nurses (aka nurse practitioners), nurse anesthetists, optometrists, podiatrists, physical therapists and psychologists. This whole thing is being sold as an attempt to "ensure quality health care" but my answer to that would be deal with your own lousy health care before you started trying to "fix" someone else's. We all know how well most physicians do with individualized care...Log in the eye anyone?

Alternatively, I've seen it described as a "clearinghouse of information about non physician providers' educational preparation, licensure requirements, and state legislation and regulation regarding scope of practice." The big question is, what do they plan on doing with the information? Oh, well, whenever there is a "scope of practice question" (that would be some non-physician profession encroaching on the income source of the physicians in that state or states) this information can be used to "address the issue" or even better "develop model legislation that can help resolve that concern." A specific example would be nurse practitioners -- currently, the education level to be a nurse practicioner is at the Master's level. There is a move in the nurse practitioner community to move to a Doctor of Nursing Practice degree, rather than a Master's degree. Why is this a bad idea? Why, it would allow nurses to call themselves doctors! And heaven knows, we can't have that...gosh, are they going to come after me too? After all, I call myself doctor....I'm sorry, but physicians don't have a lock on the generic term "doctor".

I think it is most baldly put in this direct quote from AMA resolution 902 : “that state medical boards shall have full authority to regulate the practice of medicine by all persons within a state, notwithstanding claims to the contrary by boards of nursing, mid-level practitioners or other entities.” Needless to say, they define "practice of medicine" very very broadly. Resolution 902 also asserts that “patients may be put at risk for injury or death . . . receiving care from persons
who are not physicians (MD [medical doctor] or DO [doctor of osteopathic medicine])” It is important to realize that there is NO evidence to support this statement and the AMA has been unable to substantiate it. But then again, we all know that patients are never "put at risk for injury or death" by the actions of physicians....who practice only the most scrupulously careful, up-to-date, gold standard medicine, of course.

This is a bully stealing the lunch money from the smart kid, who also happens to be a really nice kid too.

If you'd like to read some analyses of this, I've collected links here:

Coalition for Patients' Rights
Dynamic ChiropracticJune 6, 2006, Volume 24, Issue 12
Dynamic ChiropracticDecember 31, 2006, Volume 25, Issue 02
National Alliance of Professional Psychology Providers
Clinical Journal of Oncology Nursing • Volume 11, Number 2
American Dietetic Association
The Integrator Blog
Maryland Optometric Association
American Association of Nurse Anesthetists

Interestingly enough, I had a chance to discuss the quality empathetic and humane care pregnant women get from "doctors" the other night. For those who don't already know, I'm a Veterinarian and I work at a Veterinary ER Center -- I'm the person you see when your dog gets hit by a car or your cat blocks in the middle of the night (or on the weekend or the holiday, of course). I really love my work and the hours allow me to be other things besides a Veterinarian as well. When I'm working a weeknight overnight shift, I usually have 1 LVT (Licensed Veterinary Technician -- basically the Veterinary equivalent of a Registered Nurse -- they have 4 year degrees and have to pass a written and practical exam to be licensed). Anyway, we were discussing the recent birth events of another employee and I was expressing my disgust at how predictable things are most of the time -- this woman ended up with a cesarean she really didn't want at all and the way she got there was distressingly familiar to me. And my LVT, who is single, childless and in her 50's said all the right things...she was absolutely horrified that over 1 in 3 babies is born surgically. She was amazed that anyone could possibly think its a better way to have a baby. She was shocked that more women are dying in childbirth now than they were a year earlier...she was disgusted at the way OBs manipulate women at the end of their pregnancies when they are tired and exceedingly hormonal.

Too bad I'm not surprised any longer.

Gretchen

VBAC bans and other nonsense

2007-10-08T20:25:00.000-07:00

Well, look at that, here I am again. I should probably be sewing Hallowe'en costumes...gonna be a busy couple of weeks I think. Anyway, I'm going to ramble this time about VBAC (that's vaginal birth after cesarean if you don't know, and if you are google searching blogs for that particular term ;-) and how much harder it is to have one now.

There's a lot of research on VBAC out there. For the most part it can be pretty easily summed up as follows:

The one complication that's relatively unique to VBAC is uterine rupture. Uterine rupture can be catastrophic, so it isn't something to ignore but catastrophic ruptures are also rare unless you do some stupid things. The rate of uterine rupture in labors that are spontaneous (that means no induction) and in the hospital is roughly 0.5% (1 in 200), but not all of those are catastrophic. Other than uterine rupture, there's no difference between a VBAC labor and any other labor. If you use things like pitocin or prostaglandins, you will increase the rupture rate. If you've had more than one cesarean, the rupture rate will be higher but its looking like it isn't really much higher (in one recent and very large study, it wasn't higher at all). If successful, VBAC is much better for the mother (obviously -- surgery really isn't "good" for anyone, it can be necessary but not good) and probably better for the baby too. It certainly isn't worse for the baby. The rupture rate is higher with incisions in the upper part of the uterus but we really don't know what the rates are -- all the numbers are quite old and women with these sorts of incisions are rarely "allowed" to have VBACs, so we don't know what the uterine rupture rates would be in this population. Things that do not increase the uterine rupture rate include being past your due date, having a "big" baby, having twins, being old, being young, being fat, being skinny or being short. Unless of course you are being induced because of any of those things.

Back in the 90's, the medical community "supported" VBAC. I'm too cynical to believe that this support was because of some noble desire to see women avoid the knife -- well, ok, maybe that was part of it....but really, it was about managed health care and cost cutting. And that's not a good reason...the good reason would be because its better care for mothers and babies to encourage VBAC (which it is) not because it makes the profit margin look better to the share holders. The reason I say this is because the OBs just couldn't keep their hands off ... birth of any sort goes better if you just leave it alone...and they couldn't. So they started doing stupid things like inducing women willy nilly and getting very casual about the whole thing...and so, because bad behavior begets bad behavior, there were some spectacular lawsuits. Though, I've been told that this has been somewhat overblown by the obstetrical community....I don't doubt it but I can't confirm it either. Anyway, ACOG (American College of Obstetrics and Gynecology, functionally the trade union for OBGYNs) came out with a practice bulletin that made "suggestions" about how to manage a VBAC and basically VBAC became an endangered species...ACOG claims that the practice bulletins are just "suggestions" but realistically, if an OB does something counter to the bulletin, they have little to stand on if they are sued. Which leads to VBAC bans.

ICAN is in the process of updating our list but as of a few years ago, there were over 300 hospitals in the U.S. that officially banned VBAC - in other words, you can't have one at that hospital, even if you've had one or more already. At least, that's what they'd like you to believe. Many more hospitals have de facto bans in place because there aren't any attending physicians who'll accept a patient who wants one or the restrictions on having one are so outlandish that it just never happens. I don't know about you but I find it really offensive that anyone, much less a hospital administrator or Board of Directors can tell a women how she's allowed to have her baby. Plus, I'm pretty sure its illegal. Why, you ask?

I'm still figuring this out but I think there are two different laws/regulations that actually make it illegal for a hospital to refuse to allow VBACs. The first is EMTALA (Emergency Medical Treatment and Active Labor Act) which says that if a woman shows up at a hospital in active labor, that hospital may not turn her away, no matter what. The hospital is required by law to admit her and stabilize her (defined as both the baby and the placenta out) OR if they are not able to provide care, transfer her to a facility that can (if they can transfer her before the baby and placenta are delivered. A physician friend explained to me that if the baby and placenta are delivered in transport, the hospital that shipped the woman gets in big trouble because obviously, they could have handled it). What EMTALA does is get the woman in the door. THEN there are the Medicare Conditions of Participation (CoP)- these are the rules any hospital that accepts Medicare dollars (most of them) must follow. The CoP has some very specific things to say about a patient's right to refuse treatment in the section on patient's rights:

"The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate."

Now...the one thing that I see a potential problem with is that last sentence -- "medically unnecessary or inappropriate." If someone did request a judgment on whether or not VBAC bans were illegal under this clause, I have to wonder if the argument would be made that VBAC is under some circumstances "medically unnecessary or inappropriate". The notion that VBAC is a "treatment" or "service" makes me crazy -- might as well say pooping is a treatment or service, it would make as much sense but that's not how it is framed much of the time -- I see VBAC referred to as a "procedure" rather frequently, even though the best way to have a VBAC is to not do anything at all (that's an odd sort of procedure). I wonder if the powers that be in the CoP world would look to ACOG for an "expert" opinion -- calling ACOG an expert in VBAC is like calling the oil companies experts in alternative fuel sources so needless to say, I have no faith that they'd give an unbiased opinion when asked. Its an interesting dilemma...should we push for a ruling on this? Or would it possibly backfire badly. To me it seems SO obvious that it is against everything we say is important in this country with regard to individual rights to bodily integrity, etc...but we are talking about pregnant women (who in some states are not allowed to draft advance directives or living wills because they are considered incompetent by virtue of being pregnant), particularly their uteri and we all know uteri aren't all that important (50% of all women will die without theirs -- hysterectomy is the second most common surgical procedure after cesarean. Can't help but wonder if things would be different if babies came out of prostates or something...) So here I sit wondering....should we push this? Where oh where is a lawyer familiar with Heath and Human Services law when you need one?

If you know of a hospital in your area that does outright ban VBAC, keep an eye out for the online survey that will be on the ICAN website soon. I'd love to have your information.

Gretchen

I want Google to find me too!

2007-10-07T08:35:00.000-07:00

So, though the chances that you're here reading this and don't already know me are probably pretty slim, just in case you don't, I'll tell you a little bit about me. And yes, I have ulterior motives, because I'm trying to "do my part" and get birth issues onto the radar screen of the mainstream (yeah, I know, set a reasonable goal there). On the advice of a friend, who also happens to be an ultra cool cyber-savvy person and the Publications Director for the International Cesarean Awareness Network (ICAN) I'm trying very hard. She told us to go out and blog blog blog. I get the Google alerts for various topics, including "International Cesarean Awareness Network" and I want my blog to show up one of these days!

Now, you ask, why is this something you care about? Surely with 3 of 4 kids in a charter school (that means LOTS of parent involvement and 120 miles of driving each school day), a preschooler still mostly at home, a full-time job (for the moment) and all that goes with that, having a blog and actually writing in it can't be such a good idea. And maybe you are right....I've yet to prove that I can keep up with this. But, since my job does include a lot of down time in the middle of the night, maybe I can pull this off (sleep? who needs sleep....I lost that biological imperative about 9 years ago. Ha!). But seriously, why do I care?

The first reason I care is because I had a cesarean over 9 years ago and I hated it. I knew I would (it was "scheduled" so I had lots of time to anticipate just how fun it wasn't going to be, given what I'd actually planned for) but I didn't anticipate how having it would completely shatter me. I mean, really, it shouldn't have, right? -- my husband and I had a lot of trouble conceiving and maintaining a pregnancy so we ended up in treatment (somehow I guess because I didn't just fall pregnant, I was supposed to really not care how the babies "got here"), the surgery was scheduled so I was able to request (demand) certain things to make it a better (less worse?) experience, my recovery was "good" (aka not medically complicated by anything)...and it shattered me. Pain that didn't just magically go away in 8 weeks (that's when they tell cesarean moms that they'll be back to normal), delightful depression that morphed into an impressive rage, a profound disconnect with my babies (fraternal twin boys), an even bigger disconnect with my husband (you can resume "relations" in 6 weeks. yeah, right. try 7 1/2 months and then not because you actually want to, you just feel that the likely damage done to your marriage is worth prostituting yourself to prevent), doubts and regrets that never ever stop and keep you awake night after night, the inability to take a shower without sobbing (because that's the only place you can do it and not be heard). The incessant fear that you are not a good mother that in fact you are a terrible mother because if you were a good mother, the overwhelming love you instantaneously feel for your babies (that I didn't feel at all) would make all the cesarean stuff just go away....yeah, I hated my cesarean.

When I found ICAN and joined the email support group, I found other women who had very similar experiences, very similar reactions, women who really didn't like their cesareans. And, they weren't afraid to talk about it! That was a sanity saver. THEN I started to realize how many women there were....that was many years ago, and the host for the list at that time was a program that was really difficult to use -- it was complicated and somewhat arcane to join, so I'm sure there were lots of women who never made it there (took me 3 tries and I'm pretty computer literate). Imagine how many there would be if it was easy and everyone had an Internet connection? As I started to move through my journey, I developed a passion for giving other women the help I'd gotten. Eventually, I took over ownership of the list, we moved to Yahoo and the number of women who joined each day was and still is staggering. Clearly, there is a problem with cesareans....and I can't turn my back on those women who are grasping at any hope that they aren't crazy and there was a way out of the place where they find themselves.

And things just get worse....the cesarean rate keeps going up and up (in 2005 it was 30.2% of all births, kinda -- turns out they don't even count things like multiples or breech or preterm in that number! Hey, I didn't really have a cesarean then...cool. No seriously, the real rate in 2005 was probably more like 36% or so...) The infant mortality rate is going up....and guess what? The maternal mortality rate is going up too! And the interpretation of this bit of news didn't even have to be spun by ICAN -- the government stated quite clearly that the increase was most likely due to the increasing cesarean rate (and obesity, though that is likely not independent of the cesarean rate, since over-weight and obese women have cesareans at a much higher rate than other women, often for no apparent reason other than being heavy), along with better reporting. That last bit is interesting...we've suspected for a long time that childbirth related maternal mortality is woefully under-reported (as much as 4-16x by some estimates) so actually, things have been a lot worse than anyone could prove for a long time.

If you have any awareness at all that our health care system is way screwed up, you'll love this factoid: the U.S. spends more (total and per capita) on maternity care than any other country on this planet. And our measures of outcome, those good ole mortality rates, suck. We rank somewhere (depending on the list) between 21 and 25 in the list of developed nations. There are lots of developing nations that have better numbers than we do. We are throwing money away, while women and babies die. How come I never hear any of the presidential candidates talking about that? Oh, I forgot, the American Medical Association uses a lot of those health care dollars to pay really good lobbyists and to make contributions. Wait, wouldn't that be illegal? Uh huh, and nothing illegal EVER happens in health care OR politics. Your insurance premiums at work there. And you thought they were going to buy you good medical care, silly you.

Needless to say, I could go on and on and on. And I suppose that's the point of a blog...but...maybe we'll just save the rest for another time. If you are desperate to read more, you can go to my website. Start with You Should Be Grateful, the first thing I ever wrote and then go from there.

Gretchen

So here I am

2007-09-30T14:05:00.000-07:00

I've been pretty disappointed with the traffic I don't get to my other blog....now, I'm not going to abandon it, I'll probably just cut and paste between the two, since I really do love my website (and I've paid for it :-) so I thought I'd try out blogger....now they assure me that just because this is a google product, it doesn't mean I'll automatically search higher....but then again, I get Google alerts and most of the blogs in the blog alerts are blogspot. Can't hurt, right? Plus, I do have access to more widgets here and I'm needin' some widgets!

We'll see if I can import some of my other stuff....or maybe no one really cares.

Gretchen