What do I do now?

(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?

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?

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

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

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.

Happier News

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 :-)

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.

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

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!

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!

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....

More Thoughts on The Business of Being Born

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.

Ask Dr. Amy

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

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....

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....

Cesareans and Private Insurance

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

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.

I wish I'd written this!

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.

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?

N*A*T*U*R*A*L* spells....

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.