The Birth Book Blog

A birth, a boy and a book

2012-01-09T20:26:00.000-08:00

Eight years ago today, on a sub-zero morning of a full moon, my son was born by unexpected c-section. He was fine. I was upset. My husband, then a journalist, shell-shocked from witnessing the cutting, cauterizing, puking, shaking and stitching, wondered if any of it had been necessary and defaulted to skeptical reporter mode, asking the obstetrician a question when I had finally been wheeled into recovery.

"What," he asked her, "would you have done in this situation 500 years ago?"

I was groggy but overheard the gruesome answer that she delivered to him at the foot of my bed.

Her response generated more questions and my resolve to find out if what she said was true. I spent many therapeutic and enlightening hours in the rare books department at various libaries, pulled shifts in hospital maternity units, and devoted a great deal of time interviewing academics, midwives, doulas, nurses and parents, processing information for myself and what would become my book, Birth: The Surprising History of How We Are Born.

For these last eight years, Jan. 10 has been a day of reflection for me on becoming a mom and an author -- simultaneously. This year, I am noticing that my son is no longer a baby and the c-section scar, a thick keloid that looked like a frown when viewed from above, is almost imperceptible.

Finally.

A birthday thanks

2011-12-08T03:43:00.000-08:00

Today is Harrison's birthday. Four years ago, he was born in a pool of water (chronicled here) in his bedroom at our home in Boston, a VBAC attended by an amazing midwife, Deborah. As I do every year on this day, I say thank you to her for guiding me through one of the most amazing experiences of my life. This is a poem I wrote about her.

More Business of Being Born

2011-10-26T19:22:00.000-07:00

I wanted to pass along the brand new trailer for More Business of Being Born from Executive Producer Ricki Lake and Filmmaker Abby Epstein. This release follows their landmark documentary, The Business of Being Born, with a four part DVD series that continues their provocative and entertaining exploration of the modern maternity care system. More Business of Being Born, available November 8th, offers a practical look at birthing options as well as poignant celebrity birth stories from stars including Alanis Morissette, Gisele Bundchen, Christy Turlington-Burns, Cindy Crawford, Molly Ringwald, Laila Ali, Kimberly Williams-Paisley and Melissa Joan Hart. Part 4: The VBAC Dilemma is currently available for rental on demand. You can watch a trailer here.

As part of the cast of the first film, I was excited to go to its debut at the Tribeca Film Festival, unexpectedly pregnant. The film confirmed my decision -- and my husband's decision -- to have a home birth. Here's what I wrote about some of the reviews of the original film.

An amazing birth-artifact

2011-10-24T17:45:00.000-07:00

This is an amazing image for two reasons: First, it was found by a man who is legally blind. Second, it shows a common position women gave birth -- standing up, supported by ropes or vines -- before doctors determined it was more convenient for women do to deliver on their backs. Which, it turns out, is the worst possible position because it is more difficult for both baby and mother. Thanks to Carey Goldberg at the CommonHealth Blog for pointing it out to me.

Carla Bruni-Sarkozy gives birth -- without the president there

2011-10-21T13:17:00.000-07:00

Carla Bruni-Sarkozy gave birth this week to a girl, but her husband wasn't there -- he was busy jetting off to Germany to meet Angela Merkel on important business. Fair enough. Or is it? I quickly received a couple calls from journalists asking what I thought.

Throughout all of human history in almost every culture, until the last 30-50 years, men never witnessed the births of their babies. They didn't want to see it and the mothers didn't see the upside of having them there. Before birth moved from the home to the hospital in the early 20th Century, moms typically had a gaggle of other women and a midwife to support her through labor. Men were considered useless and it was not their place. This changed when birth moved to the hospital because suddenly women were often left to labor alone -- with the obstetrician stepping into the room at the last minute. This trend made women crave support -- and fathers, being family, were the only ones hospitals would allow, even if it took lawsuits to open the gates. (P.S. If the mother and father weren't married, hospitals initially refused to allow him to witness the birth. Lawsuits changed this practice, too.)

Despite that history, men are now expected to attend the births of their babies. Which is great, if they want to be there and the mother wants them to be.

But there are many dads who are squeamish, fight with staff, or freak out the mother. If the mother has other support -- and she always should -- and if she doesn't mind him not being there, fine. It may be best for everyone.

As for Sarkozy, he's left with a public perception problem. Is Angele Merkel more important than your wife? Did this birth seem less important than those with your previous wives? At the very least, when he did show up at the clinic, he should have brought flowers.

Regulating midwives

2011-07-19T18:53:00.000-07:00

Below is the written testimony I provided today during a hearing for a bill that would essentially sanction home birth midwives in Massachusetts -- some home birth midwives.

Good morning. My name is Tina Cassidy. Some of you may recall that I spent many years here in this building as a member of the Boston Globe’s State House Bureau, covering many of these sorts of hearings. If I learned anything from that experience relevant to the task before me today – it’s do your research, keep it brief, and make your case clearly. So stop me if I fail on any of those points.

First, I wholeheartedly support the concept of what you are trying to achieve with House Bill 2368. Anything that promotes midwifery care – especially out of hospital midwifery care -- is good for women’s health, and the health care system, because better care can be provided for much less. Numerous rigorous studies prove this to be true.

I also support this bill’s mandate that out-of-hospital births be covered by insurance for the reasons stated above. In the UK, the government is actually encouraging more women to give birth at home as part of the National Health System because they, too, understand the benefits of home birth, not just for women but for all of society – and the public coffers.

However, I am dismayed that in an attempt to “allow” homebirths, this bill prevents women from choosing a lay midwife, a person who could have more experience and more knowledge than those who are regulated. That is something I viscerally oppose.

At a minimum, this bill prevents many worthy and wise women from practicing an ancient tradition – a deeply respectable and important tradition as old as human history – a tradition that stopped about 100 years ago when medical colleges in the US began churning out “educated” doctors ready to deliver babies without having ever seen an actual birth. But those male doctors were regulated. The midwives, with millennia of hands-on practice, were not, and they were forced to the brink of extinction, with mothers paying the consequences when that continuum of knowledge passed on from generation to generation was all but lost. Want to know how to naturally deliver a breech baby? Ask a midwife.

I urge you today, please don’t have this bill be referendum on one lawsuit, or one midwife, or one story about a birth that went awry. Sadly, bad outcomes happen with even the best doctors with years of practice and all the technology money can buy. There are fantastic doctors in this room who have said, it’s not whether, it’s when.

When women choose a lay midwife, they often do it with far more research than a woman choosing an obstetrician. I say this from experience – as someone who was a first-time pregnant busy journalist who blindly chose the first OB with an opening for an appointment – and ended up a statistic in America’s unabiding cesarean epidemic, attended by a doctor whose definition of “normal birth” becomes more constricted every year, due to increasingly onerous guidelines and rising malpractice premiums.

For my second birth, I would have been blessed to have any of the certified professional midwives in this room attend the home birth. But the midwife I choose was a lay practitioner, someone I deeply trusted and connected with. She supported me emotionally and physically during an amazing and gentle experience, as well as in the weeks postpartum. It was blue chip care that I was willing to pay for out of my own not very deep pockets.

As she supported me, I am here to support her and others like her. In an effort to allow greater access to midwifery care, please don’t limit it.

Doing such will only drive underground those practitioners who are not CPMs and lead to the persecution of women who choose them.

Finally, please accept this additional written testimony – a chapter on the history of midwifery – from my book, Birth: The Surprising History of How We Are Born. It tells the story of the role that Massachusetts played in the near-final crusade against midwives. I believe if we don’t understand history we are doomed to repeat it.

Thank you so much for your hard work on this important issue.

Tina Cassidy

Benefits of Continuous Support in Labor

2011-02-16T08:57:00.000-08:00

Press release RE:continuous labor support leads to lower c-section rates and better outcomes for moms and babes. http://tinyurl.com/4c5pojv

FOR IMMEDIATE RELEASE - 11 am ET, February 16, 2011
Continuous Labor Support Reduces Risk of Cesarean Section and Other Adverse Outcomes in Women and Newborns
Type of Caregiver Can Make a Big Difference in Labor Experience

New York NY — Women who labor with a dedicated support companion are less likely than women without such support to experience a series of risky birth procedures, according to a review published in the current issue of The Cochrane Library. The comprehensive study of experiences of 15,061 women who participated in 21 randomized controlled trials confirms previously known benefits for maternal health, identifies an additional benefit for newborns, and finds no downsides. The study was carried out through the prestigious Cochrane Collaboration, an independent international organization that prepares and keeps up to date rigorous systematic reviews of evidence from the best available studies.

Overall, women who received supportive care from a companion throughout labor were less likely than women without such support to have a cesarean section, to use narcotics or any other pain medication, to use regional pain medication such as epidural analgesia, to give birth with vacuum extraction or forceps, and to rate their childbirth experience poorly. Having continuous support shortened labor and increased the likelihood of having a “spontaneous” birth with neither cesarean nor vacuum extraction nor forceps. These results confirm previous research. With the inclusion of six new randomized controlled trials, the present systematic review, identified another benefit of continuous labor support: reduced likelihood of a baby with a poor “Apgar score” rating of well being five minutes after birth. The authors conclude that all women should have continuous support while giving birth.
Ellen D. Hodnett, RN, PhD, Professor and Heather M. Reisman Chair of Perinatal Nursing Research, University of Toronto, and co-authors of “Continuous Support for Women During Childbirth” limited the study to randomized controlled trials. This type of research helps ensure that study groups are similar and that results are a true reflection of the effects of the care being studied — here, continuous labor support.

“Cesarean section, vacuum extraction and forceps, and pain medications are interventions that increase the likelihood of adverse short- and longer-term effects in women and babies. Continuous labor support is an important way for women to avoid overuse and harms of these practices, and to have a positive experience at this special time,” said Carol Sakala, PhD, MSPH, Director of Programs at Childbirth Connection. Dr. Sakala is a co-author of the report.

Supportive care during labor and birth does not involve clinical care, and may include:
• helping women with physical comfort
• providing emotional support
• offering information
• helping women communicate their wishes to caregivers
• engaging women’s husbands or partners, as desired by the couple.

Impact Depends on Type of Caregiver
The study provides new knowledge about effects of continuous labor support under different conditions. A major finding is that the impact of this care appears to differ, according to the type of person providing the care. Effects were strongest when the caregiver was neither a member of the hospital staff nor a person in the woman’s social network, and was present solely to provide one-to-one supportive care, such as a doula. Compared with women who had no continuous support, women with companions who were neither on the hospital staff nor in the woman’s social network were:
• 28% less likely to have a cesarean section
• 31% less likely to use synthetic oxytocin to speed labor
• 9% less likely to use any pain medication
• 34% less like to rate their childbirth experience negatively.
When compared with no continuous support, continuous support by members of the hospital staff did not appear to reduce the likelihood of having a cesarean section or improve ratings of the childbirth experience and may have increased the likelihood of using synthetic oxytocin. These results may reflect the fact that hospital staff can experience divided loyalties, additional duties, and constraints of institutional policies when providing continuous support. Continuous support from a person in the mother’s social network (for example, her partner, husband, other relative, or friend) appeared to increase the mother’s satisfaction with her childbirth experience, but did not seem to impact her likelihood of undergoing a series of labor and birth interventions.

Background
Historically, laboring women routinely received support from female companions. However, more recently in hospitals worldwide, continuous labor support has become the exception rather than the norm. “There is concern about widespread dehumanization of women’s birth experiences,” said Dr. Hodnett. “Concern about institutional routines, high rates of intervention in healthy women and newborns, limits on women’s autonomy and control, unfamiliar personnel, and lack of privacy is leading to calls for making continuous labor support widely available to childbearing women.”

Leading options for continuous labor support in the United States include trained labor support companions known as doulas and — for satisfaction with the childbirth experience — the help of a friend or family member who is invited to be present when a woman gives birth. Childbirth Connection’s second national Listening to Mothers survey found that just 3% of women who gave birth in U.S. hospitals in 2005 experienced the most beneficial type of labor support, in the form of doula care. Although insurance coverage of doula services is limited, trained doulas are available in many communities throughout the United States. Typically, a woman (and her partner, if she has one) selects a doula during pregnancy, and they discuss the woman’s goals, preferences, and concerns. Some hospitals sponsor doula programs to increase access to continuous labor support. In addition to continuous presence during labor, birth doulas may provide some support in the days after birth.
“Hiring a doula was one of the best decisions my husband and I made during pregnancy,” said new mom Jenny McElroy. “Though we prepared by reading books, taking childbirth classes, and practicing comfort techniques, we were inexperienced with childbirth. Our doula knew exactly how to help my husband support me, help me cope with the pain, and help us stay calm and have the birth experience we wanted.”

Effective Strategy for Improving Maternity Care Quality and Value
Medicaid programs and taxpayers cover about 42% of the nation’s births, and private insurers and employers cover about half. The review authors encourage policy makers to provide coverage and hospitals to provide programs for continuous labor support. “The benefits of continuous labor support for mothers and babies are numerous, well established, and compelling, and warrant economic analyses of the relative costs and benefits,” said Maureen Corry, MPH, Executive Director of Childbirth Connection. “Medicaid programs and others seeking ways to improve maternity care quality and value and women’s experiences of care should consider continuous labor support as a key component of a high-quality, high-value maternity care system.”

Resources for Childbearing Women, Health Professionals and Policy Makers
Childbirth Connection’s website includes an in-depth evidence-based section to help childbearing women understand the benefits of continuous labor support, decide whether to have a continuous labor support companion, and arrange for such care (see www.childbirthconnection.org/laborsupport/). The professional area of the website includes a summary of results of the updated review and provides access to the full review, at www.childbirthconnection.org/laborsupportreview/.
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Random thoughts on Father's Day

2010-06-20T19:52:00.000-07:00

Dictionary.com's word of the day today was couvade, and quoted a sentence from my book to describe what it means. A fitting word for Father's Day.

I also heard from my friend Jeanette, who said she was watching the film "Being Dad," a good flick for fathers-to-be. I recommend it.

And finally, nice to win this award for my blog...despite my being very distracted lately. I am in good company with the other winners.

Gisele and home birth

2010-02-04T08:08:00.000-08:00

I can finally say that Gisele and I used the same home birth midwife, a wonderful woman who believes in what she does, believes in women "owning" their birth and the empowerment it can provide.

Choosing the same midwife is not all Gisele and I have in common. Our sons were born on the same date, Dec. 8 (two years apart), and... well, we both have handsome husbands.

But seriously, I am so eager to see what effect, if any, a Brazilian supermodel's choice to give birth at home can have on women's perceptions about it and whether the publicity can help reduce the soaring c-section rate in the US and Brazil (where it is close to 90 percent in some places).

One can hope.

More on mammograms at 40

2009-12-21T09:08:00.000-08:00

Having recently turned 40, my CNM suggested a mammogram was in order, just in time for the national debate over whether and when to have one. For those like me, here's some historical context to help with the decision. I found the author's historical context very helpful in understanding the modern dialogue...But hey, that's why I love history. (I added the bolding for emphasis.)

November 20, 2009
Op-Ed Contributor
Addicted to Mammograms
By ROBERT ARONOWITZ
Philadelphia

THE United States Preventive Services Task Force’s recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It’s almost identical to the position the group held in the 1990s.

Nor is the controversy that has flared since the announcement something new. It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.

Again in 1977, after an official of the National Cancer Institute voiced concern that women in their 40s were getting too much radiation from unnecessary screening, the National Institutes of Health held a consensus conference on mammography, which concluded that most women should wait until they’re 50 to have regular screenings.

Why do we keep coming around to the same advice — but never comfortably follow it? The answer is far older than mammography itself. It dates to the late 19th century, when society was becoming increasingly disappointed, pessimistic and fearful over the lack of medical progress against cancer. Doctors had come to understand the germ theory of infectious disease and had witnessed the decline of epidemic illnesses like cholera. But their efforts against cancer had gone nowhere.

In the 1870s, a new view of the disease came to be developed. Cancer had been thought of as a constitutional disorder, present throughout the body. But some doctors now posited that it begins as a local growth and remains so for some time before spreading via the blood and lymph systems (what came to be understood as metastasis).

Even though this new consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma, and helped change the way doctors treated cancer. Until this time, cancer surgery had been performed only rarely and reluctantly. After all, why remove a tumor, in a painful and dangerous operation, when the entire body is diseased?

The new model gave doctors reason to take advantage of newly developing general anesthesia and antiseptic techniques to do more, and more extensive, cancer surgery. At the turn of the 20th century, William Halsted, a surgeon at Johns Hopkins, promoted a new approach against breast cancer: a technically complicated removal of the affected breast, the lymph nodes in the armpit and the muscles attached to the breast and chest wall.

Doctors widely embraced Halsted’s strategy. But they seem to have paid little attention to his clinical observations, which indicated that while the operation prevented local recurrence of breast tumors, it did not save lives. As Halsted himself became aware, breast cancer patients die of metastatic, not local, disease.

By 1913, the surgeons and gynecologists who started the American Society for the Control of Cancer (later the American Cancer Society) had begun an anti-cancer campaign that, among other things, advised women to see their doctors “without delay” if they had a breast lump. Their message promoted the idea that if cancer was detected early enough, surgery could cure it.

This claim, like the cancer theory it was built on, was based on intuition and wishful thinking and the desire to do something for patients, not on detailed evidence that patients were more likely to survive if their cancer was caught early and cut out. But it did create a culture of fear around breast cancer, and led the public to believe that tumors needed to be discovered at the earliest possible moment.

The “do not delay” campaign reached its heyday in the 1940s, when through lectures, newspaper articles, posters and public health films, doctors exhorted people to survey their bodies for cancer warning signs like breast lumps, irregular bleeding and persistent hoarseness. This campaign generated greater fear, which led to more demand for some means to gain a sense of control over cancer — typically satisfied by more surveillance and treatment.

During the 1930s and ’40s, more and more cancer was being diagnosed. The rising numbers led to even greater pressure to define early stages of cancer and find more cases as early as possible. Meanwhile, the apparent improved cancer survival rates — a result of more people receiving diagnoses, many for cancers that were not lethal — seemed to prove the effectiveness of the “do not delay” campaign, as well as radical cancer surgery.

By the 1950s, some skeptics were pointing out that despite all the apparent progress, mortality rates for breast cancer had hardly budged. And they continued not to budge; from 1950 to 1990, there were about 28 breast cancer deaths per 100,000 people. But calls for earlier diagnosis only increased, especially after screening mammography was introduced in the 1960s.

When the 1971 evidence came along that mammograms were of very limited benefit to women under 50, it ran up against the logic of the early-detection model and the entrenched cycles of fear and control. Detecting cancer in women under 50 should work, according to the model; indeed, younger women are the ones most likely to have the localized cancers that have “not yet” metastasized. And many doctors and women understandably objected, as they do today, to giving up the one means they had to exercise some control over cancer.

Critics of this week’s recommendations have poked holes in the Preventive Services Task Force’s data analysis, have warned against basing present practice guidelines on the older imaging technology used in the studies, and have called for still more studies to be done. They generally sidestep the question of whether the very small numbers of lives potentially saved by screening younger women outweigh the health, psychological and financial costs of overdiagnosis.

You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.

Robert Aronowitz, an internist and a professor of the history and sociology of science at the University of Pennsylvania, is the author of “Unnatural History: Breast Cancer and American Society.”

It's all Greek to me

2009-12-21T07:53:00.000-08:00

What is the proper plural form of doula? Doules or doulas? A reader of this story in the Telegraph UK suggests that it should be doules. Regardless, US doules may be shocked to see that UK doules earn alot more per birth. (OK, the spelling felt awkward.)

A note from a nurse

2009-11-14T08:30:00.001-08:00

I received an email from a maternity nurse in Maine and I thought I'd share it anonymously because she has valid points about the issues her profession faces. My responses are in bold after her comments.

"I became a nurse out of an interest in women’s health and feminism. Initially I thought I would work for a Planned Parenthood type of organization, helping to provide safe, confidential STI testing, pregnancy prophylaxis or abortion care. I wasn’t too interested in labor until I witnessed my first delivery. It was in a tiny rural Maine hospital. The woman came in and delivered precipitously, laboring on the toilet and in hands and knees position sideways on the bed. I was in awe of her beauty and her likeness to a wild animal in those moments before and during birth. I knew then and there that I had found what I was meant to do. It is my job not only to administer medications and follow physician and midwife orders, but to tune into and meet a laboring woman’s needs as well as her and baby‘s needs in the postpartum period.

I found that the discussion of registered nurses in your book did not do the profession justice or give it depth. When nurses are mentioned outside the realm of becoming nurse-midwives, the remarks are cursory or indicative of laziness. On page 232 you account a nurse-midwife’s disdain for the Leboyer baths. Though you do go on to say that later studies showed no evidence-based benefits from the practice, I am not sure whether you intended this quote to demonstrated how difficult something like the bath is to prepare and administer properly or if you wanted nurses to seem stubborn, lazy, and unwilling to adapt as the text implies." In terms of a nurse's disdain for Leboyer baths, I actually understand their annoyance. It was a ridiculous practice of yet another fad. Such fads must weigh heavily on the staffs, and have implications for childbirth in general.

"On page 102 you describe nurses undermining a woman’s wishes for natural labor by asking her “’Do you want your epidural now?’” in the hopes of having an easier-to-manage, more stationary patient. While I do not doubt that this happens, I can tell you that I try my best to respect a woman’s wishes for pain management in labor. If she comes in stating she wants a drug-free labor, I make sure she knows that resources are available if she changes her mind and that it is up to her to bring up the subject of pain medications if she wants them. Things become complicated when an obstetrician or a partner say to a woman repeatedly “You can have an epidural if you want.” It is also tricky when a woman who is initially adamantly against labor anesthesia begins to ask for these medications when she hits active labor. What is a nurse to do? Should I try and hold her off until delivery, after which she may or may not thank me and her partner for not letting her get the drugs she was requesting? Or should I immediately contact the obstetrician or midwife with her requests and give her what she says she wants now. Either way I face a conflict in respecting patient rights and autonomy, not just for mother but for baby. If she is asking for IV medication and delivery occurs within four hours, the baby may be drowsy and have a difficult time breathing because the narcotic medications typically given pass through the placenta and decrease both mother and baby‘s respiratory rates." This is, perhaps, the most salient issue of modern childbirth. The only right answer is having uninterrupted supportive care and to have the woman be comfortable in her surroundings and with people she knows are there for her. For typical hospital births, unless a woman hires a doula, or has a mother or friend there who really understands the stages of labor, she will typically be alone for long stretches with a partner who is equally anxious, and perhaps feeding her own anxiety. Of course women ask for pain relief in these circumstances, often changing their own minds. But I think what they are really asking for is someone to hold their hand or truly be there with them to encourage progress. In large urban maternity units, constant handholding is a staffing impossibility. The epidural is not. So I feel your dilemma. It is not nurses who are the problem. They are just dealing WITH the problem, just as mothers are. The system is the issue and we should all find ways as a nation to spend more money on supportive care and less on narcotics because, as you know, it will be cheaper in the long run with better outcomes and happier mothers and babies.

"Due to your extensive research and your own childbearing experience, I am sure none of the following information is news to you. However, I urge you to read the next paragraphs from a nursing perspective, imagining the responsibilities that registered nurses carry throughout the labor, delivery, recovery and postpartum period. The fact of the matter remains that emergencies do happen. Women with low-risk pregnancies can and sometimes do seize in labor or the postpartum period, a potentially fatal condition for both mother and baby. Postpartum hemorrhages after routine, low-intervention deliveries sometimes bring women to near-death experiences." I had one c-section and I witnessed several others during the course of research for my book.

"In addition to these and other emergencies, routine care duties are continuously increasing. During labor, external fetal monitoring and a highly-litigious society require that nurses document progress every 15 minutes during continuous monitoring (per protocols when a patient has an epidural, or a high-risk medication infusing such as pitocin or magnesium sulfate). Women with a positive GBS status generally have physician orders for antibiotics to be infused every 4 hours during labor. The bladder is drained every 3-4 hours by catheter if a woman has an epidural. If a fetus has a prolonged deceleration in its heart rate, it is the nurse’s job to turn her (usually many times), place an oxygen mask on her face, give her IV fluids if she has venous access, stop a pitocin infusion, call the midwife or physician to the bedside, administer terbulatine by physician order to relax the uterus, perhaps transfer her to the operating room for an emergency cesarean and, not least of all, explain everything that is happening to the patient and her family. It is not uncommon for a laboring woman to have almost all of these things simultaneously: epidural, pitocin, magnesium, GBS, and/or signs of chorioamnionitis (a condition that, if delivery is not immediately imminent, will buy a laboring woman a ticket to the OR). Having worked in a high-risk, high-interventional labor and delivery setting, I pride myself on patient interaction, understanding that labor can go in several different directions, many of which even the most educated family would not be able to imagine for themselves." As you so clearly state, much of this is done first and foremost to protect the hospital and the doctors and alot of these interventions can actually create more dangerous situations for mothers and babies. I understand postpartum hemorrhage is dangerous, but being forced to lay in bed during labor so you can be "monitored" is not a healthy way to enable labor to progress. So again, I believe the system is messed up, and if nurses didn't have so many machines to pay attention to, there would be no need for so many machines.

"Infant abductions cause scandal and add security interventions that must be completed almost immediately after birth along with standard neonatal resuscitation for the normal newborn (tactile stimulation and bulb suction), assignment of Apgar scores with the required assessment, and administration of erythromycin and vitamin K per the parents‘ request. A healthy mother and baby pair are generally allowed two hours of one-to-one nursing care before staffing regulations allow that pair to be transferred to a postpartum unit or, in the case of an LDRP set-up, that nurse is assigned other new families to care for. The nurse-patient ratio on a unit may be as high as five or six couplets, meaning a nurse is really caring for 10 to 12 patients at a time. All this inhibits a nurse’s ability to provide timely, individualized care to a family in the 2 or 3 precious days before they go home." If an infant was never separated from its mother, there would be no avenue for abductions, unless someone actually ripped the babe from arms, which seems preposterous and likely that the mother would tackle the intruder. As for postpartum care, I agree. It's a shame for all concerned, including the harried staff. Postpartum care should last longer than two days in a hospital. I believe having a checkup even two weeks out at home could prevent or help diagnose postpartum depression and breastfeeding issues, which have greater costs for society.

"I have seen how women who end up with emergency c-sections and their families can be traumatized by the experience and I want to be clear that I work very hard to help my patients process what is happening to them. I am making no statement here about whether the interventions themselves are right or wrong - I have often struggled with those questions - but let me be clear that as a nurse I do everything I can to help support my patient and her family emotionally throughout the birth process and afterwards." That is wonderful to hear. I bet nurses themselves can be traumatized by what they see tough. You have a very hard job. I couldn't do it. I remember clearly what a postpartum nurse said to me about 6 hours after my c-section, when she asked why I was crying. "I wouldn't want that to happen to me either," she said. Needless to say, it did not make me feel better.

"Maternity nurses are not merely overworked minions of obstetricians and pediatricians, we are patient care advocates who take an interest in our patients’ wellbeing and childbirth experiences. I don’t know a single nurse working in labor and delivery, mother/baby care or lactation who does it just for the paycheck. The nurses I know are passionate about patient care, are constantly asked to adapt to changing practices and are strained by ethical dilemmas. Obstetrical nurses work in a complex ethically, legally and politically driven environment, having to balance all of these factors as providers and patient advocates. I hope that I have impressed upon you the multiple stressors nurses face when providing patient care, along with this nurse’s desire to meet every need of her patient: mother, baby, partner, family." Excellent points.

And she lived to tell the tale

2009-11-03T08:03:00.001-08:00

There is a great post on Unnecessarean that aggregates lots of stories about Ines Ramírez Pérez of Rio de Talea, Mexico, who became the first woman known to have survived a self-inflicted cesarean section. I wrote about her case in my book, but you can read a bunch of fascinating news accounts about it here.

2009-10-21T18:55:00.000-07:00

I got a nice email today from a woman in Missoula, Montana, who had read my book. She said there is a big controversy in her town between the only hospital that has an OB ward and a longtime certified nurse midwife who opened a tiny independent birth center... and lo and behold, the same week that she opened her birth center for business, she was personally banned from the property of the hospital.

I think more attention (and appropriate outcry) might force the hospital to really reevaluate the issue or at least make some concessions.

Go forth and tell the hospital why they are wrong and why it is women who lose, not their bottom line. Read her story.

The midwife, Jeanne Hebl, has a website.

Evolution and birth

2009-09-01T14:49:00.000-07:00

Interesting connection between fat and newborns. I am on vacation catching up on my significant stack of unread New Yorkers and in the July 20th issue Elizabeth Kolbert has an interesting piece on the many books out there postulating on why we as a society are fat. In it, she discusses "The Evolution of Obesity" (Johns Hopkins), written by researchers at the American College of Obstetricians and Gynecologists. The authors argue that a person with a genetic knack for storing fat would have a competitive advantage in life because fat is energy rich and lightweight (surprisingly) and it helps our big brains run. "Human infants," Kolbert writes, "are unusually portly; among mammals, only hooded seals have a higher percentage of body fat at birth....Tellingly, humans, unlike most other animals, have no set season of fertility. Instead, ovulation is tied to a woman's fat stores: Those who are very thin simply fail to menstruate."

Breastfeeding Facts for Fathers

2009-08-25T14:17:00.000-07:00

75 percent of women breastfeed if their partners support it. Check out "Breastfeeding Facts for Fathers,” a short booklet highlighting the crucial role men have in encouraging their partners to breastfeed.

Why do OBs like induction so much?

2009-08-23T06:28:00.000-07:00

Thanks to a CIMS report for spotting the latest American College of Obstetricians and Gynecologists practice bulletin on induction, in which ACOG approves of inducing labor for "psychosocial" (non-medical) reasons and cervical ripening with the synthetic prostaglandin misoprostol (trade name Cytotec). By contrast, Canada and the UK do not approve of these risky methods.

Compared to women who go into labor on their own, women who have an elective induction are at increased risk for intrapartum fever, instrumental birth, cesarean section, and are more likely to use analgesia including epidurals. Babies are at risk for irregular heart rate patterns, shoulder dystocia, neonatal phototherapy to treat jaundice, neonatal resuscitation and admission to a neonatal intensive care unit. According to the white paper "Idealized Design of Perinatal Care" published by the Institute for Healthcare Improvement, "Based on a review of U.S. medical malpractice claims, [the labor-inducing drug] oxytocin is involved in more than 50 percent of the situations leading to birth trauma."

These complications of labor also impact mother-infant attachment and the initiation and continuation of breastfeeding.

ACOG approves of inducing labor at 39 weeks while a similar professional group in Canada states gestational age should be at least 41 completed weeks; UK guidelines state induction for non-medical reason can be considered at or after 40 weeks.

Misoprostol, an inexpensive synthetic prostaglandin, was developed and is marketed to prevent and treat gastric and duodenal ulcers. The use of misoprostol for cervical ripening and induction of labor (off-label use) is approved by ACOG, but not recommended by either Canada or the UK. Misoprostol is not approved by the manufacturer for use in pregnancy. Misoprostol is associated with excessive uterine contractions, fetal heart abnormality, hemorrhage, hysterectomy, and sometimes fetal death. Both Canada and the UK recommend its use be restricted to clinical trials.

Nearly one in four births in the U.S. is induced (many more receive oxytocin to speed things up) and according to the Agency for Healthcare Research and Quality (AHRQ), although it is not entirely clear what proportion of these inductions are elective (i.e. without a medical indication), the overall rate of induction of labor is rising faster than the rate of pregnancy complications that would lead to a medically-indicated induction. According to Childbirth Connection's report, "Evidence-Based Care: What it Is and What It Can Achieve," the most common gestational age at birth among single babies in the U.S. is now 39 weeks rather than 40 weeks.

A Walk to Beautiful

2009-07-23T12:48:00.001-07:00

I watched a very powerful film the other night called "A Walk to Beautiful." The documentary, released in 2008, just came out on DVD. It's the heartbreaking story of the silent epidemic of obstetric fistula in Ethiopia. This film, besides telling the first-person stories of the five women it follows from their villages to the capital for treatment, also reveals a larger narrative about maternal mortality, reproductive rights, child marriage, malnourishment, and birthing practices in a third world country.

The film has traveled the festival circuit and met continual praise from critics, for good reason.

A fistula usually develops when a prolonged labor presses the unborn child so tightly in the birth canal that blood flow is cut off to the surrounding tissues, which then rot away. The result is a hole between either the rectum and vagina or between the bladder and vagina, which means the mother leaks feces or urine uncontrollably, leaving her a social pariah, typically abandoned by her husband or family.

The most common reason for fistulas shown in this film is the practice of girls being married off too young and becoming pregnant well before their bodies can fit a baby through the birth canal. Of course, lack of proper nutrition throughout their lives can also lead to them being smaller than they should be for a safe birth.

2009-07-15T20:08:00.001-07:00

My sister-in-law in Tampa drew my attention to this front page story in the St. Pete Times; the piece about women seeking to have a VBAC came a month after another story explaining that c-sections in Florida were so common, mothers expected them. It's nice to see balanced reporting on the topic. Thanks for sending, Melissa (who managed to have two natural births in Florida somehow!).

The trouble with NICUs

2009-06-17T12:19:00.000-07:00

I have been chewing this one over for more than a month because the idea is so distasteful. But alas, I feel compelled to write about it because a friend's baby, born a little bit early but weighing more than 5 pounds, was in the NICU for no great reason and she had to go home without him.

So here it is: At a recent maternity care conference, a couple people had the courage to speak out regarding the "elephant in the room," ie. neonatal intensive care units as the new cash cows for hospitals. These specialized units are popping up even well outside the realm of the urban teaching hospital. And more babies are being sent there. If more babies need NICUs than ever before, that is alarming and we need to ask ourselves why (too many c-sections, perhaps?. If more babies don't need them but the hospitals do, that is horrible, and probably unethical.

For skeptics who may ask, "What is the harm in providing extra services for borderline cases," such as my friend's baby?

Atul Gawande's piece in a recent New Yorker explains it far better than I could.

2009-05-14T19:26:00.000-07:00

Last year in Miami-Dade County more women had cesareans than vaginal births.

This is tragic and outrageous from a medical ethics perspective. One reason for the high section rate? Virtually no docs in that part of the world carry malpractice insurance because it is too costly, so they fly bare and use cesareans as a shield if the tiniest issue crops up during labor. The rest of us pay the price of soaring medical expenses.

I also think there is something culturally different there. During my book tour, I spoke in just about every major city in this country but there was only one place -- Miami -- where a woman stood up after my talk to say that she would rather have a c-section "just because" than deal with the pain and inconvenience of a vaginal birth. It's a culture of Botox and face lifts and filling in swamp lands to build fake castles. Why do we try so hard to cheat nature?

Support midwifery, save a life

2009-05-04T18:09:00.000-07:00

Since May 5th is International Midwives Day, I wanted to do two things. First, say thank you to the two midwives who attended my second son's birth, at home.

And second, spread the word about Americans For UNFPA, the United Nations Population Fund, which provides women’s health care and promotes the rights of women around the world. AMERICANS FOR UNFPA is dedicated to building moral, political and financial support within the United States for the work of UNFPA.

Every minute a woman dies in childbirth somewhere in the world — 536,000 deaths per year — and almost all of them are preventable. Every year, the world loses $15 billion in productivity because of maternal death. It would only cost $6 billion to provide the health services to save women's lives. The Obama administration has restored funding of UNFPA, which had been suspended since 2002. And in March, Congress allocated $50 million to UNFPA and its life saving programs in 150 countries around the world. With this financial contribution the U.S. stands in solidarity with the world’s women and the 180 governments that support UNFPA’s efforts each year. This contribution will help support, among other UNFPA initiatives, training midwives to make birth safer.
Click here to help end maternal death, and declare yourself an American for UNFPA.

Inductions at record levels

2009-04-27T18:34:00.000-07:00

A report released today from thh Childbirth Connection shows a shocking induction rate in the US of 40 percent!

STUDY: MANY LABOR INDUCTIONS ARE UNNECESSARY
Widespread Use of Induction Potentially Harmful to Woman and Baby

NEW YORK, NY – Induction of labor is on the rise in the U.S., standing at 41% according to a large national survey of women who gave birth in 2005. But, a new study published in the April issue of BJOG, the peer-reviewed journal of the Royal College of Obstetricians and Gynaecologists, finds that the best available evidence does not support many reasons medical providers give for using drugs or other measures to cause labor to begin.

The investigators found support only for inducing labor at or beyond 41 completed weeks of gestation and under some conditions when a woman's membranes break before labor. However, there is not good evidence for inducing labor in many other situations, including when the fetus is believed to be large or to have restricted growth, or when a woman is pregnant with twins, has insulin-dependent diabetes, or has low levels of amniotic fluid.

The study’s lead author, Dr. Ellen Mozurkewich, a maternal-fetal medicine specialist at the University of Michigan, said, “The best available evidence does not support routine inductions in many situations for which induction is currently being recommended to patients. More research is necessary to clarify the risks and benefits of induction in these situations."

Many pregnant women may be receiving inappropriate care. For example, 17% of women who participated in Childbirth Connection's national Listening to Mothers II survey in 2005 said they had been induced because their caregiver was concerned that their baby was too big. However, best evidence suggests that labor induction is not beneficial in this case.

“We now know that every week of gestation counts in terms of brain and lung development. When there is no good reason to end pregnancy, mothers and babies benefit from waiting for labor to begin on its own,” said Carol Sakala, Director of Programs, Childbirth Connection. “Starting labor early can lead to negative outcomes for the woman and/or baby."

To foster high quality maternity care, Childbirth Connection, a research and advocacy organization, commissioned this study through a grant from the Transforming Birth Fund of the New Hampshire Charitable Foundation.

Concerns about inducing labor without an established medical rationale include increased risk of cesarean section for some mothers (e.g., first-time mothers and women with a cervix that is firm and closed), and babies who are born before full lung and brain maturation. Estimates of how long a fetus has been developing can be off by up to two weeks, and labor induction can unwittingly end with a preterm birth.

Best-feeding

2009-04-23T10:57:00.001-07:00

Thanks to Jennifer Block for setting the record straight on breast-is-best evidence. It was also good to come across a story in the NY Times a couple days ago that emphasises that not only is breastfeeding good for babies, it is good for moms. Both of these pieces come on the heels of the controversial piece that Hanna Rosin wrote for Atlantic Monthly, essentially equating the duties of breastfeeding with shackles.

Dutch treat

2009-04-15T18:37:00.000-07:00

A new study out of the Netherlands shows what we already knew: That home birth for low-risk women is as safe as hospital birth. They studied more than 500,000 births to prove it. While it may be difficult for some to understand how on earth this could be, look at the concept backwards: Hospitals can be more dangerous than your home.

Dim the lights, cut, action

2009-04-15T18:27:00.000-07:00

This is an fascinating concept: "The Natural Cesarean."

Given that c-sections are the most common surgery performed in this country, this a great step forward to humanize the experience and improve the immediate health of the newborn.... But still, nothing "natural" about it.

Transforming Maternity Care Part IV

2009-04-04T19:54:00.000-07:00

Two last things that were interesting at the maternity care summit organized by the Childbirth Connection.

1. Several people pushed to have nitrous oxide -- a.k.a "laughing gas" in the US or "gas and air" in the UK -- be a serious contender with the epidural. Why? It's easy; a woman can practically administer it to herself. That is great when you consider that 18 percent of women giving birth in this country live in rural areas, where the closest hospital does not have an anesthesiologist 24/7, a fact that usually pushes women to drive farther during labor to a hospital where they CAN get an epidural.

2. someone mentioned that infant mortality in Pittsburgh is 12.9 percent. Could that possibly be true?

Transforming Maternity Care Part III

2009-04-04T19:32:00.000-07:00

There has been much to write about related to last week's birth professional summit called Transforming Maternity Care , whose goal is to make evidence-based care the standard in America, the land where obstetrical practices -- even bad ones -- die hard in the hospital.

But one midwife stood to say that while the hours of discussion were riveting, the average mother-to-be does not even know there is a problem with maternity care.

Which is why we need a more effective communications campaign to reach them.

On my way back from the conference in DC to Boston, I shared a cab (and hours of delay at the airport) with Gene Declercq of BU's School of Public Health. I asked him, given the success of the breastfeeding campaign in recent decades, is there hope that similar tactics could be applied to a campaign to improve maternity care, so that women know what practices are truly good for them based on the evidence?

He was dubious, saying that with breastfeeding, the only stakeholders to truly oppose nursing were the formula companies and they needed to be subtle in their marketing.

With childbirth, a whole medical system -- one that is paid for performing procedures, many unnecesary and some even harmful -- is set up to keep the status quo.

Sigh.

He may be right, but as one speaker made clear, childbirth is still a sexy issue that gets people's attention. And with more than 4 million births a year in this country, there is a built in audience. Let's try to reach them.

Transforming Maternity Care Part II

2009-04-04T18:52:00.000-07:00

At last week's landmark gathering of childbirth, legal and insurance experts from around the country for "Transforming Maternity Care: A High Value Proposition," there were great ideas on how to make care more evidence-based. (Also interesting people spotting. There was Marshall Klaus, the doctor who did groundbreaking research on bonding, standing next to supermodel Christi Turlington, who is working on a documentary on maternal mortality...) But I digress.

In the blog post below I talk about insurance payments being used as a carrot and stick to influence methods of care -- to make them the right ones at the right time.

Today, let's talk about how the threat of malpractice influences care and how to change that.

Many panelists suggested setting up a financial system for disastrous outcomes that are no one’s fault (Sweden and New Zealand are models for this). The system should also incentivize having obstetric teams practice emergency situations to earn a reduction in malpractice insurance premiums, something already being done in Boston’s Harvard system. Another idea: Establish “apology” laws so providers can express remorse without admitting malpractice.

Aside from tackling malpractice issues, we also need to find legislative options to fix the disjointed system of health information technology, or HIT. Only 17 percent of American hospitals have such systems, but the number is expected to grow. HIT won’t work if we just digitize patient information; we need to embed performance measurements and code information better to enable data collection. One panelist noted that in the UK, women carry their own medical records for maternity care – “no they don’t lose it,” she said, explaining how the practice is a symbolic shift of authority that seems antithetical to the US system.

Other suggestions that came out of the conference:
--Develop national measures for birth outcomes, something necessary to accomplish the above.
--Look at what other countries are doing right (for less cost and better care).
--Within health plans, foster transparency and access to caregiver choice (ie. midwife, doula, doctor, etc.)
--Increase cultural competency as we rapidly become a nation of minority majority.

Transforming Maternity Care

2009-04-04T18:44:00.000-07:00

Yesterday I was in Washington D.C., where the scent of health care reform is as pleasant as the cherry blossoms, for a meeting of the minds on the subject of a particular brand of care: That for pregnancy and childbirth.

Childbirth is the number one reason why someone is admitted to the hospital (more than 4 million babies are born in the US every year) and the biggest contributor to the cost of health care, comprising 17 percent of the country’s GDP. About 47 million people are uninsured in this country and many more are underinsured.

So the topic is huge, no pun intended.

About 150 thought leaders from around the country attended "Transforming Maternity Care: A High Value Proposition," a confab to make evidence-based care a national conversation.

Long overdue, in my book, given that the national c-section rate is at an all-time high of nearly 33 percent, and other procedures and interventions endure despite research showing they should be a last resort, not the first. But evidence-based care isn’t always enough to change the behavior of consumers, doctors or public policy makers. There needs to be a carrot and a stick.

There were many great recommendations from the conference which have broader applications throughout the health care universe. I am going to dole it out one post at a time over the next week or so.

Starting with:

In the absence of a consumer groundswell, we need to change the system, specifically, we need a new payment system. Right now we pay for procedures. An overhauled system would reward good evidence-based practices (and discourage those that are not). For example, steer payments toward things such as providing a safe environment for VBACs, offering smoking cessation programs and diabetes control; don’t reward the overuse of technology, don’t reimburse elective inductions at 39 weeks. What if insurers paid more for first-trimester visits than third-trimester visits? Paid more for vaginal births than c-sections? Paid more for midwives than physicians?

I think we all know birth would be different in America.

Breastfeeding vs. The BlackBerry

2009-03-15T19:50:00.000-07:00

Check out "The Case Against Breastfeeding," by Hanna Rosin, in this month's Atlantic.

http://www.theatlantic.com/doc/200904/case-against-breastfeeding

I read the article as I was breastfeeding my 15-month-old, trying to put him to bed at night. It was the first moment, after a full day at work, that I could relax, yet I was getting worked up. Rosin may be right about the slim evidence about breast feeding's benefits. But having studied the social and scientific approaches to childbirth around the world over the last million or so years, I know that evidence doesn't matter much. The real driver behind the decisions women make regarding pregnancy, birth and the postpartum period have more to do with fashion and zeitgeist. Right now, our culture says breast is best. Just ask Angelina Jolie. However, Rosin's point about breast feeding being a tool to keep women down in the way that Hoover vacuums did in the 1950s? Absurd. My BlackBerry is a far worse offender. It is a cynical and exhausted woman who thinks of breastfeeding as another thing on her to-do list. Yet we've all been there. Especially those of us with more than one child. But the real issue is not breastfeeding; it's everything else: The laundry, grocery shopping, mortgage, preschool tuition, and clients who don't care how many times a baby woke you up the night before. Instead of backbiting at the playground mommy circle over who is formula feeding, wouldn't it be more productive to fight the system over the fact that women are paid less than men for the same work? Or directing that energy toward fighting for paid maternity leave -- or even an unpaid leave of any substantial amount of time -- for all women of America?

Herbal expertise

2009-02-17T18:34:00.001-08:00

Someone asked me for reading suggestions on midwifery herbs...

I haven't cracked a book on the subject in a while, but my mind went to two tomes: The Byrthe of Mankynde, the first known midwifery text written in the English language in the 16th century. Of course, the book is written in Olde English so it is a bit hard to parse its concoctions...I read an original copy at the Harvard Medical School's rare books department (you can't actually take the book out of the room, and it was while ago, so my memory may not be right) but I found a repro version exists on Amazon in the UK. Too geeky to ask for my birthday?

Another cult classic (circa 1979) is by Jeanine Parvati, called Hygieia: A Woman's Herbal.

Anyone have other ideas?

Got orgasm?

2009-02-16T18:01:00.000-08:00

My friend Viv, a journalist in the UK, was asking me recently about the film "Orgasmic Birth." She, like any good reporter, was skeptical.

"The more I read on this subject the more I just refuse to believe in the existence of the birth orgasm... They are confusing one sensation with another, I feel," she said.

Ah, Viv.

I told her that while I do believe it is minutely possible (like a plane crash) for a woman to have an orgasm while giving birth, I feel like viewers are taking the title too literally. In general, the concept of orgasmic birth should be more about enjoying the experience. I think there are many ways a woman can increase her chances of enjoying birth, especially -- and not despite -- going without pain medication.

I like to think of childbirth like running a marathon or climbing a mountain. Those who do either clearly can suffer exhaustion and pain, but there is an amazing high they feel upon successful completion from going through something so intense and those feelings would be diminished if any part of the journey were numbed...

Video contest

2009-02-16T17:44:00.000-08:00

I am trying to spread the word about an interesting film project...

Birth Matters Virginia is inviting mothers, fathers, filmmakers, film students, birth advocates, and others to create a 4-7 minute documentary video about birth. The subject can be anything related to mother-friendly maternity and delivery care, and the goal is to educate women about their options and choices. The first-place winner will receive a cash prize of $1000. Second place $500 and an honorable mention prize of $100 will also be awarded. The deadline for entering the contest is Mother's Day, May 10, 2009. The organization is based in Virginia, but entries from around the world are welcome and all are eligible for prizes, both amateur and professional.

Guest judges of the video contest are Sarah Buckley, Ricki Lake, and Abby Epstein (the former is an MD, homebirth mother of four and author of "Gentle Birth, Gentle Mothering: A Doctor's Guide to Natural Childbirth and Gentle Early Parenting Choices," and the latter two known for "The Business of Being Born," which you must see if you haven't).

For rules and to see how to enter, please visit http://www.birthmattersva.org/videocontest.html You can also join their Facebook group to get updates about the contest and exchange ideas with other participants at http://www.facebook.com/groups/edit.php?gid=73753459808#/group.php?gid=737534598\\08.

Home birth photos

2009-02-16T17:38:00.000-08:00

I just wanted to pass along the profile of a fellow former journalist who is now taking home birth photos in the Boston area. Her name is Cydney Scott and this is what she says:

I recently had the honor of photographing two home births in the greater Boston area. I am a professional photographer with over ten years experience in journalism and I have never enjoyed photographing something as much as the big event of a child's arrival!

After having to take a buy-out from my newspaper a few months ago, I have been dealing with the challenge of continuing to do what I love - document life. I would welcome the opportunity to make my services known to other parents who might want their birthing day documented.

The birth photos can be seen on my site, cydneyscott.com, listed under "Birth" under the "portfolios" dropdown menu.

Get back to work, quick!

2009-01-18T11:15:00.000-08:00

I was just reading about France's Justice Minister Rachida Dati, who was back working 5 days after giving birth earlier this month. She's 43. I think her age is a key indicator of this trend of women getting right back into it after having a baby.

Women who wait so long to have their first baby have already established their careers as being central in their lives. And when you have been working at a job so hard for so long, it becomes your whole identity. I think women also feel insecure about losing that identity when they have a baby so they fight their instincts even harder to push themselves out of the house.

Historically, women in many cultures would remain shut in with their babies for quite a long time.

I believe these customs were adaptive behaviors meant to facilitate bonding, establish good breast feeding practices, ensure that the baby thrived, the mother recovered and the newborn was kept removed from potentially dangerous diseases. Of course, today we have nannies, formula and vaccines, but women are still hard-wired to want to stay with their infants, no matter how exhausting.

The problem is, the support system to encourage moms to stay with their newborns has frayed.

Almost every culture throughout time had elaborate rites to encourage women to remain "confined" with their newborns. In Britain, women stayed confined for as long as a month, a celebratory time when new moms were fed special caudles and cocooned among their friends, outside the company of men. The women marked the changing of bed linens in a ceremony called "the upsitting", after which the mother would rest for another 10 days before moving freely inside the house. Even early maternity wards in the UK required 30-day confinements! Whether at home or the hospital, the British postpartum period would officially end with a "churching," a new mother's first trip outside. For that rite (which persisted in some areas until the 1950s) she donned a veil and was surrounded by her midwife, friends and family.

Leaving the house was a big event!

Things started to change when birth shifted in earnest to hospitals around WWII, as two weeks became standard for a lying-in period.

Today, with a vaginal birth in the hospital, lying-in is a day or two.

Birth is always a reflection of the time and place where it happens. In today's world, everything has sped up, even the time we take to recover from and enjoy having a new baby.

A little poem

2009-01-06T18:21:00.000-08:00

I wrote this poem about a year ago, when I was still pregnant, but my hormone-addled brain promptly lost the thing before I could give it to my midwife. I recently found it tucked into a notebook and am posting it here for all as a sign of my thanks.

Ode to a midwife

The neon sign above her desk says OPEN.
I get the joke and the suggestion.
Beyond the back door, ajar, birds zip and bees buzz in the garden.
On the sidetable near the easy chair
Is a bowl of cherries.
That is not just a metaphor.
It is truth.
She made me art,
A rubbing of two leaves, in blue.
She made me cry, an unlocking of my fears.
She sang a song,
Read a poem,
Told me to pee in a cup
And hop on the scale -
But only if I wanted to.
She listened to the baby's heart,
Heard the beats and hiccups,
Felt a head
And waited patiently for the day that he arrived.

Orgasmic Birth

2008-12-21T17:27:00.000-08:00

Ok, this is my attempt to stop feeling guilty about the wildly intermittent variability (is that an oxymoron?) of my blogging...

I know this post about the film "Orgasmic Birth" was a couple weeks ago on Motherlode http://parenting.blogs.nytimes.com/2008/12/11/orgasms-during-childbirth/, but the film hasn't aired yet, so I'm not too late. (It will air Jan. 2.)

While researching my book, I did discover that some women have reported having orgasms during birth (yeah for them) so I am not shocked by this. What is more surprising to me is the huge number of negative comments posted about the film/concept/title on the blog. Yes, birth can be incredibly painful, especially if we are in a strange place (aka the hospital), surrounded by strangers (aka the OB), and not allowed to move (b/c of the bed/IV/monitor etc.)

But why is orgasmic birth such a mental leap for so many women? And why is the knee-jerk reaction to the concept annoyance or hostility?

New York Times story

2008-11-13T20:15:00.000-08:00

What's fascinating about this story to me is not the content. It's the publication, which marks a turning in point in terms of the cultural zeitgeist. Something is happening....FOr the better. Yes we can!

November 13, 2008
Baby, You’re Home
By JULIE SCELFO
SQUATTING in an inflatable pool in the open kitchen of her apartment in Astoria, Queens, a very pregnant Alecia White Scharback, nude except for a bathing suit top, groaned in pain. It was 7:30 a.m. on Nov. 1, and Mrs. Scharback, 29, an actress, had been in labor for more than 36 hours. The contractions had been only mildly painful at first, but had grown increasingly fierce as a second night gave way to morning.

At the height of one contraction, Mrs. Scharback closed her eyes, bent forward and rocked her hips back and forth. “It hurts, it hurts, it hurts,” she moaned. Using a stainless steel refrigerator to steady herself, she vomited. Joshua Scharback, her husband, rushed to her side and gently stroked her head.

Mrs. Scharback was giving birth at home because she did not want any medical interventions in the process unless she needed them, she said. But after another four hours, she was beginning to doubt whether she could make it and was pleading with her midwife, Miriam Schwarzschild, for relief. “Oh, Miriam,” she whimpered, “I can’t.” Ms. Schwarzschild reassured her client: “You can. And whenever you’re ready, you can start to push.”

Home births have been around as long as humans, but since the 1950s, the overwhelming majority of American women have chosen to give birth in hospitals, which the American College of Obstetricians and Gynecologists identifies as one of the safest places for the unpredictable and sometimes dangerous process of childbirth. (The group has officially opposed home births since 1975, and this year the American Medical Association adopted a similar position.)

Recently, though, midwives and childbirth educators say, a growing number of women have been opting instead for the more intimate and familiar surroundings of home — even in New York City, where homes are typically cramped warrens of a few hundred square feet and neighbors often live close enough to hear every sneeze and footstep.

Births in New York’s hospitals, where pediatricians are able to check babies immediately for potentially dangerous conditions, it should be noted, still vastly outnumber those in its homes — in 2006 home births accounted for only one-half of 1 percent of the city’s 125,506 reported births.

But local midwives say they have been swamped with calls and requests in recent months, in some cases increasing their workload from two, three or four deliveries a month to as many as 10. (New York health department statistics for this year will not be available until 2010.) Several certified nurse midwives who have home-birth-only practices said they had gotten so many more requests in recent months that they have begun referring pregnant women to midwives in Rockland County, Long Island and New Jersey.

Erica Lyon, the founder of Realbirth, a five-year-old childbirth education center with three locations in the city, said 20 percent of the 160 couples who take her classes each month are planning home births, twice as many as six months ago. YourWaterBirth.com, one of the biggest online purveyors of birthing pools — deep inflatable tubs with a specially designed built-in seat and handles — said its sales have doubled since last year, with more than 20 percent of its customers in New York City; Waterbirth.org, another outlet, said it has sold more than twice as many pools this year as last, 25 percent of them to New Yorkers and Long Islanders.

Home birth professionals in New York City have been struck, several said, by the fact that the increase is coming not so much from the dyed-in-the-wool back-to-nature types as from professionals like lawyers and bankers. “People who wouldn’t naturally self-select for home birth are coming in and getting very open-minded,” said Cara Muhlhahn, a certified nurse midwife who has had a home-birth practice for 17 years and is now fully booked six months in advance.

One reason for the change, it seems, is “The Business of Being Born,” a documentary produced by the actress and former talk show host Ricki Lake, which ran in only a few theaters during its theatrical release in January but has become an underground hit among expectant parents since coming out on DVD. (Rentrak, a company that monitors DVD rentals, said that instead of dropping off, as typically happens with new releases, the film is being rented at consistent rates.)

With scenes of several home births (including one in which Ms. Lake delivers her second child in the bathtub of her former West Village apartment), the film argues that women’s bodies are perfectly well equipped to give birth at home and that the occasion need not be a medical event.

Many women are wary of hospital births, both because of a patient’s limited control over the process and because of the growing frequency of Caesarean sections (use of the procedure increased by 50 percent nationwide from 1996 to 2006, to nearly one in three births, according to the National Center for Health Statistics).

“The Business of Being Born” seems to offer an alternative, and “is putting home births on the map in a way that makes women feel like it’s a really legitimate option,” said Élan V. McAllister, founder of Choices in Childbirth, a four-year-old nonprofit educational group that publishes “The New York Guide to a Healthy Birth.” “In your home you’re able to move around and be in the tub or in the shower. You’re able to eat and behave in a natural, more normal way. If you believe birth is not a medical emergency, it is the ideal place because it’s the place you can really let go and follow what your body wants you to do.”

Mrs. Scharback, for example, tried many different positions over the course of her labor: leaning on the windowsill of her newly decorated nursery, sitting on a birth stool, crouching on the bed, sitting on the toilet and, eventually, leaning back against her husband inside the warm birthing pool. Finally, having endured 40 hours of regular contractions with no painkillers — like most women who have home births, she refused them — she let out a guttural scream and pushed her new son, Noah, into the world.

Home birth also appeals to the desire of many new mothers to stay put, and in continual contact with their babies, after the grueling ordeal. Michelle Zassenhaus, 33, a Web designer and photographer who gave birth for the first time in March, said her apartment in Park Slope, Brooklyn, was an ideal environment for calm postpartum recovery with her husband, Silvio Galea, and their new daughter, Lucienne.

Shortly after the birth, “the doula and midwife got us all cleaned up, cleaned up the apartment, looked in our fridge, figured out what kind of food they could prepare for us, showed us some breastfeeding techniques, put us in bed, gave us some food, and left,” Ms. Zassenhaus said. “Those first couple of days when you’re usually suffering through postpartum, we were in this very quiet, intimate state of bliss.”

NEW YORK apartments would seem to present significant challenges to home birth. For starters, there are obvious concerns about the apartment itself: the prospect of an inevitably messy process in a tight space invites delicate questions, like, What happens to the rug?

Then, too, there is the matter of space: for a woman with children, for example, it’s hard to imagine where in the apartment to put them if you want them out of range of the big event. And because women giving birth at home sometimes want to surround themselves with a doula and a cadre of other supportive women — mother, sister, best friends — along with a husband or partner, a one-bedroom apartment, much of it given over to a giant inflatable tub, can quickly come to seem oppressively small.

But for some, the biggest concern is the neighbors: natural childbirth is not usually a silent affair, and sound baffling is notoriously lousy in many of the city’s buildings.

Ms. Zassenhaus, in Park Slope, waited until three weeks before her March 28 due date to tell residents of her town house about her plans, fearful that the ground floor resident, the owner, would try to persuade her to abandon them. “At first they were shocked and fearful,” Ms. Zassenhaus said. “But very quickly they embraced it, and they were all kind of excited to be part of the process.

“I kept them apprised, and when it was coming near to the date, I put a note on their doors that said, ‘Any day now, if you have a sleepless night because of my screaming, I apologize.’ ”

In the event, Ms. Zassenhaus made barely a yelp until the final moments of her three hours of labor. “For 15 minutes I grunted really, really loud,” she said. “My neighbors downstairs lit candles all over their apartment and prayed for us.”

Elizabeth Golluscio, a marketing consultant, and her husband, Elio Narciso, a founder of the wireless media company Zero9 USA, also debated whether to tell neighbors in their Upper East Side building about their plans, not wanting to “get them freaked out,” Ms. Golluscio said. “We only bought this place in May, so we were just getting to know them. The impression is, if people are having home births, they must be hippie freaks or religious fundamentalists.”

Ms. Golluscio was thrilled, she said, when the woman in the adjacent apartment moved out for renovations, but then she worried that the construction workers might overhear her making strange noises. On Nov. 3, when she found herself giving birth in her bathtub after five days of on-again-off-again contractions, and emitting “animalistic” moans, she was still worried. “He was born at 8:16,” she said of her son, Claudio, “so I was hoping the workers weren’t there yet.”

When the couple, both 35, first considered a home birth, in February, Ms. Golluscio also wondered about some of their favorite belongings, especially an expensive wood Mobileffe bed frame. “It’s probably the most expensive furniture we have in the house,” Ms. Golluscio said. “I was like, ‘I hope this thing isn’t going to get hurt.’ ”

Mr. Narciso, who watched his wife give birth to their first child, Matteo, at St. Luke’s-Roosevelt Hospital Center last year, was even more anxious, she added. “He was like: ‘What about the mess? What do we do with it?’ ”

Their midwife explained that they should gather old towels and sheets in advance, as well as a kit of disposable medical supplies, including the kind of pads used for house-training puppies. She also recommended buying or renting a birth pool, which can have a disposable liner and is drained into the toilet. “She was very, very ‘It’s not a big deal, it’s like one garbage bag,’ ” Ms. Golluscio said. “That’s what it was. We put everything in the garbage.”

And then there is the perennial issue of space. Before the onset of her labor, Mrs. Scharback, who in recent years has worked as a doula, worried about whether there would be enough seating in her 800-square-foot apartment for all the people who would be there: a midwife, a doula, her mother, her sister and her husband, along with a reporter and a photographer. “We thought maybe we should get some floor cushions,” she said.

For several hours on the morning she delivered, the guests took turns sitting on the couch, the floor and a glider set up in the new nursery. The bed became less of an option when the doula and midwife stripped it of its green-and-white designer sheets and, using a shower curtain as a liner, remade it with old pink ones. Several minutes later Mrs. Scharback climbed on, enduring a contraction on all fours with her face buried in a pillow.

A shower curtain liner also came in handy when Kirsten Rickert, 32, a stay-at-home mother, decided before dawn on Oct. 29 that she wanted to go through labor standing up in her living room overlooking Prospect Park. Standing on top of a shower curtain layered with a sheet, she planted her arms on her white couch and bent forward.

Some people, concerned that a home birth might be traumatic for children to witness, send them to stay with a friend or relative for the duration. Ms. Rickert and her husband, Cameron Skene, on the other hand, saw it as an educational opportunity for their 2 ½-year-old daughter, Maya. “There’s nothing mysterious about birth unless you want there to be,” Ms. Rickert said. “For us it just introduced Maya to life, and how life comes about.”

Maya awoke around 4 a.m. and joined her parents in the living room. “She was munching away on her apple and talking about 2-year-old stuff when I was having contractions,” Ms. Rickert said.

When it was time for Ms. Rickert to push, Maya watched intently. Although she didn’t like the blood and water that followed the baby, her mother reported, she wasn’t surprised: for months Ms. Rickert had prepared the toddler with an explanation of what would happen.

Just after her new daughter, Elle, emerged, at 5:23 a.m., Ms. Rickert sat on the couch (the midwife having put down an absorbent pad), and Maya came over to admire her new sister’s thick black hair. “She kissed the baby and gave her lots of love, and everything was fine,” Ms. Rickert said. “Then she goes, ‘Can I watch “Dora” now?’ ”

DESPITE all the preparations, of course, home births do not always go as planned. Most home-birth specialists have a relationship with a hospital or a doctor and talk in advance with their clients about the possibility of a hospital transfer. The best study of North American home births available cites an average transfer rate of about 12 percent. “If someone is preeclampsic, they’re not going to give birth at home,” said Ms. Muhlhahn, the longtime nurse midwife, referring to a disorder that is among the leading causes of death and illness in mothers and babies. “It’s very rare something so dire would happen that we would have to call an ambulance. We don’t wait until it’s a real emergency.”

Ivonne Dersch, 28, a marketing executive at American Express, had to abandon her home birth in TriBeCa after a routine check of the baby’s heart rate showed it was decelerating. The attending midwife decided Mrs. Dersch, who had been in labor for 28 hours, should be transferred to St. Vincent’s Hospital, a 10-minute cab ride away.

“We took the elevator and my husband hailed a cab,” Mrs. Dersch said. “It was like out of a movie.”

Although he tried not to show it, her husband, William, 31, a stockbroker, became fearful — “terrified actually,” he said. “For the midwife to say you have to transfer to the hospital, it’s all those emotions running through you.”

Mrs. Dersch worried that she would be given a Caesarean upon arrival, but after examining her, the doctor told her to push. Fifteen excruciating minutes later, she delivered a son.

Other hospital transfers have less favorable outcomes. Several months ago, Dr. Erin Tracy, an obstetrician and a public health expert at Massachusetts General Hospital, received a phone call from a colleague at another hospital, distraught about a patient who had almost died after a home birth.

In the colleague’s opinion, the patient, who had a severe postpartum hemorrhage, was transferred far too late for her own safety. “She was in dire straits, she needed multiple blood transfusions, and she wound up needing a hysterectomy, which could have been averted if she had been given the appropriate medications,” Dr. Tracy said.

“Many low-risk pregnancies become high risk with no warning and can become urgent within minutes,” said Dr. Tracy, who, as a representative of the American College of Obstetricians and Gynecologists, successfully petitioned the American Medical Association this year to join the College in condemning home births.

“In a home, even with a quality provider, you don’t have access to surgeries or blood transfusions or lifesaving medications you would have in a hospital,” she added. “The literature does say the majority of normal deliveries can be done at home. But I think, and others think, the stakes are too high.”

Ms. Golluscio’s delivery, too, deviated unnervingly from the plan, though not in a way that turned out to be life-threatening.

At the moment her baby was born last week, her husband was outside on the street passing Matteo off to his baby sitter, and her midwife, Ms. Schwarzschild, was stuck in traffic. Only her doula, who was not trained to deliver babies, was with her, and Ms. Golluscio herself ended up scooping her new son from the bathtub water.

But she considered the event a success. “I feel physically awesome right now,” Ms. Golluscio said three days after the birth, adding that natural childbirth at a hospital might have left her feeling good, too, but that she attributed a big part of her well-being to “being home and in the water.” She added, “Even with all the uncertainty of not having my midwife there, this was the best thing ever.”

Playing It Safe

The American College of Obstetricians and Gynecologists has had an official policy against home births since 1975, and this year it asked the American Medical Association to adopt a similar statement. The A.M.A. agreed, and in June also condemned home births.

“The A.M.A. supports a woman’s right to make an informed decision regarding her delivery and to choose a licensed health care provider” and “stresses that the safest setting for delivering a baby is in the hospital or a birthing center within a hospital complex,” Dr. Steven Stack, a board member, said in the statement. “Serious complications can arise with little or no warning even among women with low-risk pregnancies.”

In contrast, health authorities in Britain view home births as a safe option for women at low risk of complications. In April 2007 the United Kingdom Department of Health rolled out plans for a “national choice guarantee,” to be put in place by the end of 2009, ensuring that all women can choose among giving birth at home, or at a hospital or another facility, and still have access to midwifery care.

The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives issued a joint statement in support, agreeing that for most women, home births “may confer considerable benefits for them and their families.”

JULIE SCELFO

2008-11-02T11:20:00.000-08:00

This news story brought back flash backs from two women in my family who were both put through the ringer over prenatal tests that raised alot of concern and anguish...only to result in healthy babies. I see parallels between these tests and microscopes from 100 years ago. You see things never before possible and it all looks very scary. But of course, we now know that not all bacteria is bad...

New prenatal tests raise concerns
October 27, 2008

WASHINGTON - Doctors have started using powerful new DNA tests to screen fetuses for a wider range of genetic abnormalities, spotting more problem pregnancies early but stirring fears that the results will increase abortions as well as confuse and needlessly alarm many couples.

The tests, which use "gene chips" to detect much subtler chromosomal variations than standard prenatal testing can, have also triggered complaints that they mark another step toward a society that seeks to weed out aberrations in the quest for the perfect child.

Proponents maintain that the technique, called comparative genomic hybridization, allows couples to target genetic-based illnesses, which can alleviate their worries in some cases and in others identify abnormalities soon enough to terminate the pregnancy or prepare to care for an afflicted baby.

But critics say the tests have not been thoroughly validated and threaten to produce a flood of murky, misleading results that will subject emotionally vulnerable couples to unnecessary anxiety, perhaps prompting some to abort healthy pregnancies.

Some worry that they could be used to hunt for the rapidly growing list of genetic markers that merely signal an increased risk for cancer, diabetes, mental illness, obesity, addiction, and other conditions later in life.

WASHINGTON POST

1 in 2,500 vs. 1 in 10,000

2008-11-02T11:12:00.000-08:00

This tragic story in the Boston Globe serves to remind us all that there is no such thing as a "routine" cesarean...and why c-section rates in general should be lower. Deepest condolences to the family.

Patient dies during C-section at Beth Israel Deaconess
October 21, 2008 07:01 PM
By Carey Goldberg, Globe Staff

For the first time in more than 10 years, a Beth Israel Deaconess Medical Center patient has died while undergoing a Cesarean section, the hospital reported today.

The mother died on Friday, and the baby experienced complications but appears to be improving, Dr. Kenneth Sands, the hospital's senior vice president of health care quality, said in a brief statement.

"This sad and very rare event appears to relate to an unanticipated complication at the time the baby was delivered by Caesarian section," it read.

"We immediately launched an internal review and have reported to the Department of Public Health. This is obviously a very sad and distressing event for our staff at Beth Israel Deaconess Medical Center who have not experienced a loss like this for over 10 years. We continue to extend our deepest sympathy to the family."

The risk of death from a Cesarean section is estimated at less than 1 in 2,500, according to information on the Beth Israel Deaconess website. That is significantly more than the roughly 1-in-10,000 risk of a vaginal birth, but still low enough that the operations are performed more and more often in the United States, now comprising nearly one-third of births.

Navajo and New Mexico

2008-10-12T07:49:00.000-07:00

We are in New Mexico for the weekend and, among other things, we visited with my husband's childhood friend, John, who lives in Santa Fe and is now a public health doctor who has been working for years for the Indian Health Service. His stints have included time with the Navajo, though he now serves a Pueblo population that we are going to see today. John, my husband and I were discussing how different these Native American groups are. As the stereotypes go, the Navajo is stoic and reserved, while the Pueblo is more open and friendly. But what was interesting to me is that he said Navajo women giving birth are practically silent; that it goes against their culture to give a voice to pain. If I've said it once I've said it a million times: Birth is a reflection of the culture where it happens. Fascinating to me.

Birth and Boston College

2008-10-12T07:19:00.000-07:00

Last week I had the privilege of speaking on a panel after a screening of "The Business of Being Born" at Boston College. On the ride over to the college with Abby Epstein, the film's producer, she was reminding me about the history of Catholic colleges not being open to frank talk about women's reproduction (a la, banning the Vagina Monologues from campuses...) Anyway, the organizers for this event were warm and open-minded and I had the distinct sense that times have changed. The crowd of young people that turned out to see the film seemed truly moved by its message: That hospitals are not the best place or a low-risk mom to give birth.

Before I left BC for the night I had an interesting chat with a pregnant professor who was talking about the differences between radical feminists (those who believe in the power of the female body and therefore understand how transformative a natural birth can be for a woman) and other feminists who believe that an unnecessary cesarean is also a woman's right to choose. The question is: which feminist agenda will win the day?

One other note from that event: Abby and Ricki Lake are busy making a sequel to the film. Stay tuned.

2008-09-21T17:16:00.000-07:00

This was an intersting piece in the Telegraph (UK). It shows how government policies and national culture can really affect how and where birth happens.

Home births still rare despite Government pledge
The number of women giving birth at home has slumped in the space of two generations, a Government report will say this week.

By Patrick Sawer
Last Updated: 12:46AM BST 21 Sep 2008

Research by the Office for National Statistics (ONS) will highlight how the proportion of deliveries taking place at home fell from one in three in 1955, to just one in 40 by 2006.

While home births have undergone something of a renaissance in the past few years - with celebrities such as Charlotte Church and Davina McCall opting to give birth at home - the report will demonstrate just how far the level remains below what it was in the Fifties and Sixties.

The Government has promised that by next year, all women in England should be given the option of where to have their baby. However, a shortage of midwives often means that women are not offered a home birth, or have it cancelled at the last minute and are forced to go into hospital.

There was a significant increase in home births in 2006, when 18,953 deliveries took place at home compared with 17,277 the year before. Yet despite the rise, only 2.5 per cent of deliveries in 2006 were at home, compared with 30 per cent in the Netherlands.

Nice surprise

2008-09-18T19:04:00.000-07:00

I complained bitterly in an earlier post about my health insurer for not covering the cost of my oh-so-frugal home birth, the price tag of which was 1/7th the amount of my previous birth in a hospital. I ranted about the system being messed up, short-sighted and overrun by bean counters who don't even know what a midwife is.

But today, I received a check in the mail. Reimbursement. Granted, it only took 10 months...

Still, I consider this progress. Ultimately, even if we weren't reimbursed, the home birth was worth every penny out of pocket. As I said to the midwife recently, if she had asked for a Mercedes the night our son was born, we would have figured out a way to give her one. Thanks, Blue Cross.

Dr. Phil

2008-09-17T18:39:00.000-07:00

Did anyone see that episode on home birth? Did it air? I rarely have the TV on.

Born in Brazil

2008-09-14T19:27:00.001-07:00

Tonight I saw "Born in Brazil," a documentary about the soaring c-section rate in that country. It became very clear to me how much class has affected the rates there in a couple ways. First, poor women give birth in nasty public hospitals where they labor alone. Of course, they all aspire to the private hospitals, where doctors like to perform c-sections because they can charge for them. Another wrinkle: Abortion is illegal there, and poor women have the worst access to birth control, but a woman can get a tubal ligation when she is having a section. Sigh.

The screening was part of a panel I was on at Wheaton College. I was joined by Megan McCullough, an anthropology professor there, who had studied aboriginal women in Queensland, Australia, who at 39 weeks, would get flown far away to give birth, again removed from family. They, too, have very high c-section rates.

And what happens when the machine is wrong?

2008-09-14T19:27:00.000-07:00

This. Is. Gross. The computer rendering of the mother doesn't help.
http://www.barnev.com/www.barnev.com/index7797.html?CategoryID=187

Dr. Phil vs. Ricki Lake

2008-09-09T18:43:00.000-07:00

This is one wrestling match I'd pay to see. (I think Ricki would win!)

Dr. Phil is doing a special on "Bad Home Birth Experiences." He is asking anyone who has had a negative experience with their home birth midwife to get in touch to be on his talk show. Seems like an odd choice for him, but with Ricki Lake's documentary, "The Business of Being Born," bringing so much positive attention to home birth, he must want a little of the action. Below is a link where they are looking for guests on the show. Feel free to share hospital horror stories. MRSA anyone? Forced c-section? Unnecessary episiotomy? The choices are endless.

http://www.drphil.com/plugger/respond/?plugID=12524

Catching up

2008-09-08T19:33:00.000-07:00

I can't believe what a delinquent blogger I've been. I guess it was summeritis. We were away in a remote part of Vermont for a while and there was a satellite internet connection when we arrived at the house but within a couple days the groundskeeper ran over the the line behind the barn with his tractor and that was that. For weeks. By then, I was weaned from my techno urges and enjoying a real vacation.

Some random catch-up thoughts: This story got alot more traction in the UK than it did the US, not sure why, even though it was a study out Yale. If Angelina Jolie does have postpartum depression - and, frankly, with colicky twins, that would be excuse enough -- this might go further in explaining why.

From the BBC, Sept. 3
"Natural birth 'may aid baby bond'
Mothers who give birth naturally are more responsive to the cry of their baby than those who choose to have a Caesarean, American research suggests.

Brain scans on 12 new mothers soon after birth found more activity in areas linked to motivation and emotions in those who had a vaginal delivery.

The Yale University team says differences in the hormones generated by birth could be the key.

The women in this study were those who elected to have a Caesarean.

The contractions which are an essential part of a natural birth trigger the release of the hormone oxytocin, which is thought to play a key role in shaping maternal behaviour.

However, undergoing a Caesarean does not trigger the same release of hormones.

The procedure has been linked to an increased risk of post-natal depression.

The Yale team carried out brain scans on 12 women two to four weeks after they had given birth - known as the early postpartum period.

Half had a Caesarean, the other half gave birth naturally.

The differences in brain activity were found in regions that not only appeared to influence a mother's response to her child, but also to regulate her mood.

Lead researcher Dr James Swain said the study, reported in the Journal of Child Psychology and Psychiatry, might help provide a better understanding of the chemistry underpinning the attachment between a mother and her baby.

"Our results support the theory that variations in delivery conditions such as with caesarean section, which alters the neurohormonal experiences of childbirth, might decrease the responsiveness of the human maternal brain in the early postpartum."

Personality factors

Professor James Walker, a spokesman for the Royal College of Obstetricians and Gynaecologists, said: "We have long recognised that people who have a caesarean section do sometimes have some problems bonding with their baby."

2008-07-22T18:04:00.000-07:00

I thought this was one of the clearest, most evenly written pieces on the home birth date that I've seen in a while.

Laboring to save home births
Amish groups rallied politically against state closure of midwife Diane Goslin's practice.

By Mary Beth McCauley / July 22, 2008 edition
E-mail a friend Print this Letter to the Editor Permissions ShareThisGet e-mail alerts RSS

Correspondent Mary Beth McCauley explains the Amish preference for home birth.

Mary Beth McCauley

--------------------------------------------------------------------------------

Bradley Bower/AP

Time of need: Pennsylvania Amish groups rallied last year to save Goslin’s practice. Susan Rocca, with her son, Nicea, supported Goslin at the state capitol.

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Midwife Diane Goslin’s farmhouse office bustles with activity this summer morning. Horse drawn buggies line the driveway, while pregnant women line the waiting room inside – their hair tucked into bonnets, their dark dresses covered by black aprons.

A mother expecting her 11th child arrives with her daughter, who is expecting her first. Women do mending as toddlers scoot around their ankles. Childhood friends reunite, chattering in Pennsylvania Dutch. Sisters shriek with laughter at the unexpected sight of their expectant aunt.

Outside, on the porch – in a waiting room of his own – a lone, straw-hatted man rocks, amused, pretending not to overhear the women.

The Amish here in Lancaster County may go to the hospital if they break an arm or need surgery, but when it’s time to give birth they stay home. Usually, they deliver their babies with the aid of a midwife, and the women in this waiting room half-joke that if Ms. Goslin goes out of business, they are through with childbearing.

It appeared to be coming to just that last fall when the Pennsylvania Board of Medicine ordered Goslin to cease and desist assisting her mothers, deeming it “practicing medicine and nurse midwifery without the appropriate licensure.”

Though the case arose because an infant delivered by Goslin died a day after birth, it was never considered her fault, nor has there ever been any suggestion that her rates of death or complication are unusual. If she were practicing in any of the 24 states that recognize her status as Certified Professional Midwife (CPM) by the North American Registry of Midwives, she’d have proceeded with her usual 200 to 300 deliveries a year.

But Goslin’s case illustrates the debate about whether childbirth is a natural bodily function or a medical event necessitating hospitalization. As in all ethics-meet-medicine turf battles, one party’s science is often another’s smokescreen.

Indeed, this isn’t new for the Pennsylvania midwife. Last fall’s case was the third time similar charges were brought against her in 18 years, and the third time they were dropped. In May, a 5 to 2 decision by the Pennsylvania Commonwealth Court overturned an $11,000 fine and lifted the cease-and-desist order. All three cases were brought after the state received complaints that Goslin was violating its licensing regulations. Simply doing what she does is against the law, maintains the state. And her business card, on which Goslin “is advertising her services,” is “clearly evidence of unlicensed practice,” says Leslie Amoros, of the Pennsylvania Department of State, which oversees the board of medicine.

Though cleared, Goslin’s work continues under a legal question mark because Pennsylvania recognizes only nurse midwives. Most of those are hospital affiliated and unavailable for home birth.

• • •

In the Amish farmhouses of this rolling hill country, Goslin is considered family. For some women, she’s delivered a dozen babies. And, in Goslin’s own time of need, this community rallied to help – a departure for the reticent Amish who generally refuse to be photographed or be quoted by name. But on behalf of their midwife, they protested at the state capitol, staged benefits and teas, and filed an amicus brief.

Non-Amish – who make up 35 percent of Goslin‘s practice – also turned out, as did advocates of women’s right to give birth in whatever setting and with the attendant of their choice.

The home birth debate has been joined recently by such participants as talk show host Ricki Lake, with her pro-home-birth documentary film, as well as by traditional players such as the American College of Obstetricians and Gynecologists, which recently reiterated its opposition to home birth.

“The [issue of] the medicalization of childbirth has been around for a long time, now,” says Arthur Caplan director of the Center for Bioethics at the University of Pennsylvania. “There will always be [people like] the Amish, who want no technology” on one end of a continuum, and those who will refuse to have a baby “if they can’t deliver at University of Pennsylvania” on the other. He argues that the home-vs.-hospital argument should be removed from the ideological push and pull, and instead be driven by safety data specific to the woman‘s age and risk factors as well as the availability of emergency backup care.

But it’s not always that simple. Such data are everchanging, and, debatable. Research, reports the Midwives Alliance of North America, suggests that safety rates of home births are equal to or better than those of hospital births for low-risk women (with no other health problems). Even so, that’s a difficult comparison, because the total – 40,000 to 45,000 babies born at home each year, according to alliance statistics – remains only about 1 percent of all US births.

• • •

But demand is still high enough that in her 28 years of midwifery, Goslin has never advertised, nor had to hang a shingle.
The world of medicine, for Goslin, is no enemy. Raised in an extended family of doctors, and the mother of a physician as well, she became interested in home birth, she explains, when a hospital-acquired infection she sustained at the birth of her oldest child left her infertile.

Seven years later and about to begin medical school herself, Goslin learned that – in spite of her diagnosis – she was pregnant and decided against medical school.“I wanted to raise my miracle baby myself,” she says. She delivered with a midwife and, believing that such care shouldn’t be solely a counter cultural option, began to apprentice with a midwife.

With 5,000 babies under her belt, Goslin seems to have encountered every twist and turn that childbirth can take. She points out that CPM certification requires attendance at more than double the number of births required for nurse-midwife licensing. Many of these births are required to take place outside the hospital, thus affording rare experience in successfully delivering breech babies, twins, and handling many other conditions that in a malpractice-minded age often trigger automatic cesarean sections in hospitalized patients. But, she adds, “I never had a baby that I could say ‘if that baby had been born in a hospital it would have been OK.’ ”

Now a mother of five, Goslin has been married 34 years to her junior-high school sweetheart, a teacher who is so familiar with her work that she calls him her “armchair midwife.”

She is a member of a conservative evangelical church. “I’m a Christian. I pray for each of my patients. I ask God for wisdom.”

During labor, Goslin’s mothers find that Scripture reading often calms them, and in the packet of instructions on diet and exercise she gives new patients are suggested Scripture passages. She says she feels called by God to her work, and assisted by God in her work.

• • •

On Wednesdays, once again, the gentle, dark-haired Goslin presides over her office as staff prepare the women – taking belly measurements, recording vital signs, and screening for conditions requiring special instructions or referral to an obstetrician. They lend books on pregnancy, answer questions, and make appointments – “You say you all want to come back in on the same day?” Though she has been paid in quilts or livestock, the customary charge is $1,000 per delivery.
When labor begins, parents will lay out linen, basins and other supplies, and contact Goslin, who, with an assistant, heads out into the hills, her 2003 Subaru already loaded with delivery bag, emergency equipment, and – the mothers’ favorite – Goslin’s personally designed birthing chair.

After checking on the patient, she may tidy up a kitchen, cook for a husband, or read. “Most of the time, if truth be told, we’re not needed,” she says. But at other times she is perhaps actively directing a mother through an arduous delivery, or removing a wrapped umbilical cord, or suctioning a baby that has breathed in meconium.

Annie (who, agrees to be identified by first name) is expecting her seventh child, and she knows the drill. “I pace my kitchen floor, lean over my chair, say my prayers…. When Diane comes, she’s my boss.” Even Annie’s most difficult delivery was met with a sunrise, a moment so tranquil, she recalls, she gave the child the middle name of “Joy.”

An Amish mother expecting her sixth child recalls how Goslin strapped her birthing supplies on a toboggan and walked uphill to her farm when the road was impassible one winter. “I didn’t even think to be worried. I figured she’d get here. She always does.”

( More backstory articles )

A star has a natural birth

2008-07-16T18:34:00.000-07:00

Stop the presses.

According to OK Magazine, Jessica Alba's birth of daughter Honor Marie Warren on June 7 was anything but chaotic.

"I didn't scream," Jessica tells OK! in an exclusive interview and photo shoot. "It was really Zen." And Cash could only marvel at his wife's quiet strength when she gave birth. "She didn't make a sound," he says. "It was amazing."

Yes, I'm sure it was.

72-year-old gives birth in India

2008-07-08T18:15:00.000-07:00

She must be exhausted, is all I have to say.

This news from Mumbai, India:

A 72-year-old woman who has two children and five grandchildren has given birth to twins, making her the world's oldest mother.

Omkali Panwar gave birth to twins. Omkari Panwar delivered twins, a boy and a girl, by Caesarean section last week.

"I am very happy," Charam Singh, 75, the father of the twins, told ABC News through an interpreter.

Singh was reluctant to speak because he has received negative publicity for his wife's having children at such an advanced age. Even many people of his village in India's state of Uttar Pradesh haven't supported the decision. Still, he and his wife are happy.

"The desire for a male child has always been there, but God did not bless us with a male child," he said of the son who is a product of in vitro fertilization. "Now, we are very grateful to God, who has answered our prayers."

Earth-Birth

2008-07-08T18:03:00.000-07:00

I have agreed to serve on the advisory board for an amazing organizing called Earth-Birth, a model for a global women's health care collective. The pilot programs are now being set up in Uganda, Sudan and Brazil and sustained by local midwives. The organizers have a vision for holistic women's healthcare that unites women and health care practitioners in a global dialogue. Their birthing centers are not only clinics but community sustained spaces for refuge, learning and the sharing of stories. They are starting in East Africa because of the impact that years of internal genocide has had on women's reproductive and emotional health. They will then model the program in Brazil to begin the global connections in an area where the C-section rate is one of the highest in the world.

The idea is to foster an international women's health movement that encourages and promotes safe and peaceful birth as an act of social justice and community healing. They are offering a holistic approach to women's health care that is both community centered and internationally connected. Their goals include community sustainability, lowered maternal and infant mortality rates, lowered mother to child HIV transmission, access to supplies, access to trauma counseling, the ability to articulate ones story and the facilitation of positive and empowered childbirth experiences.

Check out the website at www.earth-birth.com

And a man gives birth

2008-07-08T17:52:00.000-07:00

I have zero interest in the moral debate about Thomas Beatie, the transgendered "pregnant man," who gave birth last Thursday to a healthy baby girl.

What I am fixated on is the idea that he had a "natural" birth. Granted, I know nothing about what it took to reshape Thomas' clitoris to make it more like a penis, but he could still pass a baby through that? Amazing.

What are the odds he had an epidural?

Young women and birth

2008-07-08T17:40:00.000-07:00

I received an email from the certified professional midwife in New Hampshire who wants to target young women (college-aged, for starters) about normal birth. She is considering showing the "Business of Being Born." I think it's a great idea to try to shape the way young women think about birth before they are inundated with peer and other cultural experiences...which brings me to the cover of Star magazine. I was in the checkout at CVS printing some pictures of my kids at the beach when I saw the headline "Delivery Room Drama" about the birth of Jamie Lynn Spears' new daughter, Maddie Briann.

"The baby's heart rate dropped every time she tried to push," a family insider told Star. "They did an ultrasound and quickly discovered that the umbilical cord was too short." But despite the doctors' dire warnings, the 17-year-old "was adamant about having a natural delivery." The report goes on to say that "Everyone in the room at Southwest Mississippi Regional Medical Center in McComb, Miss., pleaded with Jamie Lynn to listen to the doctors — including big sister Britney. Brit had already been with Jamie Lynn for hours, massaging her back as she endured painful contractions. 'But she got mad,' says the insider. She told Jamie Lynn to 'just have a damn Caesarian,' as she did. 'Britney then ran out in tears because she couldn't bear to see what was happening.'"

How many 12 year-old fans read this story?

(The next day OK mag was reporting that Spears was induced, but she gave birth " 'naturally' without any complications." Not much natural about a Pit drip.

I fear that by the time girls get to college, it's too late. Any notion of 'normal birth' has been eclipsed by tabloid sensations. Next up: Brangelina's complicated pregancy and expected c-section. Sigh.

Making home birth illegal in Massachusetts (part 2)

2008-07-01T18:24:00.000-07:00

Although I have already blogged about the American Medical Association's resolution against home birth, I've decided to paste below the full text. The AMA is also now attacking legislation in states where home birth would be sanctioned, including Massachusetts, one of the first states to outlaw midwifery in the early 20th century. It's as if doctors(and there is a great concentration of them in Mass.) and midwives cannot coexist. It's shame, because each bring their own talents to the room.

AMA RESOLUTION 205:
Whereas, Twenty-one states currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay” midwives), not the certified midwives (CM) credential which both the American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse Midwives (ACNM) recognize; and

Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as “Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film” ; and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that “the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers” (New HOD Policy); and be it further

RESOLVED,

That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” (Directive to Take Action)

AMA RESOLUTION 239:
Whereas, A bill has been filed in the Massachusetts (MA) Senate, and passed the first two reads, that would establish a separate “board of registration in midwifery,” with expansion of scopes of practice and with educational requirements for licensure being left to the discretion of membership organizations¹; and

Whereas, This would remove the current oversight exercised by the Massachusetts (MA) Board of Registration in Nursing (involving Certified Nurse Midwives, CNM), and potentially grant MA licenses to certified midwives (CM) and “lay” midwives (or “certified professional midwives, CPM); and

Whereas, As of 1997, CMs were deemed eligible to sit for the national American Midwifery Certification Board, with the requirement being 3 years of university-affiliated training, but no nursing prerequisite²; and

Whereas, CPMs, as defined in the American College of Nurse-Midwives (ACNM) position paper, are “traditional, independent (of the health care system), non-formally trained and community-based provider(s) of care during pregnancy, childbirth and the postnatal period,”often are self taught and in an unregulated apprenticeship-model²; and

Whereas, Twenty-one states currently license midwives to attend home births using the CPM credential, not using the the CM credential which is recognized by both the American College of Obstetricians and Gynecologists (ACOG)³ and ACNM²; and

Whereas, According to the AMA Scope of Practice site, in the 2008 legislative session there are a number of states confronting similar public health issues regarding “lay midwives” of CPMs (certified professional midwives), including Missouri (direct access), Idaho (authority to perform surgery), Massachusetts (separate licensing board), Delaware and Idaho (licensure); and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous educational standards and appropriate oversight of obstetric providers to ensure the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association develop model legislation regarding appropriate physician and regulatory oversight of midwifery practice, under the jurisdiction of either state nursing or medical boards (Directive to Take Action); and be it further
RESOLVED, That our AMA continue to monitor state legislation activities regarding the licensure and scope of practice of midwives (Directive to Take Action); and be it further

RESOLVED, That our AMA work with state medical societies and interested specialty societies to advocate in the interest of safeguarding maternal and neonatal health regarding the licensure and the scope of practice of midwives. (Directive to Take Action)

Making home birth illegal?

2008-06-20T20:17:00.000-07:00

Much has been written this week about the American Medical Association, a trade association for doctors, drafting a resolution calling for the illegalization of home birth and blaming Ricki Lake for making it trendy with the film she and Abby Epstein made called "The Business of Being Born." (I highly recommend the film, which you can get on Netflix, and not just because I am interviewed in it. ;)

So I will try not to repeat what others, including Ricki, have said in response to the AMA, which boils down to a proverbial flip of the bird. Instead, I hope I can offer some context and history here.

1. The American Medical Association was a big part of the campaign to eradicate midwives nearly a century ago, a move that was largely successful, and this country is still grappling with the public health consequences of that -- with 99 percent of births taking place in a hospital; 1 out of every three births a c-section; and half the women in the hospital getting Pitocin. The campaign then was about money and power, as it is now.
2. I have NEVER heard a woman who has given birth at home say she made a mistake or that it was a horrible experience. If there are any such moms out there, I'd love to hear from you. By contrast, I hear more and more from women who have horrible hospital experiences with OBs who still think episiotomies are necessary and no woman should push for more than two hours.
3. Those who are against home birth will typically post on blogs with remarks that start like this: "My baby had shoulder dystocia...thank God I was in a hospital and that wonderful doctor saved me and my baby..." Well, guess what, that doctor probably performed the Gaskin maneuver, named after a MIDWIFE, who knows a thing or two about shoulder dystocia in home birth.
4. Throughout history, whenever women felt they did not have a choice in childbirth, they spoke out, voted with their feet, and forced change. Clearly, woman are beginning to feel pushed around, and many are choosing to stay home, in part, I hope, because they are being empowered by the FACTS, by scientific studies, by films, and by books such as mine and Jennifer Block's Pushed.
5. I had a home birth 6 months ago. It blew my mind. It was as birth should be and I am no radical. If home birth suddenly became illegal, and I suddenly became pregnant again, I would still find a way to give birth at home. Oops, guess I couldn't make it to the hospital in time. And you can bet that midwives would still come if called, regardless of the consequences. Tell me, how would illegalizing home birth do anything but force it underground and make it less safe?

On Father's Day

2008-06-15T20:05:00.000-07:00

I made an appearance in central Mass. the other night for a screening of the "Business of Being Born," an event organized by doula/Mothers & Co. owner Jeanette Mesite Frem. Jeanette was telling me that she is in a new film called "Being Dad," filmed by Australians and premiering in the US this summer. The film is meant to answer the question what should men expect when they're expecting?

To view the trailer, see: http://apac.vividas.com/5784_BeingDad/web/
I believe there are clips on YouTube, as well.

It's a great idea for a film. Whatever it takes to keep men connected and from saying things like, "Do you really want another piece of cake," when his wife is 9 mos. pregnant.

Meanwhile, today I got an email from Clay Nichols, who runs DadLabs, which is back from a five-day excursion to Stockholm to see first-hand the most dad-friendly place on earth. They were hosted by Baby Bjorn, who introduced the to politicians, daycare centers, and dads that have benefitted from Sweden’s progressive pro-family policies. DadLabs was most impressed with how connected to their children and happy with the paternity leave policy the dads of Stockholm were. The trip culminated with a meeting with the man behind the brand, Bjorn Jacobson.
www.dadlabs.com

Breakfast with Gloria Steinem

2008-06-04T18:36:00.000-07:00

I had breakfast with Gloria Steinem this morning -- me and 1,000 other of her BFFs in Boston, at an event put on by The Commonwealth Institute, an organization that promotes women in business. She said a few things that really made me think. And a few things that really made me laugh, including: "I'd like to create a button that says 'The truth shall set you free, but first it will piss you off.'" Amen sistah.

She also talked alot about how family forms have a real connection to international and governmental relations. For example, the Native Americans had egalitarian family structures, where gender was never an issue. That lack of bias or set roles was reflected in their government, where female elders chose a chief and they could remove a chief. With three boys in the house, I will consider it a job well done if, when they grow up, they empty the dishwasher without their wives having to ask.

Later in the program a member of the audience asked her why younger women don't seem to appreciate all the hard-fought freedoms they have. This question posited -- without saying it -- why is this generation of women getting MBAs and then become stay-at-home moms? Gloria said she did not think young women don't appreciate their freedoms. It's just that women tend not to become activists about anything until they are older, and begin to feel their personal power slip away. Young women have all the power; they are fertile, pretty, etc., she said. As we age, all that changes.

2008-06-01T18:44:00.000-07:00

From today's New York Times, an absolutely outrageous tale of insurance companies denying coverage for women with previous cesareans. As always, it is money dictating the rules of health care. Of course, money (malpractice fears) is one of the reasons why the c-section rate in the US at 1 out of every 3 births. Honestly, it is surprising that it took insurance companies this long to wake up to the fact that they are paying either way -- for the c-sections that don't get done when they should, those that get done poorly (regardless of whether they were necessary) or when a woman is denied access to a vaginal birth after cesarean, which is happening more and more...

June 1, 2008
After Caesareans, Some See Higher Insurance Cost
By DENISE GRADY
When the Golden Rule Insurance Company rejected her application for health coverage last year, Peggy Robertson was mystified.

“It made no sense,” said Ms. Robertson, 39, who lives in Centennial, Colo. “I’m in perfect health.”

She was turned down because she had given birth by Caesarean section. Having the operation once increases the odds that it will be performed again, and if she became pregnant and needed another Caesarean, Golden Rule did not want to pay for it. A letter from the company explained that if she had been sterilized after the Caesarean, or if she were over 40 and had given birth two or more years before applying, she might have qualified.

Ms. Robertson had been shopping around for individual health insurance, the kind that people buy on their own. She already had insurance but was looking for a better rate. After being rejected by Golden Rule, she kept her existing coverage.

With individual insurance, unlike the group coverage usually sponsored by employers, insurance companies in many states are free to pick and choose the people and conditions they cover, and base the price on a person’s medical history. Sometimes, a past Caesarean means higher premiums.

Although it is not known how many women are in Ms. Robertson’s situation, the number seems likely to increase, because the pool of people seeking individual health insurance, now about 18 million, has been growing steadily — and so has the Caesarean rate, which is at an all-time high of 31.1 percent. In 2006, more than 1.2 million Caesareans were performed in the United States, and researchers estimate that each year, half a million women giving birth have had previous Caesareans.

“Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,” said Pamela Udy, president of the International Caesarean Awareness Network, a group whose mission is to prevent unnecessary Caesareans.

Although many women who have had a Caesarean can safely have a normal birth later, something that Ms. Udy’s group advocates, in recent years many doctors and hospitals have refused to allow such births, because they carry a small risk of a potentially fatal complication, uterine rupture. Now, Ms. Udy says, insurers are adding insult to injury. Not only are women feeling pressure to have Caesareans that they do not want and may not need, but they may also be denied coverage for the surgery.

“You have women just caught in the middle of this huge triangle of hospitals, insurance companies and doctors pointing the finger at each other,” Ms. Udy said.

Insurers’ rules on prior Caesareans vary by company and also by state, since the states regulate insurers, said Susan Pisano of America’s Health Insurance Plans, a trade group. Some companies ignore the surgery, she said, but others treat it like a pre-existing condition.

“Sometimes the coverage will come with a rider saying that coverage for a Caesarean delivery is excluded for a period of time,” Ms. Pisano said. Sometimes, she said, applicants with prior Caesareans are charged higher premiums or deductibles.

“In many respects it works a lot like other situations where someone has a condition that will foreshadow the potential for higher costs going forward,” Ms. Pisano said.

Her group has reported that although most Americans with health insurance, 160 million, have group plans through employers, the number needing individual policies will probably keep rising, because more and more people are becoming self-employed or taking jobs without health benefits.

In a letter to Ms. Robertson, Golden Rule, which sells individual policies in 30 states, said it would insure a woman who had had a Caesarean only if it could exclude paying for another one for three years. But in Colorado, such exclusions are considered discriminatory and are forbidden, so Golden Rule simply rejects women who have had the surgery, unless they have been sterilized or meet the company’s age requirements.

“If you don’t work for someone who has insurance, and you have to get insurance on your own, this is terrifying,” Ms. Robertson said.

A spokeswoman for Golden Rule declined to explain how long it had been excluding Caesareans, how it had decided to do so or how many were affected, saying the information was proprietary. The company, based in Indianapolis, is owned by UnitedHealthcare, which collects more than $50 billion a year in premiums and has 26 million members, most with group coverage.

In Colorado, people denied individual health insurance can obtain it through a state program, Cover Colorado, which insures about 7,200 people. But the premiums are high, 140 percent of standard rates, a spokeswoman said, adding that some women had enrolled specifically because prior Caesareans had disqualified them from private insurance.

Blue Cross Blue Shield of Florida, which has about 300,000 members with individual coverage, used to exclude repeat Caesareans, but recently began to cover them — for a 25 percent increase in premiums for five years. Like Golden Rule, the company exempts women if they have been sterilized.

“After five years, if there is not a complication of pregnancy, another C-section, or if they get their tubes tied and are no longer in that risk situation, that rate-up goes away,” said Randy M. Kammer, the vice president for regulatory affairs and public policy.

The higher rate is based on a Caesarean costing an average of $2,700 more than a vaginal birth (assuming no complications in either type of delivery). Ms. Kammer said Blue Cross Blue Shield could not provide a tally of how many members were paying the higher rates because of Caesareans.

“The aggravating thing is, there are a lot of elective Caesareans, and that adds to costs,” she said.

Elizabeth Bonet, who lives in Sunrise, Fla., learned about the higher rates this year when she applied to Blue Cross Blue Shield of Florida.

“I was very angry, outraged, shocked,” Ms. Bonet said. “It made me feel very helpless. These were not Caesareans I wanted. They were not elective Caesareans. I very much wanted natural births with both babies and was not able to have them, and to have to pay for that for years is outrageous, and I feel it’s discriminatory as well.”

Each state’s Blue Cross Blue Shield plan sets its own policies. In Texas, a spokeswoman said, a prior Caesarean will not affect a woman’s premiums or insurability, as long as she has recovered fully.

A spokeswoman for another major insurer, Wellpoint, said the company’s decisions about prior Caesareans varied case by case, but declined to explain further.

Aetna does not treat a Caesarean itself as a pre-existing condition, but does factor in chronic or recurring problems that might have led to the Caesarean, like diabetes or high blood pressure, a spokeswoman said.

A spokeswoman for another company, Mega Life and Health Insurance, in North Richland Hills, Tex., said: “If the Caesarean section was considered by the physician to be medically necessary for the safety of the mother or child then coverage is issued without conditions. If the procedure was determined to be ‘elective,’ coverage would be offered with a temporary waiver or at a higher premium rate.”

Insurers often accuse women and obstetricians of scheduling unneeded Caesareans for their own convenience — to deliver the baby at a certain time, or to avoid labor. But it is not known how much of the overall increase in Caesareans is because of a rise in unnecessary operations, or how many Caesareans are done at the mother’s request, according to a 2006 report by the National Institutes of Health.

“I think it’s really a very small amount, but we need more data,” said Dr. Mary D’Alton, chief of obstetrics and gynecology at Columbia University Medical Center, and an author of the report.

She said she was amazed to hear that insurers would charge higher premiums or deny coverage because of a past Caesarean.

“I would think if it’s happening, the medical profession has to take a stand,” Dr. D’Alton said.

But to people familiar with the rough and tumble world of individual insurance, the companies’ practices are no surprise.

Individual insurance differs sharply from the group coverage with which most people are familiar. Group policies generally require that the insurer cover everybody in the group, and charge the same rates for all. But with individual coverage, insurers in many states can vary their prices based on medical history, exclude certain services or reject anyone they consider a bad risk. (Several states, however, including New York, New Jersey and Massachusetts, ban such practices.)

Insurers say they need these strategies to protect themselves, because some customers apply only after they get sick or pregnant, skewing the pool toward people with high expenses.

Ms. Robertson said that had she known a Caesarean was grounds for rejection, she would not have even applied to Golden Rule, because the denial may be held against her in the future. Insurers routinely ask applicants if they have ever been denied, and red-flag anyone who says yes.

“My understanding is that once you’re denied it’s hard to get other insurance,” Ms. Robertson said. “Man, is that a scary thing.”

A new c-section product

2008-05-28T18:47:00.001-07:00

I received an interesting email from Digital Influence Group, a social media agency that actively engages in online conversations on behalf of their clients -- in this case, Genzyme, the biotech firm. Here's what the email said: "Digital Influence has been "raising awareness about c-sections; particularly c-section related adhesions, for Seprafilm, an adhesion barrier manufactured by Genzyme which helps minimize the risk of forming adhesions following abdominal surgery. As a result of our research, we’ve found that few women are aware of this potential complication, and that even fewer know there are preventative measures that can be taken. We’ve put together a quick list of links on this topic at http://del.icio.us/adhesion_awarenesss to help spread awareness, and thought you might be interested in the content there as well."

The constant gardener

2008-05-26T17:14:00.000-07:00

This is Harrison today, at 5 months, enjoying his first picnic in the park, after which we decided to go home and plant my placenta. I took it out of the freezer last night, as if it were a piece of steak, but somehow it just did not seem right sticking it in the ground frozen. This morning, I couldn't look at the plastic Ziploc bag anymore and made haste to buy a plant to go in the ground. I chose a climbing rose bush with fragrant peachy blooms. I dug a hole in the one spot in the garden where the rose bush would fit, hard by a tree stump. I couldn't dig quite so far because I kept hitting roots. So I eyeballed the depth and, with sweaty brow, unwrapped the placenta and its loooong cord, marveled at it, was thankful for it, and tried not to wretch. I put it in the ground, placed the bush on top and began back filling. Of course, the hole was not deep enough. The only other place to plant it was in a large whiskey barrel. I dug a hole there, yanked up the bush, and then kept digging looking for the placenta. Suddenly, I felt like I was living an episode of CSI. What was wrong with me? I glanced up to see if any neighbors were looking. I grabbed the earth-encrusted placenta, dangling from its cord, and placed it in the planter, dropped in the bush, and covered it all up quickly.

I can't wait to see -- and smell -- it bloom.

ACNM's Annual Meeting

2008-05-24T18:18:00.000-07:00

I gave a little talk and signed some books at the American College of Nurse Midwives' Annual Meeting in Boston today. And after the book signing, there was a screening of the "Business of Being Born," a documentary that every woman should see. Anyway, what really struck me was how transformative the film can be for lay people. After the show, a young couple who had wandered in off the street to see the film came up to me, clearly moved by what they had seen. "Where do I even begin to look for a midwife?" she asked. "To think that an hour ago I was making fun of the word 'doula,'" he said. "What a cute couple," I thought. Another person made the comment that home birth midwives are suddenly very, very busy. Music to my ears.

Placental palliative

2008-05-23T03:12:00.000-07:00

As we head into Memorial Day weekend, and I finally pull my placenta out of the freezer and plant it (your suggestions have been fantastic, thank you!) I came across this news story on Indian MSN and it made me think even harder about what an interesting organ the placenta is.

http://lifestyle.in.msn.com/health/article.aspx?cp-documentid=1413857

Birth waste to heal wounds faster

The delicate and durable membrane that protects the baby in the mother's womb called amnion is normally discarded after the baby's birth. But now this membrane is being used here in eye surgery besides ulcers, burns, diabetic ulcers, bedsores et al

Eighteen-months old Raju (name changed) screamed with pain when boiling dal fell on him. His tender skin - half his body - had suffered second-degree burns. Panic-stricken parents rushed him to Mumbai's known plastic surgeon Dr Kalpesh Gajiwala.

After cleaning the wound and removing the dead skin, Dr Gajiwala placed the transparent biological dressing ‘Amnion' directly on the wound. The transparent thin dressing stuck easily to the oozing surface and sealed it completely . It automatically peeled off after the wound had healed. The child was saved from the trauma of daily dressing.

In the words of Dr Kalpesh who uses amnion quite extensively either in preparing the burn wounds for a skin graft or to help heal the sites from which a skin graft has been taken says, "It helps in faster healing and causes much less scarring."

Perhaps there can't be a better recycling of "after birth waste."

The delicate and durable membrane that protects the baby in the mother's womb called amnion is normally discarded after the baby's birth. But now this membrane is being used here in eye surgery besides ulcers, burns, diabetic ulcers, bedsores et al. And it is available in ‘ready to use' packs at India's only ISO 9001:2000 certified Tissue Bank of Tata Memorial Hospital.

As of now the hospital recovers this precious after birth waste from the two maternity hospitals in its vicinity to be processed; freeze dried, sterilised by gamma radiation and packaged. As amnion dressings are stored at room temperature, packets are easily mailed anywhere in the country .

Unfortunately this amazing membrane is going waste in the rest of the city and country. The solution lies in setting up a national bank. As its production is directly linked to the childbirth, the raw material availability will never be a problem in a country that is battling to arrest the birth rate. Only the donors will have to come forward as their consent is required even though it is a discarded tissue.

"The donor has to know its specific use and also give consent for the testing of the do- nated blood sample for HIV Hepatitis , etc," says Dr Astrid Lobo Gajiwala, head of the Tissue Bank. As many as 5,00,000 patients are treated in United States every year with amnion.

The biological wound dressing can be used on any part of the body. The largest size available is 20X20cms and smallest is 4X4cms. It sticks like a stamp, seals off the wound and peels off as the wound heels. Its cheap, it's transparent, and is usually preferred as it mimics the skin. Analgesic use is also reduced, as there is almost immediate pain relief.

Placenta puzzle

2008-05-14T05:48:00.000-07:00

OK, it's spring, and I am as behind on gardening as I have been on posting to this blog. I blame the mommy vortex for sucking up any free time. But anyway, I am realizing that I have a short window to take my placenta out of the freezer, bury it in the garden and perhaps plant something on top of it. Any recommendatins? We live in the city and have a very small backyard, already full with flowers and lilacs and forsythia. In other words, a maple tree won't work. Thoughts welcome!

Cast a vote

2008-04-21T05:27:00.000-07:00

The headline in the paper today made my heart leap: "Push for Labor Support." Really? I thought. It's about time! Every woman deserves encouragement when giving birth. But then I realized the story was about Obama and Clinton and trade unions. Bummer. Clearly my head is in a different place.

Our new baby, installment #36

2008-04-05T18:36:00.000-07:00

... and second guest appearance by the home birth husband. Americans get entrenched in a set way of doing things; the years go by and all the protocols become automated, the accepted process is the path of least resistance, and it takes real effort to do anything differently. It's that way with sprawl, a subject I've written about, and this kind of self-reinforcing dynamic is very much at work in the business of being born. The hospitals take care of all the little details of bringing a new person into the world. Two specifics: the birth certificate and the social security number. In the days following Harrison's birth I called City Hall to see what I had to do to get a birth certificate, and wasn't given the full story. I came in armed with what I thought was sufficient documentation, only to be told I needed our marriage license; not immediately apparent why the city needed to know if we were married or not, but if we weren't, the mother needed to come apply. There was no answer at City Hall in Cambridge where we were married -- it was a Friday -- so I drove down to the state bureau of vital statistics to pull a copy (for about $20). Then I had to fill out a lengthy questionnaire with all kinds of personal questions that I had to ask Tina on the mobile phone in the busy municipal office. Needless to say this took the better part of a day. Next task: taking said birth certificate down to the Social Security administration to apply for Harrison's number. We need it for our tax return to prove the addition of a dependent, but the mutiple pages of instructions on the web seem to indicate it could take 12 weeks. And so we're forced to enter into another tried and true convention: the filing extension. Small price to pay, all of this, but just another indication of how the system makes us feel like we did something really unusual.

You call that a vacation?

2008-03-31T03:41:00.000-07:00

So we're just back from Disney World...I have two things to say. First, we paid ten bucks for a balloon. One balloon. And second, the only billboard between the Magic Kingdom and the airport that was not for a theme park? It was for www.vasectomy.com.

Our new baby, installment #35

2008-03-24T18:40:00.000-07:00

About 10 weeks after Harrison was born at home, my mother asked me to come down to Bellani Maternity, a boutique near her house, to watch a screening of "The Business of Being Born," Ricki Lake's new documentary, for which I was interviewed. What was special for me about this night was that my grandmother and my sister-in-law would be coming, too. Before we watched the film, my mother and I added up all the births among the surviving women on our one side of the family. My grandmother had three children. My mother two. My aunt 2; her daughter, 1; my sister-in-law, 1; and I had two. Out of those 11, 10 births were either horrendous, cesareans, or extremely painful. Only one birth was absolutely without complications and would be remembered for how simply wonderful it was -- the one that happened at home, with a midwife, my second child. Although my mother finally understands why hospitals can get in the way of childbirth, the results of our little mathematical exercise was still surprising. After the film, I mentioned the family statistics to my grandmother, who was unconscious during her births thanks to Twilight Sleep, and I think for the first time she, too, understood that birth could be better if we left it alone. It was a small triumph.

Our new baby, installment #34

2008-03-17T19:23:00.000-07:00

Our midwife came to check on us three times after the baby was born, each time staying for more than a hour, weighing the baby, giving me a once-over, talking with the older boys. From a service perspective, it was downright luxurious, not having to dress a newborn and head out to a doctor's office in the freezing cold. This postpartum care was included in the fee we had to pay out-of-pocket for a home birth -- a cost that our premium insurance policy does not cover even though we are fully insured. Just because it happened at home. Knowing that insurers had spent $25,000 for my cesarean four years ago, and had just spent $11,000 for my cousin's vaginal birth in a hospital (she was later readmitted for infection but that was a separate bill), the thought that the insurance company could pay a fraction of those costs and have better outcomes and happier moms is nonsensical. It's a very dysfunctional system.

Our new baby, installment #33 (guest blogger/the husband)

2008-03-12T18:03:00.000-07:00

I guess you can consider me the home-birth husband. When Tina first suggested it, I wondered if there was a middle ground -- a birth attended by a midwife in a birth center. No such thing, she reminded me, in Massachusetts. I then said a home birth is one thing, but a home birth VBAC sounded hard-core. Wrong again, as our wonderful midwife explained; no particular issues there. Then why don't hospitals do VBACs? A questionnable study, insurance, and lawsuits. Such was the process of my re-education. I learned I had to buy-in 100 percent and nothing less. No emphasis on the back-up plan, transport to the hospital if 'something goes wrong.' No dwelling on something going wrong. So when it was clear that Tina was in labor that Friday night, I felt disciplined, and was thinking positive, which helped me be less nervous. Although I did want the midwife to be there the minute after the first strong contraction. In retrospect I thought maybe I put my heart and mind in the hands of the midwife in the place of the doctors at the hospital -- the new expert to calm my fears -- but that wasn't really what happened. She came, I parked her car, she had a suitcase of stuff, and she went to my wife. The next two hours were between Tina and her. I fetched things and paced around the tub I had set up. After reading Tina's book, I was at peace with a man's minimal role. I caressed her forehead but it didn't seem like she was too aware of my doing so; she was busy, in the zone. It was an incredible athletic event, and I didn't feel like saying 'You're doing great' or any such thing, any more than it would be effective to say something encouraging to Derek Jeter ranging for a sharply hit ground ball. Maybe I was in a trance, but I even went along with the gag on the whole thing happening in the water. My surprise was that it was a boy. I was impressed by how attentive the midwife team was on checking Harrison out, and examining Tina -- checklists, all very thorough. I had no idea there was any kind of issue about the placenta and didn't worry at that stage, either. When it was delivered the midwife showed me what an ingenius contraption it was, sustaining Harrison for 39 weeks. It was a cold night, and I remember thinking, all they had to do was move one room over, mother and child. We were home.

Our new baby, installment #32

2008-03-09T18:19:00.001-07:00

Once labor and birth were finished, the reality of being at home really kicked in. The midwife weighed Harrison (7 pounds even) in a sling right by my side. She did her check up of him beside me on the bed. There were no heel pricks. No Hep B vaccines. No sugar water on the tongue. No discussion of circumcision. No incubator. No one saying they were taking him away for a bath.

My husband rummaged through the dark to find the baby something to wear -- no standard issue hospital garb. I jumped in the shower and gingerly got back in bed. My husband made me a sandwich and brought me a big pitcher of water to slake my thirst and we toasted the midwives and Harrison with some champagne and cake, which the midwives ate downstairs to give us time alone.

Harrison was born at 5 minutes past midnight. The midwives stayed to check on us all until close to 4 a.m., when they finally said goodbye, with assurances of a visit later in the day. We were too excited to fall asleep, and stayed in bed marveling at the baby. At 5:30, our 4-year-old came in and did a double take when he saw his new brother in the bed. It was like Christmas morning. He crawled in with us and we all stayed happily together until my parents, grandparents, aunt and cousin arrived with breakfast. It felt so great having them all there at the house, knowing they could stay as long as they wanted. My 85-year-old arthritic grandfather endured a long car ride, and even climbed a big flight of stairs to the bedroom, to see Harrison. He scooped up the baby and there we both cried. My grandfather was the one, throughout the entire decision to have a VBAC at home, to support it vocally. Having served on New Guinea during World War II, he saw many indigenous women give birth there. That exposure made him appreciate, respect and understand the process in ways that my grandmother and mother -- who had never known birth outside a hospital -- could not. I was grateful for his support. And loved that he could be there that morning.

Our new baby, installment #31

2008-03-05T19:22:00.000-08:00

I still have a fair amount to say about my home VBAC. For starters, a faithful reader of this blog asked me if I was worried about having a placenta issue, since a prior cesarean can cause the placenta to adhere to the scar or even implant through the uterus -- both serious problems. The short answer is no. Despite having researched such problems while writing my book, a sort of haze effected my brain while I was pregnant and I thought nothing but positive thoughts, perhaps reinforced by my ever positive midwife. So, even when she seemed slightly concerned that the placenta was not coming out quickly, and told me to get on the bed and push, I was not worried. And sure enough, it all came out smoothly, in one piece. And when the weather turns nice, it will be taken from the freezer (it's wrapped in a towel in a Ziploc bag beneath some ice cream sandwiches the boys love) and buried in the backyard. Mom, are you rolling your eyes?

Our new baby, installment #30

2008-03-04T18:09:00.000-08:00

This is Harrison. And me. If you look closely, you can see that the cord is still not cut. We waited until it stopped pulsing and it was tied off with a string. Still no sign of that placenta. So after what seemed like an eternity holding Harrison in the tub, the midwife told me I should get out, and let gravity help expel the afterbirth. I felt a little wobbly in the knees. I handed the baby to my husband, climbed out and walked to my bed, which I had made up like a layer cake of sheets and shower curtains.

Our new baby, installment #29

2008-03-03T17:54:00.000-08:00

One more contraction, and our baby was out, a successful and stunningly uplifting home VBAC.

"It's a boy!" the midwife said, her first words in a long while, as his body popped up to the surface.

Although his head had emerged with the cord wrapped around his neck, the midwife had reached into the birth tub to check on him, felt the cord pulsing, and knew he was OK. All through the two hours I spent kneeling in the water, she never once told me to push. And I never did. My body did the work on its own and I let everything take its time. I think the reward was in not needing a single stitch.

I sat in the tub holding him, transfixed, looking in his dark eyes, his hair curled from the wetness. He was breathing just fine, very alert, not crying, checking out his new bedroom, moving his eyes across the room. His body, covered with creamy vernix, was incredibly soft and I held him close. He took to nursing like a champ. My husband finally decided it was OK to take a picture (maybe I will post one tomorrow)and we all rejoiced in the moment.

A couple minutes later, our second midwife, who had gotten caught in a construction tangle on the turnpike, arrived -- deflated she had missed the birth.

All seemed well. But where the heck was the placenta?

A book in the mail

2008-02-29T18:07:00.000-08:00

I just have to share about a very sweet note tucked into a book that arrived on my stoop today. Both the letter and the book, Artemis Speaks: VBAC Stories and Natural Childbirth Information, were written by Nan Koehler. (The book in 1985, the letter two weeks ago.) Nan says she still has a 1,000 copies of her book "in the barn" but that used book dealers are selling them for $50 a copy. I haven't checked Amazon.

Anyway, in her book it says that Nan is (was?) a traditional birth attendant/botanist/herbalist living in California who was part of the home birth movement back in the day.

In her letter, she remarks that the hormone relaxin is very close to insulin. "One atom different," she writes. "So the solution for easy birth is walking - exercise...to circulation the relaxin in the pelvis."

She also said I should have mentioned that in some cultures there are dietary taboos "that ensure that babies remain smaller - then they are fattened up after birth..." Fair enough. I'd love to know more on this. I bet lots of New York women would buy that diet book.

And then she wrote that the real reason why labor begins at night for so many women is because their hormonal output is greatest at 3 a.m. (when most labors begin) and the low point is 3 p.m., when labor tends to stop. Makes sense.

She also highly recommends castor oil over pitocin. (My response: Anything is better than pitocin...)

She concludes the letter by responded to a section in my last chapter, on the postpartum period, where I discuss various methods traditional midwives have used to dress the cord stump, including cow dung and ashes.

"Cow dung is very sterile," she says. "Check that some more."

Indeed I will!!

Can't wait to read Artemis Speaks.

Our new baby, installment #28

2008-02-28T17:24:00.000-08:00

Much like labor itself, this story may seem to have no end, and to some, it may even be painful. For that, I apologize. But if I could play the role of midwife to my readers, I would say: "Almost there! Don't give up! You've stuck it out this far!"

You would think that I would have many details to share, and that, being a writer by profession, I would have carefully chronicled, perhaps even videoed our planned home VBAC. But I didn't. I didn't want to. I lived every moment of it for myself. So while there were things that I do remember clearly -- the thoughts in my head that played over and over like a skipped record as I was in the birth tub, my lack of self-consciousness, my inability to tell time, my need for silence and the presence of those I knew I could count on -- there are some things about this story I just cannot recall.

I have no idea what my poor husband was doing. I know he was in the room but I did not see him once. My eyes were closed tight. When they were open, I was not seeing. I remember that in that moment, I was dissecting the pain, trying to understand it and get my arms around it. But today, I honestly cannot remember the pain. I cannot explain it. I cannot compare it to anything. Not because it was worse, but because I don't know what it was. I cannot say if I moved from my kneeling position. Ever.

However, I knew the end was near when my hips reflexively thrust forward, uncontrollably. I had read about this. Michel Odent, the French obstetrician credited with "inventing" water birth, calls this, well, something like the reflexive hip thrust! It is nature's way of opening the pelvis to expel the baby. I don't know how many times that thrust happened to me, but sure enough, I felt the head move down quickly. I absorbed the meaning of "ring of fire" and began a high-pitched chant of OW OW OW OW...

The head was out. My midwife reached in. She felt the cord wrapped around the baby's neck. But kept that information to herself.

Our new baby, installment #27

2008-02-27T07:53:00.000-08:00

The birthing tub, as I had learned the week before labor started by submersing myself in it, brought instant relief in so many way because it took gravity out of the equation. The pressure and weight of a big belly, the inability to move into a comfortable position, these were nonissues in the water. When the home birth midwife suggested I get in the tub, I flung off my nightgown, grabbed an elastic and a headband and twisted my hair into a crazy style, and got in -- quickly -- between contractions, with help. We had set the tub up in the baby's room, which was warm and dark. The house, thankfully, was quiet. I immediately settled into a kneeling position, gripping with white knuckles the side of the tub and pushing my forehead into the padded lip. The midwife checked me for the first time, and said I was fully dilated, after about only 3 hours of active labor. Every time a contraction hit, I marveled at the sound coming from my throat and kept thinking I would wake up our 4-year-old, or the neighbors, as our old town house is attached on two sides. For the next two hours, the only words I remember saying are: "When will this end?" "Soon," was her response.

I also had two constant thoughts running through my head: "Now I know why women considered childbirth the Curse of Eve...because if one did not choose to go through this, and had to do so every couple years, it could make you a very bitter woman."

The second thought was more of a question -- "How many other babies were born in this house, built in 1874? And what was it like for them?"

Our new baby, installment #26

2008-02-24T19:44:00.000-08:00

Continuing my story about planning a home VBAC, when I called the midwife to tell her my water had broken and the fluid was greenish, she very calmly said, "that's OK, about 1/3 of all water is tinged and it's not a problem."

On the other occasions throughout the pregnancy when I needed reassuring (uterine rupture risk? elevated blood pressure? confusion over whether to have a Step B test...)her positive attitude and patient answers propelled me up some hill I could not climb alone. I cannot say how important these little words were. They were little. And they were huge. I cannot say for sure, but I believe that had my greenish waters broken in the hospital, it would have caused more of a stir, which would have made me scared, which would have made me doubt.

On this night, I did not doubt. I gamely timed my contractions on a piece of paper. I broke out into a sweat leaning on my husband and it made me think of all those Hollywood films when the laboring woman has a mop of wet hair. I always thought that was overly dramatic. But I had not worked that hard on a treadmill. Ever.
And when I could not write times anymore, I put down the pen. My husband dialed the phone. The midwife asked to speak with me. She wanted to hear what my voice sounded like. And 10 minutes later the midwife was hauling her bag up the main staircase in our house. She whispered something to my husband, dropped her bag and suddenly a nuclear contraction hit and a sound came from my toes up through my throat. She told me to get in the tub right away.

Our new baby, installment #25

2008-02-23T05:36:00.000-08:00

So after getting a testy email from my mother, who says I am not blogging fast enough for her taste (yes, she knows it has been school vacation week)I am posting over coffee while my husband cleans up the hot chocolate that our 4-year-old just spilled all over the kitchen.

Where did I leave off?

I was pretty sure I was in labor with intermittent contractions. My husband was rushing home through traffic. I had a car full of groceries and a kid in tow. I emptied the car, thinking it might help me realize if I was, in fact, in labor. With everything put away and my husband home, I began to time the contractions. They were about five minutes apart.

"You should call the midwife," he said.

We called, told her what was happening, and said we were OK on our own for now. She said to call her back as soon as I needed her and she was going to lay down and get some rest. It was about 7 p.m. I wanted to read our son a book before bed. But because I was so huge, and his twin bed sits high, I had been having difficulty reading to him in his own bed. So we all climbed into my bed and plugged in The Polar Express movie. My son and I drifted off to sleep. And then -- S-P-L-A-T. My water broke. It woke me up and I immediately jumped out of bed. My husband ran to get towels. This was no trickle. It was then that I noticed that the waters were tinged, a slight greenish brown.

"Quick!" I said. "Call the midwife!"

Our new baby, installment #24

2008-02-20T17:30:00.000-08:00

The cousin is home, feeling better and the hospital says they have no proof it was an infection, at least that was what they said when she inquired if it could be staph...Hm...Don't know why they would put her on antibiotics if it wasn't an infection. But anyway.

As I waited for my own labor to begin, I cleaned the refrigerator (naturally) and had to squeeze in one more trip to the grocery store. I was like a squirrel with a nut, having to put everything in order quickly, before the first frost.

It's amazing how strong the mind-body connection can be. On my way home from the grocery store, with my entire to-do list checked off, and my son picked up from school, I started getting contractions. Of course, it was a Friday and I knew my whole family would be around that night and through the weekend. My husband called to say that he had to stay a bit late for work. I told him he needed to come home.

Our New Baby Installment #23

2008-02-18T10:37:00.000-08:00

My cousin is still in the hospital with a postpartum infection....

But I figured I would add another installment about my journey toward a home VBAC.

At our next midwife appointment (horns and drum roll, please...) my blood pressure was FINE. Back to normal. I was relieved. My family was relieved. My midwife didn't say 'I told you so.' But she had told me so. I tried to listen. I gagged myself on protein, soaked in the tub, quit working and tried to be nice to my poor husband.

Now, with my blood pressure in the 117/70 range, there were no worries. I was just really eager and centered. When I went home and started cleaning my refrigerator, I knew I was ready for labor.

Another birth in the family

2008-02-17T03:39:00.000-08:00

I have been a delinquent poster not just because of my own family circus, but because of an extended family drama. We were delighted on Thursday to welcome another baby into the family: My cousin had a baby girl, Elyse. Anyone who has read my book knows that one of the things that inspired me to write about the history of childbirth was trying to understand three generations of births (my grandmother, my mother and aunt, my own)all which were quite different, and also quite bad. As I was concluding the book, my sister-in-law's twin had a baby, which became fodder, and I ended the book questioning whether my sister-in-law, when she had a baby, would schedule a c-section, as she hoped to do. Well, I've already blogged about my sister-in-law here, who had her baby about 7 months ago. Today, I am focused on my cousin, who had a relatively easy vaginal birth in the hospital with her first son. This being her second child, labor progressed just fine and despite being 7 cm and feeling no pain, she got an epidural. A couple hours later, she had a girl and a few stitches. The next day, she said she felt an unusual amount of stomach pain. And the next day they sent her home. Last night, she raced back to the hospital with a raging infection. Her baby stayed home with her dad. The last three women I have personally known to give birth in a hospital have had to return to treat an infection. And given the post below, this is very frightening in an age when infections are becoming resistant to antibiotics. More women should know that this happens.

C-section leads to quadrupal amputation

2008-02-12T18:53:00.000-08:00

This is the first installment of a two-part piece being published in the Boston Globe.

http://www.boston.com/bostonglobe/magazine/articles/2008/02/10/saving_monica/

Our new baby, installment #22

2008-02-12T17:31:00.000-08:00

In the days before we were to meet with our home birth midwife again, a few things happened. First, our midwife, who knew I was at my tattered edge with the elevated blood pressure issue and just generally Done Being Pregnant, sent me a long and thoughtful email that basically boiled down to this: Relax. Soak regularly in the birth tub to get used to it (it will also lower the BP). Stay home and listen to your body. Force feed the protein (a homeopathic remedy for elevated BP). Walk twice a day. Let your husband do nice things for you -- and stop yelling at him (I had entered the grouchy phase I am sorry to say...) She wrote many other thoughful words but I will keep those for myself. I was moved that she sensed I could use a pep talk. And it worked. I did as she advised. I did NOT go back to the doctor for a blood pressure check, a decision I came to on my own. And given my recent frustrating experiences going to those medical offices I decided to forgo a Strep B test, embracing instead a prophylactic homeopathy.

At our next appointment, I was eager to see what my blood pressure was.

Our new baby, installment #21

2008-02-11T10:27:00.000-08:00

Continuing the story of my plan for a home VBAC, I was mulling what to do about Strep B testing, the enormous birthing tub was finally set up, and I was meeting with the midwife for a weekly appointment. It was then that she took my blood pressure and found that in the space of a week, it had jumped from about 115/70ish to 139/80ish, with 140/80 being the benchmark for preeclampsia, a mysterious and potentially fatal afflication for which the only cure is delivery of the baby. Yikes. For the first time, I was worried, even though she did not appear to be. She said she did not think I was preeclamptic; that elevated blood pressure was just one symptom and I had no others. I was swollen but not more than most pregnant women in the last weeks. Still, we agreed to monitor this closely.

The next day, I felt a bit more swollen, so instead of trekking a few miles to my midwife's office, I thought I'd go to the medical practice right next door to my office. In my naivete I thought I could simply call up and ask to have my BP taken. Which I did. And they all but laughed. Who is your primary care doctor, they asked. My primary care doctor had left the state some time ago and I never bothered to find a new one. (There is a shortage in Massachusetts, by the way, and long waiting lists.) Anyway, I was outraged that no doctor or nurse would take my BP, even though I had insurance and saw doctors in that practice.

I quit working that day and followed the midwife's advice to consume as close to 120 grams of protein per day as possible. Not easy to do. I tried to pack in the protein by drinking Kashi protein shakes, eating lots of eggs. It was gross.

A couple days later I felt a bit more swollen and wanted to check my blood pressure again. Although my midwife's office was not far away -- just a few miles -- it was more convenient to go to the medical practice office where my kids go for their pediatrician visits and where I had been seeing a certified nurse midwife for my primary screens and GYN appointments long before I was pregnant. I had not seen an OB in about 4 years, since my first son was born. So, I waddled into the office and asked if I could have my blood pressure checked.

"Do you have an appointment?"

"No," I said, giving her the name of provider I last saw there.

"Why do you want your blood pressure checked?"

I told her it was elevated.

She told me to take seat.

Then someone whom I think was a nurse called me in and asked with big huge eyes and hushed tones what was wrong. I repeated the situation again. She looked very concerned. She asked me what hospital I was delivering at. I stuttered. I said I just wanted my blood pressure checked. She asked me who my OB was. I felt like I was about to be grounded. For some reason I panicked and gave her the name of my last OB. I thought I would get kicked to the curb if I told her straight. Anyway, it was no surprise that when she took my blood pressure it was 140/80. The. Stress. Of. Going. To. That. Office. Was. Awful. She told me to get to the OB immediately.

I left really upset and called my midwife. She told me to go home and rest and offered to come to me to take my BP. It seemed like a silly thing for her to have to do, given that I had closer options.

I demurred, went home and had a protein shake. The next day, I was feeling stubborn. I figured I would go to the local health clinic around the corner from my house, a clinic where people without health insurance go. I knew they would gladly take my health insurance and co-payment and take my blood pressure. They did. It was a few points lower. I skipped the blood tests, went home, and had more protein. I talked my midwife, who reassured me that all was well.

Again she said she would come to me. But I figured I could wait until my next appoinment with her a few days out. At least I hoped I could. In the meantime, I fumed about the health care system.

Thanks

2008-02-10T16:16:00.001-08:00

Can I just say that I am grateful for all of the amazing posts I've been getting from this blog's readers. Intelligent. Witty. Insightful. That includes you, mom. You are all keeping me going.

Pushing back

2008-02-09T18:49:00.000-08:00

In response to the ACOG statement on homebirth, The Big Push for Midwives Campaign issued the following press release, quite well done. If you aren't familiar with the Big Push, check out the link below.

PushNews from The Big Push for Midwives Campaign
CONTACT: Steff Hedenkamp, (816) 506-4630, RedQuill@kc.rr.com
FOR IMMEDIATE RELEASE: Thursday, February 7, 2008

ACOG: Out of Touch with Needs of Childbearing Families

Trade Union claims out-of-hospital birth is “trendy;” tries to play the “bad mother” card

(February 7, 2008) — The American College of Obstetricians and Gynecologists (ACOG), a trade union representing the financial and professional interests of obstetricians, has issued the latest in a series of statements condemning families who choose home birth and calling on policy makers to deny them access to Certified Professional Midwives. CPMs are trained as experts in out-of-hospital delivery and as specialists in risk assessment and preventative care.

“It will certainly come as news to the Amish and other groups in this country who have long chosen home birth that they’re simply being ‘trendy’ or ‘fashionable,’” said Katie Prown, PhD, Campaign Manager of The Big Push for Midwives 2008. “The fact is, families deliver their babies at home for a variety of very valid reasons, either because they’re exercising their religious freedom, following their cultural traditions or because of financial need. These families deserve access to safe, quality and affordable maternity care, just like everyone else.”

Besides referring to home birth as a fashionable “trend” and a “cause célèbre” that families choose out of ignorance, ACOG’s latest statement adds insult to injury by claiming that women delivering outside of the hospital are bad mothers who value the childbirth “experience” over the safety of their babies.

“ACOG has it backwards,” said Steff Hedenkamp, Communications Coordinator of The Big Push and the mother of two children born at home. “I delivered my babies with a trained, skilled professional midwife because I wanted the safest out-of-hospital care possible. If every state were to follow ACOG’s recommendations and outlaw CPMs, families who choose home birth will be left with no care providers at all. I think we can all agree that this is an irresponsible policy that puts mothers and babies at risk.”

The Big Push for Midwives calls on ACOG to abandon these outdated policies and work with CPMs to reduce the cesarean rate and to take meaningful steps towards reducing racial and ethnic disparities in birth outcomes in all regions of the United States. CPMs play a critical role in both cesarean prevention and in the reduction of low-birth weight and pre-term births, the two most preventable causes of neonatal mortality.

Moreover, their training as specialists in out-of-hospital maternity care qualifies CPMs as essential first-responders during disasters in which hospitals become inaccessible or unsafe for laboring mothers. In addition, CPMs work to ensure that all babies born outside of the hospital undergo state-mandated newborn screenings and are provided with legal and secure birth certificates.

Currently, Certified Nurse-Midwives, who work predominantly in hospital settings, are licensed and regulated in all 50 states, while Certified Professional Midwives, who work in out-of-hospital settings, are licensed and regulated in 24 states, with legislation pending in an additional 20 states.

The Big Push for Midwives (www.TheBigPushforMidwives.org) is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care.
Media inquiries should be directed to Steff Hedenkamp (816) 506-4630, RedQuill@kc.rr.com.

#####

Latest ACOG statement against home birth

2008-02-09T05:23:00.000-08:00

On Feb. 6 the American College of Obstetricians and Gynecologists issued the statement below on how the group is opposed to home birth. What is interesting to me is why they are issuing the statement now. A clue comes in the paragraph that begins: "Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre." Does this mean ACOG ackowledges that home birth is suddenly trendy? Did you all see the article in Vogue a couple months ago, a favorable essay by a New York City mom who gave birth at home? Perhaps the people at ACOG saw that and got worried... home birth was literally in Vogue...Then of course there is also the Ricki Lake documentary, "The Business of Being Born," which comes out this month on Netflix! I would be worried if I were ACOG, too, as the film makes a compelling case against The System.

The statement goes on to say: "Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades..." (SO WHY DOES THE RATE KEEP GOING UP, NOW EXCEEDING 30 PERCENT, WHEN THE WORLD HEALTH ORGANIZATION ESTIMATES THAT ANY RATE ABOVE 10-15 PERCENT IS DOING MORE HARM THAN GOOD?)..."Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice" (THIS IS A SMALL PERCENT BUT GROWING AS DOCTORS BOTH ALLOW AND ENCOURAGE SECTIONS FOR NO MEDICAL REASON; SCARE THE DAYLIGHTS OUT OF WOMEN WHO THEN THINK THEY MUST HAVE A SECTION; AND REFUSE TO ATTEND VBACS) "and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes." (SO BLAME THE MOM). Nowhere in this statement is there any mention of malpractice fears among OBs, how overly managed labor is resulting in countless iatrogenic problems, leading to even more sections, etc.

Finally, where ACOG questions studies about the safety of home birth (there have been many large-scale ones, recognized around the globe as being well done)it is important to note that in the UK, the government there is actually advocating for MORE home birth, precisely because it is safe and because they recognize that birth in the hospital will almost always end up being more complicated because it is made so by the people who work there. Period.

Anyway, here is the ACOG statement in full. Feel free to write a letter. The address is at the bottom.

Washington, DC -- The American College of Obstetricians and Gynecologists (ACOG) reiterates its long-standing opposition to home births. While childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.

ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births. Nor does ACOG support the provision of care by midwives who are not certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB).

Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby. Attempting a vaginal birth after cesarean (VBAC) at home is especially dangerous because if the uterus ruptures during labor, both the mother and baby face an emergency situation with potentially catastrophic consequences, including death. Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly if necessary, she puts herself and her baby's health and life at unnecessary risk.

Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades and ACOG remains committed to reducing it, but there is no scientific way to recommend an 'ideal' national cesarean rate as a target goal. In 2000, ACOG issued its Task Force Report Evaluation of Cesarean Delivery to assist physicians and institutions in assessing and reducing, if necessary, their cesarean delivery rates. Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes.

The availability of an obstetrician-gynecologist to provide expertise and intervention in an emergency during labor and/or delivery may be life-saving for the mother or newborn and lower the likelihood of a bad outcome. ACOG believes that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets the standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.

It should be emphasized that studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous. Moreover, lay or other midwives attending to home births are unable to perform live-saving emergency cesarean deliveries and other surgical and medical procedures that would best safeguard the mother and child.

ACOG encourages all pregnant women to get prenatal care and to make a birth plan. The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby. For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.

http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm

ACOG Office of Communications

202.484.3321
communications@acog.org

Our new baby, installment #20

2008-02-07T07:20:00.000-08:00

As I was pondering how to handle testing (or not) of Group B Strep, we began to set other plans in motion for a home VBAC, or HBAC. My primary focus was on setting up the birthing tub. Our midwife said her favorite (lucky) tub was one that was six feet around, which sounded enormous. I knew I wanted the tub for labor, but was unsure whether I wanted to actually give birth in it. I thought about the origins of water birth, how in some tropical climates women would have waded in the ocean during labor. I also saw how strongly my midwife encouraged the use of the tub.

We made arrangements with another family who had the tub on loan(that home birth went swimmingly)and were ready to pass it along. The dad dropped off the tub, which was broken down into a large box and several hockey bag-sized duffles. I nagged my husband for days to set it up, which he finally did, in the baby's room upstairs. And then we realized that in our ancient house, with 130-year-old original faucets, no modern hose would connect with them so we could fill the tub!

Eventually, we rigged a board and hose and used gravity to accomplish the job but my husband sat there for hours directing the water into the tub. We treated the water, ran the motor to heat the pool to a safe temperature and put a lid on it to make sure the 4-year-old didn't go for a dip when we weren't looking. I couldn't wait to get in the water, as even our deep clawfoot tub was no longer big enough for me to submerge my entire belly.

Our new baby, installment #19

2008-02-05T07:44:00.000-08:00

OK. So that was not so brief a pause after all. Whoo.
But I am moving on here, perhaps to even more controversial territory in this serialized tale about a journey back to the future, with a home VBAC.

One of the bigger questions I was facing was: What to do about having a Strep B test? Did I need it? Did I want it? Is it necessary? What were the homeopathic options and were they effective?

I knew that testing positive for Strep B COULD prove fatal to a newborn, which might pick up the bacteria on its way down the birth canal.

These were some of the homeopathtic options up for consideration -- things one might do prophylactically, in place of being tested.

ORALLY:
500-1000 mg Vitamin C with bioflavinoids, twice per day.
Vitamin C is water soluble and extra is excreted by the kidneys.

Eat cranberries and garlic daily; or take cranberry capsules and garlic pearls three times per day.

Plenty of live culture yogurt; or Acidophilus capsules daily.

Bee propolus; or tincture.

Echinacea is very Strep specific, according to one source. As a preventative, use 10-15 drops of tincture in a glass of water twice a day for a minimum of five days. [As a curative, use two cups of E. infusion daily for five days followed by one cup daily for another five days. Continue for a full ten days. If only the tincture is available, use 1 drop per two pound of body weight. (ie.. 150 pound Mama = 75 drops.) Repeat the dose three to four times a day until fever abates, then two times a day for an additional week.]

Estragalus tincture ½ tsp or one dropper full 2 times a day. Can use equal parts with Echinacea tincture.

Note: Tinctures can be purchased in either a glycerine or alcohol base. Might have to special order glycerine based tinctures.

VAGINAL RINSES FOR GROUP B BETA STREP:
Do not douche in pregnancy. Rinse. Go easy. Separate labia and spray externally. Rinse anal area also. Remember to treat your partner.

1. Thyme, Rosemary, Calendula, Yarrow: Mix equal parts of herbs in a bowl.
Take 6 tablespoons of mixture and add 1 quart of boiling water. Infuse in covered
container 4 hours. Strain into a clean jar. Discard herbs.
Use 1 ½-2 cups per time as a rinse.
Optional: Add ¼ cup sea salt, 10 drops of lavender oil, 1 oz Echinacea tincture.

2. Echinacea infusion.

3. After 37 weeks, use Golden Seal gel capsules, deep in the vagina, if possible up
behind the cervix (not in cervix). Can cause uterine contractions.You can use these infusions for Sitz baths too.

4. Some practitioners recommend a very dilute solution of Hibiclens (an over-the-counter product which has in it an antimicrobial skin cleaner), Hydrogen Peroxide (food grade), or a very dilute solution of bleach: one teaspoon in a quart of water as a genital area rinse.

VAGINAL SUPPOSITORY RECIPE:
Place 1 cup Echinacea agustifolia root, cut; 1 cup Usnea lichen, cut; and 1 cup Calendula flowers in a quart jar.
Melt 8 oz. cocoa butter with 16 oz. coconut oil; pour over herbs.
Heat-infuse by placing the covered jar in a crockpot; add water to immerse the jar three-quarters of the way; set on low and cook 12-24 hours. Cool and strain.
To 1 cup of the infused oil add 1 tablespoon of these herbs: Slippery Elm Bark, Comfry Root, and Marshmallow Root.
Add 20 drops of these essential oils: Lavender, Rosemary and Tea Tree.
Chill slightly in an ice cube tray. When blocks are solid, cut them into quarters.
Insert one small cube into vagina before bed.

MISCELLANOUS CONSIDERATIONS:
Use cotton underpants.
Use vinegar or baking soda in the rinse cycle of washing machine when washing your
underpants.
Change your underpants (or panty liner) if damp. Best to go without - to air out!
Use warm water wash from squeeze bottle after pooping, then pat yourself dry.
Beta strep can be more prevalent in conjunction with urinary track infection. Urine should be checked for B-strep in this case.
Yeast infection conditions can give rise to increased Beta strep population.

So...what to do? Sit in a bucket of bleach????

Repeated VBACs are safe; repeated cesareans are not

2008-02-02T17:13:00.000-08:00

I am taking a brief brake from my serialized birth story to report on a study out of Case Western that just came out in Obstetrics & Gynecology (2008;111:285-291).

The study's OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.

RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.

Contrast that study with another from Obstetrics & Gynecology (2006;107:1226-1232) which found that there is maternal morbidity associated with multiple repeat cesareans.

OBJECTIVE: To estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002).

RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Thanks to Carol Sakala at the Childbirth Connection for sending me those...

Our new baby, installment #18

2008-01-31T19:13:00.000-08:00

Having written a book, read every book, seen every video (except for the dolphin one), it was time to start making some hard decisions about our plan for a home birth. First, did we want a waterbirth? If so, which rental pool should we use? The midwife had a few to offer. She recommended the "lucky" one six feet around and said it should be set up at least a week before I went into labor. But gee, when would that be? Where was I going to put something that big? How would I keep the boys out of it in the meantime? And my mother, always on the lookout for catastrophe, wanted to know if the pool that size filled with water would crash through the floor of our 140-year-old house.

Second, what to do about Strep B, that nasty bacteria that sends OBs running for antibiotics? I had tested negative for that the first time around. Did I need another test? And if I tested positive this time, would it throw the whole plan a curveball?

Little did I know it, but all of these decisions were making my blood pressure rise. Little. By. Little.

Our new baby, installment #17

2008-01-30T19:12:00.000-08:00

In addition to the copy of Optimal Foetal Position, our home birth midwife each week would send us home from our appointment with something else to read or watch. On one ocassion, it was a vintage VHS of a film called "Birth in the Squatting Position," which was only about 10 minutes long but showed the crowning and births of a handful of babies in stark anatomical fasion. The only sound one hears in addition to the background music is the narrator in his English accent sounding like the host of Wild Kingdom's World of Animals as he explains in awe that women actually give birth squatting -- and smile as they do it! It took many weeks for my husband to bring himself to watch the film, which left him sort of speechless. It left me sort of speechless, too. One of the births shows a baby whose head molded so incredibly that it looked more like a summer squash than a human!

Our new baby, installment #16

2008-01-29T18:17:00.000-08:00

During one of our regular visits with a home birth midwife, we talked about my first birth (in the hospital, back labor, epidural, hours of pushing, cesarean, yadda, yadda, later to learn that the baby was posterior, or facing the wrong way, face up, as he tried to make his exit.) Recently, I told the midwife, I had heard a statistic that some 30 percent of all first births involve a posterior baby.

"Why is that?" I asked.

The answer seems to be a bit of a mystery but one thing is for sure: Posterior babies in general are becoming increasingly common. Perhaps that is because of our sedentary lifestyle, sitting at desks all day using poor posture, driving home in a car with bucket seats and then lounging on the couch at night...the baby settles into the mother's body as if it were laying in a hammock, its back curved against the slouch of the mother's spine, she explained.

Alarmed, I sat up as the midwife reached over to her shelf and handed me an older book called Optimal Foetal Positioning (I don't even think the book is in print anymore, but please correct me if I am wrong), written by a midwife and a childbirth educator, one of whom had been trained in engineering. They explain that if the mother sits forward and upright, the baby is nudged out of the hammock and will assume the proper position. I devoured the book and began to keep better posture immediately.

Of course it is tricky for a very pregnant woman to sit forward because the belly gets in the way. So I made it a habit of sitting in a very unladylike fashion, legs spread, belly pushed forward, sitting on the edge of my seat. I was pretty sure the technique was working, if for no other reason than I did not feel the same sort of back pain toward the end of my pregnancy that I had felt the first time.

The solution seemed so easy and so low-tech. If every pregnant woman in America could read this book, would the c-section rate still be more than 30 percent?

In the end, I wondered, would the book save me from having another posterior baby?

Our new baby, installment #15

2008-01-28T15:44:00.000-08:00

Continuing the drama about my decision to attempt a home VBAC, also known as an HBAC, or home birth after cesarean, I had disinvited my parents from being at the house while I was in labor. This decision was despite my mother having met the midwives over dinner at our home, despite my mother having read my book, despite how strongly she knew how I felt. She just could not change her position. She could not change who she was. And that was fine. We agreed to disagree. Of course, she was not the only one in the family who thought I was nuts. My grandmother, whom I adore, accused me of "going backwards." This, despite that Gram had her three children in the hospital under the spell of Twilight Sleep, a mix of morphine and the amnesiac scopalamine. Thus, she does not remember giving birth except for the fact that "it hurt" and the nurses told her to "shut up." My aunt, who is only 13 years older than me and has always been the "cool" one in the family and saw a midwife (in the hospital) for her oldest child's birth, sort of understood where I was coming from in deciding to stay home. But she kept calling and asking what my backup plan was. In a nice way. There were a couple of surprising supporters. My sister-in-law, who had had a cecearean a few months before, was very supportive, saying I was better educated than anyone in the family on the subject and therefore I would be OK. And my grandfather, who is well into his 80s, was quietly approving, perhaps in his old fashioned way appreciating that women have been doing this forever.

But the remark about me going backwards is one that I keep thinking about. Was shunning the hospital and its malpractice fears, its MRSA infections, its aggressive obstetrics, its lack of support for VBAC, really going backwards? Or was it the most progressive thing I could do? Should the new post-modern reality be all about less is more, whether we are talking about calories, house size, miles driven or medical interventions?

What do you think? Was I going backwards?

Our new baby, installment #14

2008-01-25T19:05:00.000-08:00

As I was saying in my previous post, it is a statistical fact that the majority of women around the world tend to labor through the night. (For nocturnal creatures, the opposite is true.) Why? Well, some scientists posit that laboring at night is the result of evolutionary biology. Going back to early human times (and as is the case with the majority of other mammals) we want to give birth safely surrounded by those we trust - our tribe, clan, family etc. During the day, the men would have been off hunting woolly mammoth and the other women far flung gathering nuts and berries. At night, everyone would have been around to protect the space from predators.

I wondered whether I would fall into that pattern with this birth. Of course, I hoped I would because my mother, whether she remembers it or not, was disinvited from coming to the house to take care of our other two boys during labor. And having an active four-year-old and an 11-year-old who did not really want to see or hear any of this birth, we were worried how it would work out.

Our new baby, installment #13

2008-01-24T08:08:00.000-08:00

After the home birth midwife and my husband and I discussed the logistics of who would watch the kids when I went into labor (like, on a Saturday afternoon)I called my parents.

"Do you want to be there?"

"Of course," they said. "We would love to."

"Can you check your nervousness and negativity at the door?" I asked.

"Yes," they both said.

So I went and reported this back to my husband and the midwife, who both looked at me skeptically.

Then, a few weeks later, having Sunday dinner with my parents, we discussed this plan some more.

"Well, just tell me what to do if you say you want an epidural," mom said, knowing that such pain relief would require transfer to the hospital.

That was the deal breaker. It was clear that the default setting in her brain was THIS WILL BE UGLY AND MY ROLE IS PROTECTOR.

I called mom later to tell her she and dad were off the hook. We now had no plan B for childcare.

Mom admitted to being relieved. I guess I was too.

There was one phenomenon working in my favor, however. It is a statistical fact that the majority of women tend to labor through the night. (For nocturnal creatures, the opposite is true.) In my next post I will explain why.

Our new baby, installment #12

2008-01-22T04:45:00.000-08:00

Continuing the story of our experience with a home birth midwife, at one of our visits we discussed the logistics of what would happen when I went into labor -- who would watch the other two boys, a four-year-old and my 11-year-old stepson. We have many nice neighbors with kids of their own, and we could probably ask them for a favor. But still, I felt as if the right person for the job was my own mother. She's a very attentive grandmother. The boys adore her. But she is a terrible Nervous Nelly. Could she deal with being in the house when I was in labor? With my first son, I vowed I would not call her until after the baby was born, to save her the fret. (I crumbled, and called her on the way to the hospital.) She did, however, keep it together when she saw me wheeled out of the operating room, post-unwanted c-section. I was devasted and exhausted. She was nothing but supportive. Still, she and I were not on the same page this time. She was horrified by the idea of a home birth. It was time for a heart-to-heart with her.