For them I could

Sometimes I feel like it's inevitable. I'll probably end up a midwife, in the end. But most of the time I don't really look forward to it. It terrifies me to imagine holding the lives of women and babies in my fallible human hands. I don't really want to be a midwife. But I've been thinking lately of some facts and figures that just might be enough to propel me forward on the path toward midwifery.

First, my cousin-in-law, Liz, wrote a blogpost discussing the book Half the Sky. She shared a couple of excerpts that have been reverberating through my skull ever since:

In much of the world, women die because they aren't thought to matter. There's a strong correlation between countries where women are marginalized and countries with high maternal mortality. Indeed, in the United States, maternal mortality remained very high throughout the nineteenth century and beginning of the twentieth century, even as incomes rose and access to doctors increased. During World War I, more American women died in childbirth than American men died in war.... 'Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.' (p. 115-116)

"More women die in childbirth in a few days than terrorism kills people in a year." (Jane Roberts, letter to San Bernadino Sun, qtd. on p. 146)

Then, last night, my brother-in-law watched a PBS segment on maternity care in rural Peru. He thought I'd be interested, so he passed along the link to me. Last year, CNN reported that Peru's pregnant women were "dying at scandalous rates"(source). Yesterday, PBS shared some of the solutions that are being implemented to reduce the mortality rates in Peru's remote areas. The segment starts with this intro:

High in the Andean Mountains of Peru, far from the modern conveniences of a city, generations of indigenous women have given birth at home, their only help from family or a village midwife.

The longstanding tradition of childbirth at home wasn't a problem for most women. But, in that small percentage of cases where complications developed at the end of a pregnancy, in a remote rural area, you could be days away from the nearest medical facility on foot, even multiple-hours' drive.

(Screenshot from the PBS segment)

I've been studying childbirth for the past seven years, but most of my reading and research has revolved around maternity care in the U.S. Although we still have a long way to go here in the U.S., our risk of dying in childbirth is far lower than the risk most women of the world face. I think I could feel content remaining a doula/birth activist if the rest of the world didn't exist. But it does exist.

The World Health Organization puts things into persective:

Every minute, at least one woman dies from complications related to pregnancy or childbirth – that means 529 000 women a year. In addition, for every woman who dies in childbirth, around 20 more suffer injury, infection or disease – approximately 10 million women each year.(Source)

Far too many women die simply because they lack "skilled care during pregnancy, childbirth and the first month after delivery," according to WHO.

While I don't feel compelled to become a midwife for my fellow American sisters, I do think I'd be willing to shoulder the risks inherent in midwifery in order to help save the lives of women in places where maternal deaths are excessively common. For them I could do it.

Unfortunately, those who are able to help these women often lack the ability to communicate in indigenous languages. I have a deep love for languages and have always wanted to learn to speak more of them. I've also always wanted to travel to Africa, South America, and other far-off places. I couldn't think of a better reason to fulfill those dreams. Someday down the road... I hope.

Thank you, ABC News

For raising awareness about the many problems with our maternity care system in this country and the rising maternal death rate.

Now let's change things.

In praise of good birth attendants

I brought these mini rose bushes, thank you cards, and copies of my birth slideshow to my midwives today. It was my 10 week postpartum appointment. I was thrilled to see their new, gorgeous, and much larger office. Their practice is growing, and that makes me so happy.

This is the first time I've ever wanted to give a thank you gift to my birth attendant. And I'm feeling even more grateful today than I was a few weeks ago. Some scary complications following my sister-in-law's home birth have shaken me up over the last couple of weeks. And they have shown me more clearly than ever how valuable an experienced midwife is. I love midwives. I think more women should be attended by midwives. I think we need more midwives in this world. But I now know that I will never feel comfortable putting my or my future babies' lives in the hands of just any midwife.

I sat and talked with Mary today at my appointment. She held and admired my beautiful Bubby, of course. And we chatted for a bit about my birth and my sister-in-law's birth. Every midwife is so different. Not all midwives will handle a situation the same way. But I think one of the reasons Mary's outcomes have been so consistently good is that she can sense when something is going to happen... before it happens. She told me that most midwives develop that ability after they've practiced for more than 15 years. Mary's been a midwife for over 30 years, so her sense is especially in tune. And I'm so grateful for her gift. Because it kept my Bubby safe when she sensed he needed to be born quickly. I also think her years of experience have exposed her to nearly every possible complication, so she has witnessed and learned the best ways to handle those problems.

I had a really hard time keeping my "birth faith" during and immediately after my sister-in-law's brush with catastrophe. I even contemplated quitting this blog altogether. But then I cooled down and got my head in order and realized that her experience didn't change what I already knew deep down. The birth process was beautifully designed, but that doesn't mean complications don't ever happen. No one ever said bad things don't happen in home births. What we do know is that home birth is just as safe for low-risk women as hospital birth, but there is always the "with a skilled attendant" to qualify that safety. Midwives have varying degrees of experience, skills, and credentials. So what exactly qualifies someone as a "skilled attendant"? I'm not really sure what the answer to that is. But I am grateful and fortunate that I chose Mary--without a doubt one of the most skilled attendants there is.

Fortunately, my sister-in-law is doing much better now. Thank heaven for doctors and hospitals when we need them! No doubt about it... we are so fortunate to have modern medical intervention at our service when we need it. And, fortunately, my sister-in-law's birth experience itself was wonderful and beautiful. In fact, to this day she can't remember feeling any labor pain. Now that's incredible! I guess I need to look into that hypnobirthing stuff!

Birth Faith

This pregnancy has tested my faith in so many ways. But my deepest fear has definitely tested it most of all.

At our doula training two weekends ago, we did an introspective exercise. We were all given a piece of paper and a marker. Then we took the marker into our non-dominant hand and drew or wrote something to represent our deepest fear about our actual or hypothetical upcoming birth. For me it was very actual... very real. It was a limp and lifeless baby with his arms and legs hanging down below him. A dead baby.

I have never needed to face that fear before. I never worried that my daughters or I would die in childbirth. I worried about other things... logistics... would the staff pressure me to have interventions I didn't want? Would I be able to handle the contractions? Would I tear? I never asked, "Will my baby die?" This is the first time I've asked myself that question. And what a heavy question!

Of course my daughters could have died... even in the hospital. Babies sometimes die. I suppose the difference now is that I don't have the other logistical worries to occupy my mind. I know there will be no unnecessary interventions. I know I will be surrounded by support. I know I can handle the contractions. But I also know that, if something bad happens, those who have questioned our home birth will shake their heads and point their fingers at ME. No one would ever think to point their finger at a mother whose baby died in the hospital... even if it was her own ignorance of the risks of interventions or poor choice in doctor that led to the death. It would be absolutely unheard-of to blame the mother. Home birth mothers don't get that kind of courtesy... even when their babies' deaths have nothing to do with their birth location and would have died in the hospital anyway.

So I do think about it. And I know I wouldn't be able to handle facing that deepest fear in real life... without my faith. When that fear starts wrapping itself around my heart, it is my faith (and my husband's even stronger faith) that slowly eases the panic.

As we did the fear-facing exercise at our doula training, we went on to contain our fears with the internal and external forces/influences that would be at our disposal. I contained that frightening image with my husband, my midwives, preparation, and God. I suppose you could say, I contained that fear with my faith in them.

I had a really reassuring chat with my midwives this morning at my appointment. It was reassuring that they can't even remember the last time they had to transport a woman who'd given birth before (to the hospital). And their confidence that they could get to my house in 20 minutes put my "what if the baby comes too quickly?" fears to rest. They've never lost a mother or baby. They have seen it all when it comes to birth... over and over again (Mary, for 30 years!). And they're not afraid. So why am I?

My husband, who was always afraid of home birth in the past, has no doubt in his mind that everything is going to be fine. He isn't the least bit worried. At all. No matter how many times I ask him, in my weakness, "Our baby's not going to die, right?" He always responds with the same steadfast assurance and peace, "No. Everything is going to be fine." He has total faith in our path. So why can't I?

More importantly... God has never let me down. I have no reason not to trust Him. He guided us to this particular path and urged us not to fear. So why do I?

I suppose it wouldn't be called a "test of faith" if it wasn't hard. :-)

Sometimes I like to imagine that moment when my son emerges and I take his slippery little body into my arms... you know, that moment that always makes me cry in birth videos... I like to imagine hearing him take his first breath and use his lungs and vocal chords for the first time. And I imagine the overwhelming relief that will wash over me with each breath, each sound, each vigorous movement of his arms and legs... he is alive! That imaginary instant may be just in my mind, but it feels so real every time it presents itself. So real, in fact, that I think I just might have enough faith to believe I'll see that moment happen.

Meet my midwives

Today was my first check-up with my new midwives, Mary and Nedra. I'm just loving these ladies, and loving that I get to have two birth attendents for the price of one! Not only are they personable, fun, and great with my kids, but they are also excellent midwives. I think you'd be hard-pressed to find any doctor or midwife with stats as impressive as theirs.

Mary, the senior of the two, has been practicing as a midwife for over 28 years. She graduated from the Arizona School of Midwifery in 1980 and has attended over 2000 births. Nedra has been attending birthing women for about nine years as a doula and apprentice midwife and received her midwifery license in March. Now check these numbers out:

C-section rate 1-3%
Hospital transfer rate 2% (for women like me who've given birth before)
Perineal tears "almost never" (maybe once a year they have a woman who needs stitches, approx 1.5%)
Infant deaths None (excluding those with defects incompatible with life)
Maternal deaths None

Can you believe those numbers?! Pretty incredible. The only bad outcome these midwives have ever seen occurred not because of a mistake on their part but simply because the parents refused to transfer to the hospital until it was too late (as a result, their baby's health was compromised). Since that time, Mary and Nedra have adopted a policy to only accept clients who agree ahead of time in writing that they will transfer if it becomes necessary. And I happily signed that agreement!

You might remember this post explaining the extremely painful tearing I sustained when my first daughter was born. When Mary told me how anal retentive they are about preventing tears and that they "almost never" have a client who needs stitches, I think I heard the heavenly choruses singing "Hallelujah!" I am determined that I will give birth to my baby boy without tearing, and it's such a relief to know that my midwives will be doing everything they can to facilitate that goal!

I also love how kid-friendly their office is. They have the coolest wooden toys and puzzles (some with babies inside mommys' tummies), and they have given both of my girls a balloon at each visit. Here they are at our visit today...I love that "midwife" is a regular word in my girls' vocabulary and that it is easy for me to include them in the pregnancy process because of the efforts my midwives make to welcome young children into their office. I love that they get to hear the baby's heartbeat regularly and are already comfortable with Mary and Nedra. So, when their little brother is born, there won't be any strangers coming into our home. Just two women they will already know and love.

I am so thrilled to have chosen Mary and Nedra as my midwives. I know my baby and I are in the hands of remarkable women.

Some Birth Research Headlines

Courtesy of the Lamaze Institute for Normal Birth Research Summaries:

Prenatal Diagnosis of Suspected Fetal Macrosomia Increases Risks of Cesarean Section and Maternal Morbidity without Improving Newborn Outcomes

Sadeh-Mestechkin, D., Walfisch, A., Shachar, R., Shoham-Vardi, I., Vardi, H., & Hallak, M. (2008). Suspected macrosomia? Better not tell. Archives of Gynecology and Obstetrics, doi: 10.1007/s00404-008-0566-y.

"An initial suspicion that the baby is large may instill fear in the pregnant woman which may impede both her confidence in her body and her labor progress. Slow labor progress reinforces the suspicion that the baby is big and more aggressive management ensues. This management often hinders the woman's ability to move freely and assume the positions that may help her baby negotiate through her pelvis, further slowing progress and reinforcing the perceived need for surgical intervention. Based on this study and previous evidence, women should strongly consider refusing tests late in pregnancy intended to estimate fetal weight.

"The estimate itself may be bad for her health because the care provider's expectation that the baby will be macrosomic appears to increase both unnecessary medical intervention and the morbidity that may accompany it" (exerpt from the Lamaze Research Summary).

Women Having Spontaneous Vaginal Birth Without Episiotomy Least Likely to Experience Postpartum Pain

Declercq, E., Cunningham, D. K., Johnson, C., & Sakala, C. (2008). Mothers' reports of postpartum pain associated with vaginal and cesarean deliveries: Results of a national survey. Birth, 35(1), 16-24.

"One argument made for elective cesarean surgery is that it avoids the pain of labor. Its proponents also allege that surgery occurring before labor offers advantages over intrapartum surgery. This study, however, finds that women having cesarean surgery are more likely to experience pain that interferes with routine activities and to experience long-term pain than women birthing vaginally and that timing of the surgery makes no difference.

"Women considering elective surgery to avoid labor pain should be advised that while labor pain can be controlled, cesarean surgery substantially increases their risk of experiencing many months of pain postpartum or pain that affects their quality of life. Instrumental vaginal delivery likewise increases the probability of experiencing perineal pain in both the short and long term compared with spontaneous vaginal birth" (exerpt from the Lamaze Research Summary).

Prenatal Yoga May Result in Less Labor Pain, Shorter Labor

Chuntharapat, S., Petpichetchian, W., & Hatthakit, U. (2008). Yoga during pregnancy: Effects on maternal comfort, labor pain and birth outcomes. Complementary Therapies in Clinical Practice, 14(2), 105-115.

"This study provides evidence that regular yoga practice in the last 10-12 weeks of pregnancy improves maternal comfort in labor and may facilitate labor progress. The researchers offer several theories for these effects. First, yoga involves synchronization of breathing awareness and muscle relaxation which decrease tension and the perception of pain. Second, yoga movements, breathing, and chanting may increase circulating endorphins and serotonin, "raising the threshold of mind-body relationship to pain" (p. 112). Third, practicing yoga postures over time alters pain pathways through the parasympathetic nervous system, decreasing one's need to actively respond to unpleasant physical sensations.

"Prenatal strategies that help women prepare emotionally and physically for labor may help reduce pain and suffering and optimize wellbeing in childbirth by providing coping skills and increasing self-confidence and a sense of mastery. More research is needed to confirm the findings of this study. However, yoga's many health benefits and the lack of evidence that yoga is harmful in pregnancy or birth provide justification for encouraging interested women to incorporate yoga into their preparations for childbirth" (exerpt from the Lamaze Research Summary).

Love this!

I love this excellent parody/response to the ACOG anti-homebirth press release posted by Tienchinho on the MotheringDotCommune Forum. Here are my favorite excerpts:

"As a home birth after cesarean mom (HBACM), I reiterate my support of home births. While complications can arise with little or no warning even among women with low-risk pregnancies, childbirth is a normal physiologic process that most women experience without problems. Continuous monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center has not improved maternal or fetal outcomes."

"Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by hospital birth advocates, a highly medicalized labor and delivery can physically and emotionally scar both the mother and baby. . . . Unless a woman is in a supportive birth environment that allows the birth process to unfold on its own schedule, she puts herself and her baby's health and life at unnecessary risk."

"It should be emphasized that childbirth comes with inherent risks. Implying any guarantee otherwise is misleading and unjust to a birthing mother and her family. Although able to perform live-saving [sic] emergency cesarean deliveries and other surgical and medical procedures, board-certified obstetricians have been cornered into practice styles that perpetuate the need for these same measures. They have lost skills such as detecting and adjusting a baby in the occiput posterior position. Untreated, this condition can result in prolonged labors mislabeled as 'dystocia' and in cesarean sections. They minimize the profound impact of a woman’s birth experience on her future relationship with her children as well as her own view of herself. Since suicide and substance abuse are leading causes of maternal mortality, disregard for a mother’s emotional health can lead to tragic consequences for her and her baby."

Click here to check it out!

Obstetric trade union threatened by homebirth

[An opinion piece I recently sent to a local newspaper]

With Ricki Lake’s new film, “The Business of Being Born,” giving homebirth a high-profile legitimacy, the American College of Obstetricians and Gynecologists had to do something. As if their monopoly on maternity care in the U.S. wasn’t extensive enough, they felt a need to, once again, stake out their turf. On February 6, the ACOG issued a press release outlining their strong opposition to homebirth. They claim to be concerned for the well being of women and infants. Given the state of maternity care in this country, I find the ACOG’s supposed concern highly questionable.

The ACOG press release criticized mothers who choose homebirth for placing “the process of giving birth over the goal of having a healthy baby.” Women choosing homebirth are often accused in this way. How could they put their own comfort before the health of their baby? The problem with that accusation is that it should really be turned the other way. How can obstetricians put their comfort before the health of the baby?

Many prevalent hospital birth interventions including labor induction for non-medical reasons, elective cesarean section, continuous electronic fetal monitoring, routine use of IVs, early amniotomy (artificial breaking of water), episiotomy, and withholding of food and liquids have not been shown to improve outcomes and, in many cases, lead to other harmful complications for both infants and mothers (click here for more info). These interventions are warranted in rare cases, but they are being used excessively. When many of the most common birth interventions used by obstetricians in hospitals cause unnecessary harm, it is hard to believe that the ACOG’s concern for the well being of mothers and infants is at all genuine. Interestingly enough, most of these interventions reduce the amount of time doctors must spend attending a laboring mother and protect them from possible malpractice lawsuits. It is obstetricians that are putting babies and mothers at unnecessary risk for their own ease and comfort, not homebirth mothers.

The ACOG press release also erroneously claims that there are no scientifically rigorous studies demonstrating the safety of homebirth. There are, in fact, many reputable studies demonstrating that a midwife-attended homebirth is just as safe as a hospital birth for healthy women with normal pregnancies, and with much lower intervention and c-section rates. The most recent and largest of these studies was published in the British Medical Journal in 2005 (“Outcomes of planned home births with certified professional midwives: large prospective study in North America.” Kenneth C Johnson and Betty-Anne Daviss).

The United States is unique among developed nations in its obstetric-heavy maternity care system. The developed nations with the best birth outcomes, the lowest c-section rates, and the lowest rates of maternal and infant death have the majority of women attended by midwives and a significant portion of them giving birth at home. The United States trails behind 27 other developed countries in terms of maternal death and 35 other countries in terms of neonatal deaths.

Homebirth is not “trendy” as the ACOG would have you believe. Women have been giving birth in their homes for thousands of years. Being induced early or opting for an elective c-section are the truly dangerous trends. Women who choose homebirth do so after much research and soul-searching. They deserve our admiration and respect for their courageous choice to avoid the complications stemming from medical intervention and follow their birthing instincts. It is these informed women who will stem the tide of obstetric abuse. As Marsden Wagner, Director of Women’s and Children’s Health for the World Health Organization for 15 years, pointed out, “In every country where I have seen real progress in maternity care, it was women's groups working together with midwives that made the difference.”

Midwives and Emergency Preparedness

Deborah Smithey makes a great point in her article, "The need for certified midwives," when she argues that midwives are a great asset to any city's emergency preparedness plan. Pregnant women are at great risk during and following natural or man-made disasters. When hospitals may be over-flowing with sick and injured survivors and electricity may not be available, women who would otherwise have given birth at the hospital will have to seek alternatives. Smithey explains how midwives are prepared to handle just such circumstances:

"Certified Professional Midwives are trained to work in homes and other out-of-hospital settings. Many midwives serve the Amish and Mennonite communities, and are accustomed to working without electricity or other modern conveniences."

Having certified midwives accessible throughout each community ensures that all pregnant women have access to high quality care regardless of any disaster that may occur. Read her full article here.

And still rising...

Have you heard about the latest c-section data from the CDC? They just recently published the data from births in 2006. The c-section rate from last year is at a record high--31.1% of all births!

Eugene Declercq, Ph.D., Professor of Maternal and Child Health at Boston University School of Public Health highlights some concerns: “At a time when maternal and infant mortality rates are decreasing throughout the industrialized world, the United States is in the unique position of having both a rapidly increasing cesarean rate and no improvement in these basic measures of maternal and infant health.”

That's right. As cesarean section rates rise, so do maternal and infant deaths. Though it's no proof of a connection, it is a frightening snapshot of the state of maternity care in the U.S.

If you'd like more information about how to avoid a cesarean, how to have a vaginal birth after a cesarean, or need resources for recovering from a cesarean, check out the International Cesarean Awareness Network.

Childbirth Mortality Rate is Rising in the U.S.

"Valerie Scythes, a 35-year-old elementary school teacher, died in March at a hospital in New Jersey -- the state with the highest caesarean section rate. She had had a C-section, as did another teacher at the same school who died after giving birth at the same hospital two weeks later."

It's all over the news this weekend. See these links:
Experts: U.S. childbirth deaths on rise
Rate of death in childbirth rising in the U.S.
Rate of U.S. women dying in childbirth rising
US childbirth mortality rate increases

More and more women are dying! Do we really need any more evidence that maternity care in the U.S. needs an overhaul?! Raise an uproar, write a letter to the editor, spread the word, do whatever you can! Let's stop this madness!

Let's get angry and organized.

"We Americans are consumed with the need to believe that we are number one. But here's a wrenching fact: forty-one countries have better infant mortality rates than the United States does. In 2002, our infant mortality rate went up, not down, and if the United States had an infant mortality rate as good as Cuba's, we would save an additional 2,212 American babies a year. And mothers? Women are 70 percent more likely to die in childbirth in America than in Europe, and the rate of women dying in childbirth in America has been going up every year for more than twenty years. . . .

"Just as those who never make mistakes can never learn from them, so too those who must always be number one can never learn from others. . . .

"[S]omething happens in the countries at the bottom of the chart. It varies from country to country, but whatever it is, when things get really bad and women's reproductive freedom is abused severely enough, some precipitating factor or series of events finally brings women's attention to the power doctors hold over their reproductive lives. This leads to women's disillusionment, anger, and resentment and a call to action. . . .

"[Midwives] join with the angry women (often forming coalitions that also include scientists, journalists, some politicians, and some doctors and nurses) to start the long, difficult process of regaining women's autonomy in childbirth and reproduction, moving the country up . . . .

"It seems there is at least one thing more powerful than the medical establishment: women, when they are angry and get organized" (Marsden Wagner, Born in the USA, p. 212, 214-215).