Sunday, November 27, 2011

A lesson in being wary of health articles in the news

I recently read a news article about a new study on the safety of home birth. Later, I wanted to find the article again. All I remembered was that it was from the Huffington Post, so I navigated back to that site, and what did I see in the pregnancy section? I saw this unintentionally hilarious juxtaposition of articles:

They really are right next to each other like that. See for yourself here (at least until new stories push it off the front page).

One of these articles is about how home birth is basically safe. The other is about how it's really risky for first-time mothers.

The best part? Both articles are based on the exact same study - this one that was recently published in the British Journal of Medicine.

And it's not just that each article is highlighting a different aspect of the study. They each pull out different figures to talk about the risk to first-time mothers to make it sound more or less safe, according to the article's mission.

The pro-home birth article says: "... researchers found a higher risk for first-time mothers planning a home birth. Among those women, there were 9.3 adverse events per 1,000 births, including babies with brain damage due to labor problems and stillbirth. That compared to 5.3 adverse events per 1,000 births for those planning a hospital birth."

The second article, the one highlighting risk, says: "Serious adverse outcomes for the baby are rare - occurring just 3.5 times for every 1,000 babies whose birth was planned in an obstetric unit. But the research, carried out at Oxford University, shows this figure rises to 9.5 per 1,000 babies if the mother chooses a home birth."

These articles are actually using two different figures for the risk of adverse outcomes for babies born in a hospital! So what's the truth? Is a home birth, according to this study, less than twice as dangerous to the baby, or almost three times as dangerous? Because one article says one thing, and the other article says another.

Fortunately, the BMJ study is available online, so we can find out. First of all, a summary website for the study uses the 5.3 vs. 9.5 per 1000 figure. Doing a quick skim and a text search of the article itself, I couldn't even find that 3.5 adverse outcomes per 1000 births figure, but I did find a statement that the study overall had 4.3 adverse outcomes per 1000 births. That number includes both first-time mothers and mothers who have had children before. Knowing that, I'm guessing that the 3.5 per 1000 figure must be multiparas (women who have had at least one child before).

Thus, it seems clear that the second article cherry-picked its numbers, and compares multiparas giving birth in the hospital to nulliparas giving birth at home in order to make the risk sound greater than it is. On the other hand, the first article definitely downplays the risk and glosses over it.

This highlights the importance of always being wary when we read health news in popular media. Authors often misinterpret, misrepresent, and misconstrue the data, and almost everyone has some bias toward one side or the other. This may be deliberate, unconscious, or accidental, but it's still very common.

Sorry for the funky formatting in this post. I messed it up and can't figure out how to fix it.

Friday, October 7, 2011

First birth

Well, I went to my very first birth recently. Up until a few days ago, I'd never so much as been around a woman in labor (except for when I was inside one, as the baby).

I'm still processing it, but I'll say one thing: I wish it had occurred to me to look up some YouTube videos of transition, and not just "Jason's peaceful waterbirth!" Because, whoa, I was not prepared for that. (I know that women often freak out during transition, but I clearly did not realize what level of panic was possible. I also didn't have enough experience to be confident that it was transition, and if it wasn't even transition yet, yikes...)

P.S. I was an apprentice doula, mostly just being an assistant to a very experienced doula and observing.

Thursday, August 11, 2011

Quickie book reviews

The Birth Partner by Penny Simkin:

  • Lots of very practical information for helping a woman in labor. For example, I'd heard of doulas doing "take charge routines," but I didn't completely understand what it was until I read the description in this book. Lots of great tips on positioning and many ways to support a woman in labor.
  • I felt like this book was aimed mainly at birth partners like dads, co-parents, friends who would be at the birth, etc. It's not just for doulas. It's very accessible to someone who just wants to help their wife/friend/partner give birth.
  • Talks about pregnancy discomforts and how labor and birth go so you can be informed as a birth partner. It's quite comprehensive and really covers all you need to know if you're the dad supporting your wife, for example.
  • Very helpful for doulas, too.
HypnoBirthing by Marie Mongan:
  • Gotta be honest, I had to return this one to the library before I could finish it. 
  • Enjoyed reading the history of HypnoBirthing - what a cool lady she was to fight for her right to be awake at her birth and have her husband present! Contains some lovely, positive birth stories.
  • Good overview of what self-hypnosis is; nice focus on positive language; etc. Has some nice relaxation and visualization exercises.
  • The book is clearly designed to be used with a course; sometimes there are notes about exercises that "you'll learn during your course." Because of that, I certainly wouldn't say that I "know" HypnoBabies just from reading this book. If I'd listened to the CD I'd probably know it a little better. As it is I'd say I'm at least more familiar with it now, especially with the positive language and how the relaxations work. 
  • I'd say that you can probably learn a lot and get pretty good at it just from reading the book, doing the CD, and practice your relaxation a lot. Not having access to a course shouldn't be a barrier to doing HypnoBabies, but the author clearly thinks that you should be doing a HypnoBabies course if at all possible. 
Born in the USA by Marsden Wagner.
  • A book about the flaws in the modern American maternity care system, sort of in the same vein as Pushed. The big difference is that this one was written by an OB, not by a journalist. It has a lot of great "insider" information coming from an OB, but is, I think, less balanced; he's not a journalist and he doesn't work quite as hard to include the "other side's" view. Pros and cons. I appreciate having a book like this from an "insider," though, and I think that value helps to balance out the flaws.
  • The main point of the book is that our current system really puts doctors first. I'm paraphrasing here, but he notes that  ACOG is a trade organization, like a labor union. They have two main priorities: protecting the interests of their members, and producing a better product (in this case, health babies primarily, also healthy mothers). However, if there’s any conflict between those two goals, the interests of the members always come first. (ca. p. 32)
  • His argument (it's the subtitle of the book, in fact) is that our maternity care system must be changed to put women and babies first, not doctors and hospitals.
  • Makes some good points about how loyalty to the ACOG party line is strictly enforced, as OBs who try to do things differently from their colleagues are often ostracized: fired, hospital privileges revoked, unable to work and forced out of town, etc. This makes it very difficult for reform to come from within that community.
  • He actually seems to be a fan of lawsuits because it's a way for non-doctors to force change. He also makes a good point about capping damages: if you cap damages at $250,000, but medical negligence disables your child to the tune of a million dollars in lifetime care and medical bills, is that right? Should that family go bankrupt for the sake of a doctor's malpractice premiums?
  • He talks a lot about Cervidil, and rare but disastrous consequences from other interventions.
  • Makes some very good points about how universally accessible prenatal care would prevent many, many premature births and neonatal deaths, and also save a lot of money on NICU care.
  • I did find the book to be quite biased in some cases exaggerated to the point that it does hurt the message a little.
  • Overall, though, I found it to be quite thought-provoking and mainly pretty reasonable. I think it's valuable to have an OB speaking about the problems he sees in obstetrics and arguing for more midwives and the evidence is good. The book is very well-cited with an extensive list of sources at the back.

Friday, August 5, 2011

Book review: Birth as an American Rite of Passage

Today's book review: Birth as an American Rite of Passage by Robbie Davis-Floyd.

I read this book at least two months ago, honestly. I think I had a hard time writing about it because it was so amazing. It was hard to think of just writing a few paragraphs about it when I just want to basically reproduce the book, I had so much to say about it.

This book looks at birth in the USA from an anthropologist's point of view. Specifically, it uses anthropology's observations about the construction and function of ritual in society to analyze birth as a set of rituals. The main argument is that (1) rituals perform a function in communicating the values of society to the person/people taking part in the ritual, and (2) birth as it as set up today functions as a ritual. The concepts come from academia, but Davis-Floyd takes care to explain the academic concepts in everyday terms. The book does have a bit of an academic tone but it's set up to be accessible to any reader. I've never taken any sort of anthropology or sociology class and I didn't have a hard time with it.

I found the analysis very powerful and very illuminating. It's not hard to see how modern hospital birth has many elements of ritual to it. These days, many women have the experience where they come in, they put on the hospital gown, they get their IV, they get their fetal monitor, the bag of waters is broken, etc. These things, when does as part of the routine of arriving at the hospital, are not done because they are necessary, but they feel like things that must be done. There's this whole ritual to getting set up for birth, a whole ritual to labor.

Additionally, modern hospital birth has many elements in common with rite-of-passage ceremonies throughout the ages: the "initiate" (being initiated into motherhood, in this case) is put in unfamiliar circumstances, put in strange clothes, often made to do things that she doesn't fully understand - "made strange to herself," and put into circumstances where she is vulnerable and unsure, making her very receptive to the messages that the ritual is sending.

Now here's where the book really blew my mind. Often, when I read about interventions in labor and birth that are proven to be unhelpful or harmful except for rare cases (episiotomy, augmentation with Pitocin, confinement to bed, etc.), I ask myself, "How on Earth can so many doctors do this when we know that this performs no useful function?"

This book, at last, answers that question. The answer: they do these things because they do perform a function. They help communicate the message of the ritual. The messages of the ritual include:

  • that a woman's body is defective and can't be expected to work properly without help.
  • that technology is always good, and adding in technology always makes things better. 
  • that nature is subordinate to humankind and its technology. (This is communicated by the relentless speeding of labor, the near-compulsory Pitocin augmentation, etc. The natural rhythm of the mother's body and labor must be made to fit into the rhythm of the hospital schedule.)
  • that society has a certain ownership of and interest in the baby. (Hence, taking the baby away from the mother for a time, asserting that the hospital's right to the baby trumps the mother's. Also, court-ordered C-sections and such things symbolically show that society has the right to override the mother's wishes because the baby belongs to society, not just to the mother.)
What an eye-opener for me. Why does a doctor perform an episiotomy? It shows that the doctor (and society and technology) is the savior, saving the woman both from tearing and from the inadequacy of her body to stretch properly and let the baby out. And it shows the woman that her body cannot birth without the help of the doctor, society, and technology. 

To readers who are unfamiliar with this kind of analysis, I want to emphasize that, no, this doesn't necessarily happen consciously. Doctors don't sit down together and say, We want women to really get the impression that their bodies are bad, and we really want to communicate how technology is paramount and way better than nature. How are we going to do this? Let's strategize! That's not how it happens. 

Rather, the doctors started out already with the belief that women's bodies were defective - that belief goes back a very long way, to the Greeks and Romans and beyond - and that technology was better than nature. That certainly came about in the Enlightenment, but the Christian belief in man's superiority to nature goes back farther than that, too. So we have doctors, we have men and women at the turn of the century, totally steeped in these beliefs. These beliefs then shape their actions: Women's bodies are weird and defective, so we need to intervene in birth. Technology is better than nature, so if we use technology, things will happen better. From that line of thinking, these practices emerge. And they become entrenched, they become part of the ritual. 

Once a ritual is established, you feel like it must be performed that way in order to make things turn out well. And when you perform that ritual right and things turn out well, you get the feeling that everything turned out well because you performed the ritual well.

Imagine a wedding where they didn't exchange rings, or where the bride just showed up without walking down the aisle to great ceremony, or where they just exchanged rings without saying any vows. You'd get a bad feeling about it, wouldn't you? You might think that the marriage probably isn't going to turn out very well, because if they didn't even care enough to go through the whole marriage ritual, well, what does that say about how seriously they're taking this? 

Now that doesn't even have the weight of scientific studies, or the word of thousands of doctors; that's pure ritual. Imagine how much harder it is to shake off the childbirth ritual that is supported by these doctors who we respect so much! And so you get the situation of, well, I've done thousands of births with Pitocin and episiotomies, and I've got lots of healthy moms and babies. What's going to happen if I stop?!

So these beliefs shape what doctors do, which becomes ritual. And the ritual shapes what women believe, because those original beliefs are encoded in the ritual, and they send those messages to laboring women. 

Of course, how successful the ritual is at communicating those beliefs varies. There's a whole chapter on it in Davis-Floyd's book where she analyzes the messages that women got from their births and whether they internalized or resisted those messages. It's quite fascinating.

I really can't recommend this book enough. The analysis is so powerful, and the understanding that it provides about the function of the modern birthing apparatus above and beyond producing healthy babies is terrific and invaluable.

For what it's worth, although it's kind of an expensive book, I found it at my local library.

Friday, July 29, 2011

Doula training

Oh my goodness. Doula training was amazing. Just amazing. 50 women, every one so passionate about birth, together for four intensive, wonderful days of education and training. There was just so much energy and joy in the room.

I'm going to compromise my anonymity here, because I think it could be valuable to others for me to say what class I took. So, it was at the Simkin Center at Bastyr University near Seattle, and one of the instructors was the legendary Penny Simkin. I know, how lucky am I, to live in this area and have that opportunity?

Demographics-wise, I was expecting the class to be fairly small - say, 20ish people; and I was expecting to be perhaps the only woman without children. I had the impression that many women get interested in birthwork after having a birth experience, so I expected it to be a crowd of mothers.

Instead, the class was a full 50 women! An unusually large group, I've since heard. The vast majority of the class was under the age of 35; there was even at least one high schooler, which I thought was neat. Slightly over half of the women did not have children. There were actually quite a lot of the early-to-mid-20s, childless women, like myself. I found that very reassuring. In a way, I'm glad that we had such a big class, because there was such a diversity of experiences. We had college students, we had a few ladies in their 50s, mothers and non-mothers; women who wanted to be doulas, women who were already doulas, women who wanted to be midwives; nurses, lactation consultants... oh, and quite a few pregnant ladies, too!

As far as the course material, it was quite comprehensive. There were some basic overviews of pregnancy, the stages of labor, complications, etc. - stuff that we were expected to know, but it was reviewed. Probably the most useful thing was our discussions and practice on how to be active listeners. That made me realize that I very rarely practice active listening. My main goal in a conversation is just to keep it going; I often want to hear information from the other person, but I want to give information from them, too. Sometimes I just want to hear or tell an entertaining story. The give and take is important. But in doula work, the doula's role as a conversation partner is much more as a listener, and much less as a teller, than in an everyday conversation.

Overall, I found the training to be incredibly inspiring and encouraging, as well as very informative and educational. It was a very supportive environment that gave me a lot of confidence that this is work that I can do. I am very lucky to be starting out in a region where doulas are very supportive and collaborative, not isolated and competitive as they can be in some other places.

Friday, July 8, 2011

Pre-Modern Death in Childbirth

More than once, I've seen homebirth advocates remark that homebirth is good and safe because it's natural: before there were hospitals, every woman gave birth at home, and most of them came through it just fine!

And just as many times, I've seen homebirth opponents reply: Yeah, umm, a lot of those women died. Giving birth at home is like giving birth in the middle ages, when mothers were dying left and right! (The Middle Ages gets mentioned a lot in this sort of argument. I guess we're to picture homebirth as if it were taking place in the most exceptionally ignorant, disease-ridden situation we can imagine.)

Of course, both arguments are wrong. The evidence of the past doesn't support or preclude homebirth. Things were very different then. Looking at the past, those of us in developed countries should be very glad that birth is so much safer now (for us, in our countries). In wealthy countries, our comparative good health and ease of access to information and skilled birth attendants makes birth remarkably safe, regardless of where we do it.

What, I ask myself, were the biggest killers of women back in the day? My suspicion is (1) infection, the deadly "childbed fever," and (2) postpartum hemorrhage. If I'm right that those were the major killers, well, that really speaks for the safety of homebirth today! Modern understanding of hygiene helps to prevent infections; antibiotics can (for now) take care of any infection that does occur. As for hemorrhage, it's scary, but any good midwife should see it happening and get the woman to the hospital in time, where the mother will most likely be saved. The literature for the LifeWrap notes that a woman can bleed to death in less than two hours. That's very bad news if you're hours away from a hospital, but it's kind of encouraging for women giving birth in developed countries who can get to a hospital in just a few minutes.

Anyway, I'm trying to do some research to see if my ideas here are correct. Here's what I have so far.

This website has a graph midway down the page of leading causes of modern maternal mortality. This is worldwide, not just U.S. Ignoring the many deaths from unsafe abortion, pregnant and birthing women are most likely to die of:
  1. Hemorrhage.
  2. Sepsis (infection).
  3. Obstructed labor.
  4. Eclampsia.
This WHO page gives different percentages, and it puts eclampsia down as a more frequent killer than obstructed labor, but the top four killers remain the same. That particular page cites a much lower percentage of death from unsafe abortion, though still 13%.

Maternal mortality is going to be dominated by places where we could characterize medical care as "pre-modern": places where women have poor pre-natal care, little or no access to trained and skilled birth attendants, and long distances or no access to hospitals. According to the WHO, "99% of all maternal deaths occur in developing countries, where 85% of the population lives." Thus, we can take worldwide causes of death in childbirth as representative of "pre-medical" birth.

The most deadly countries for mothers have maternal mortality rates of 1,000 maternal deaths for every 100,000 live births. That's about a 1% chance of dying each birth. (Well, probably greater, when you consider that some women are going to die after a stillbirth, or from an obstructed labor with no live birth.) In the countries with the worst maternal mortality, 1 in 6 childbearing women die from pregnancy-related complications in that country. That's in Afghanistan and Sierra Leone. It's 1 in 7 in Niger. (For comparison, in Europe, it's 1 out of 30,000 women. The worldwide average is 1 in 74 women. Source - Lancet article.)

That Lancet article, "Maternal mortality: who, when, where, and why," backs up the above-cited article and says that postpartum hemorrhage is the leading cause of maternal mortality worldwide.

That same article also notes the disparities in maternal deaths between rural and urban areas. On average, worldwide, a woman giving birth in a rural area is half again as likely to die during birth as an urban woman. (About 640 deaths per 100,000 in rural areas, 447 per 100,000 in urban areas.)


Okay, so, that's modern statistics that may be somewhat representative of past conditions for women. How about actual past conditions? That's not so easy because people weren't exactly doing big medical studies in the 1500s, but there is some evidence, of course!

Here's a cool article available as a PDF online that anyone can access. Published in 1982, it's called "An Attempt to Estimate the True Rate of Maternal Mortality, Sixteenth to Eighteenth Centuries." (Found via this article, which contains a fascinating account of childbirth in ancient Rome!) I will spend the rest of this section discussing that paper.

The article notes first that, of course, the evidence is flawed and incomplete; any estimate of maternal mortality from the 16th to 18th centuries cannot be any better than a very rough, error-riddled estimate. That said, here's what they found. In one parish in England, church registers counted 23.5 maternal deaths per thousand baptisms (so, per thousand births, assuming each birth results in a baptism). The London Bills of Mortality count an average of 15.9 maternal deaths per thousand baptisms from 1666 to 1758, not counting plague years. That's a maternal mortality rate comparable to that in modern Afghanistan. The paper notes that these are "certainly underestimates." For example, deaths from ectopic pregnancies or early miscarriage complications might not have been counted if they couldn't be recognized.

Continuing on, death rates in the mid-1800s were apparently lower, on the order of 5 maternal deaths per 1000 live births. That's a bit higher than Bangladesh's rates today. Odds of the mother dying were much higher when the baby was stillborn, ranging from 57 to 137 maternal deaths per 1000 stillbirths. That's as many as 13% of women dying while giving birth to a still baby. Sort of an intuitive result: unknown pregnancy complications, on which we can only speculate, mean a much higher chance of both maternal and fetal death.

Overall, the paper estimates about 25 deaths per 1000 live births from the 16th to 18th centuries. That's a 2.5% chance of death per birth, or 2500 in 100,000 live births. That's quite a bit higher than the rate in Afghanistan today, which is 1800 maternal days per 100,000 births.

As far as causes of death: a male midwife who lived 1596-1768 described postpartum hemorrhage as one of the leading causes of death in his patients. He also noted that women who delivered on their own had infections less often. Infection was nonetheless a great danger. The paper notes that "even in normal cases, the vagina was repeatedly smeared with materials such as butter, goose grease, capon's or hen's fat, or whole egg. Operative procedures almost inevitably meant infection." Not so hygienic, back in the day.

Now, this was just one paper, so take it with a grain of salt. However, from it, we can glean that pre-modern childbirth was more dangerous than it is in the most dangerous-to-birth-in countries today. Some evidence from New England suggests an average maternal mortality rate of 2.5%. That is, for every 1000 births, there would be 25 women who died. In countries with the maternal mortality closest to that, 1 in 6 childbearing woman will die from complications of childbearing; we can expect that the rate was similar in pre-modern times.


What's my take home message here?
  • Birth in the past was very dangerous. 
  • In developed countries, birth is very safe: we're generally healthy and well-nourished, making complications less likely. When complications arise, we can generally treat them quickly, effectively, and safely.
  • In many countries of the world, birth today is nearly as dangerous as it was hundreds of years ago. In far more countries, maternal mortality rates are 10 to 15 times as high as the rate that appalls us here in the States. We are right to care about having a rising mortality rate in the U.S., but it is also right to care about the staggering maternal mortality in the countries we don't think about very often.

Thursday, June 16, 2011

Big steps

I signed up for a doula training course.

On one hand, it's not much. Just training. I'm not quittin' my day job and I'm not committed to anything more.

On the other hand, it feels huge.

Sunday, June 12, 2011

What does it mean to be a midwife?

Most of the midwives the U.S. are certified nurse-midwives (CNMs). The CNM - by definition as far as I know - is an RN with a Master's degree. However, most of the midwives that attend births at home are direct-entry midwives (DEMs), often certified professional midwives (CPMs). DEMs train for three years of coursework and apprenticeship, but they have no nurse training. Some DEM programs, like Bastyr University's, require a Bachelor's degree as a prereq, but most programs do not require a college degree.

To give you the numbers, about 8% of births in the U.S. are attended by midwives, but only 1% of all births are home births (Source: Pushed). Taking those numbers, I think we can say that roughly 1 in 8 US midwives are DEMs, and they are the ones who attend homebirths.

One of the criticisms leveled at home birth in the U.S. is that its attendants are underqualified, and that home birth in all other developed countries are attended by CNM-equivalents. (See here for an example of such an assertion.) I wonder: Is that true?

So, I'm going to do a series on midwifery education in other countries. Look for them under the tag "educationseries"!

Also, if anyone would like to contribute a guest post on midwifery education in their country, I would love that! Between the languages that I myself speak and online translators, I figure I can get a decent amount of coverage, but obviously it will be difficult for me to cover countries whose languages I don't speak. Basically I've got German, French, and Spanish covered (and English, of course!). If your country speaks a different language, please e-mail me. You can find my e-mail address in my profile. Just make sure to delete the "DELETETHIS" that I stuck in there to try to prevent robo-spam. :)

Saturday, June 11, 2011


Recently, on The Unnecesarean, there was a post about how 94% of US births had "complicating conditions" in 2008.

Now, as some astute commenters pointed out, complicating conditions does not mean exactly the same thing as complications. Complicating conditions does include things like hemorrhage, episiotomy, etc. - things going wrong and injuries - but it also includes things like the patient being of "advanced maternal age," very minor first degree tears that don't need repair, etc. Basically, any deviation from "mother in her 20s, hasn't had too many kids, spontaneous physiological delivery over intact perineum" gets put into the "complicating conditions" box.

Now that that's clarified, I'd like to look at the two major opposing viewpoints in the comments.

(1). A lot of these aren't real "complications." I mean, a woman over 35 who otherwise has a perfect birth gets put in the "complicated" box just because of her age. Many, many of these "complicating conditions" are either nothing but the hospital's definitions, or they are caused by the hospital. How ridiculous is it that the hospital treats 95% of births as complicated, when birth left to its own devices might be uncomplicated, if not 95% of the time, probably at least a good 80% of the time! (That is a totally made up but vaguely-ballpark stat.)


(2). Look how complicated and dangerous birth is! How ridiculous it is to "trust birth" when something goes wrong 94% of the time. This is proof of how inherently unsafe birth is, and of how much would be going wrong if most births didn't take place in hospitals with modern medicine.

Neither of those are direct quotes, and #2 is certainly exaggerated beyond what that commenter would probably actually say, but I think that both of these little "summaries" describe pretty accurately how the extreme camps feel.

I just think this is an interesting example of how two people can look at the same fact and draw wildly different conclusions about it. One group looks at "94% rate of complicating conditions" and concludes that hospitals make normal birth scarier than it has to be to justify their control of it. The other group looks at that 94% and says, look how scary birth is, hospitals need to be in control of it!

Thursday, June 9, 2011

Quickie: Another thought on insiders & outsiders

One of my favorite anecdotes in Henci Goer's The Thinking Woman's Guide to a Better Birth was this:
Someone once asked her what her credentials were. What gave her the authority to write books about medical research?

Her answer: "I can read."

I love this. So empowering! How fantastic is it, that she is communicating that anyone who can read has the right and the ability to understand and critique medical research? It totally goes against the idea sometimes espoused by OBs that only doctors can understand medical research, and so only doctors can make decisions about medical care. (Like: a woman who asks questions or tells her OB about some research she heard about it, and getting asked with a sneer, "And where did you get your medical degree?" Most OBs are nicer than this, thank goodness, but this has happened to plenty of women nonetheless!)

Not everyone who can read can be a doctor. But pretty much anyone who has the cognitive abilities to read can educate themselves enough to be active participants in their medical care, not just passive recipients of care.

Another thought on Spritual Midwifery

Why do I keep breaking these things into two posts lately? Mainly because I forget to include some point, and I write such long posts as it is that it seems like a bad idea to just make the previous post even longer, I suppose.

Anyway, one thing I forgot to write about is the way that Spiritual Midwifery tries very hard to be as accessible as possible in the medical/technical chapters. It does this mainly by trying to avoid medical jargon as much as possible. So, she writes pee-hole instead of urethra, butthole instead of anus, taint instead of perineum, etc.

Personally, I found this quite off-putting. I'm a scientist. I like technical language. I prefer it. I'd much rather talk about urethras than pee-holes. And I've been a birth nerd for long enough to know very well what a perineum is.

But I just started reading Robbie Davis-Floyd's Birth as an American Rite of Passage, and she makes the point in Chapter 1 that "technical jargon... shouts 'off-limits to the unitiated" (p. 30). She also notes that one way that men historically created power over women was by creating "spheres of authoritative knowledge" to which they then denied women access. To put it more simply, using technical language can be way of asserting "I'm the expert, and you're not, so just listen to me." Technical language in writing can be a way of signalling to a reader, "If you're not comfortable with this language, you probably shouldn't be reading this. You don't have a right to this knowledge if you don't understand this vocabulary."

By using language that is very common, sometimes vulgar but always comprehensible, Gaskin is asserting that the knowledge she puts down in her book is for everyone. It's knowledge that is available to someone who doesn't know the difference between a urethra and a ureter. Gaskin is saying that it doesn't matter if you know what a urethra is; you don't need fancy vocabulary to understand your body. You know where your pee comes out, and that's what you need to know to understand your body!

So, although it may not be my preferred language, I acknowledge that Gaskin may be doing a great service to the average woman by using such plain and easy-to-understand language.

I also find it interesting to think about what sort of language I should use with clients, someday, when I'm a midwife. In my ideal of midwifery, the midwife should not be an authority figure who has power over the birthing woman. She should be a source of knowledge and skills who offers up that knowledge in service, and works with the woman to communicate that knowledge and assist the woman in making her own choices. In my mind, I imagined that this would include educating the woman on technical terms for anatomy, but now I wonder, how important is very technical language? Does it not in some ways go against the ideals of midwifery to use technical language that functions to set up the midwife as the expert, the authority figure, the guardian and sole holder of knowledge? We know that many doctors use knowledge to give themselves control: some doctors say that their great knowledge gives them the right to command and control the birthing woman. If a midwife uses technical language that sets up her client as an outsider, unitiated, does it set up the expectation in the woman that she ought to be obedient and is not the one in control?

Book Review: Spiritual Midwifery

Today's book review: Spiritual Midwifery, the classic by Ina May Gaskin!

I really got a kick out of this book. When I was a little girl, I wished that I had been born in the 50s or 60s so that I could be a hippie, but my idea of "being a hippie" pretty much entailed having long hair and flashing peace signs. Maybe because of that, I very much enjoyed getting to read the accounts of hippie living. I certainly learned a lot. The first edition was written in the early 1970s and it really shows!

Roughly the first 200 pages of the book contain nothing but birth stories. Lots and lots of birth stories, mostly very positive, natural, out-of-hospital births. There's a section on instructions to the pregnant couple on nutrition and exercise in pregnancy, mentally preparing for birth, supporting and caring for each other during pregnancy, etc., that I thought was very nice. Then there's a large section on "instructions to midwives" and technical/medical advice, ranging from supporting a woman during labor to suturing perineal tears.

For the most part, the birth stories are great. Reviewers on Amazon love them. I can see how a pregnant woman would love this compilation of birth stories. Most of them are positive. There are at least two deaths (one premature, one anencephalic baby), a few premature births, at least one C-section (I didn't read all the stories), and a few with complications, but most of them are smooth, at-home births. The hippie language pervades the birth stories, and to be honest, I had a little bit of a hard time taking it seriously at first. All this talk of "we were totally getting high on the energy in the room, man" and "being telepathic with each other" and sharing energy, switching bodies, "psychedelic," "tripping," "far-out"... I did like the term "rushes" for contractions. It's concise and nice. I've heard of "pressure waves" as a term - I think they use it in hypnobirthing - but I like "rushes."

I think that one of the best things about these birth stories is the focus on the mental state and spiritual health of the mother. I think that reading at least some of these stories is a good idea for both parents-to-be so that they can keep in mind how their mental states can affect the birthing, and so that the birth partner can understand that getting in tune with the birthing woman's emotions and encouraging her to express emotions can be very helpful. There are also good ideas on coping with labor and helping it progress contained in the stories.

For the most part, the instructions and medical advice were good, too. There were a few things that I felt might be a little outdated - some of the instructions didn't seem as conservative about giving episiotomies as I expected, for example, and most of the photos showed women giving birth in sort of half-sitting-half-lying-down positions. But there's a lot of great information - for example, the sections on pelvic anatomy, fetal positioning, and suturing tears were great. I wouldn't treat this book as an infallible Bible but it is a terrific source of information.

I do think that there are some cautionary tales in this book, too. It seemed to me that early on in the history of the Farm and Caravan, they had quite a few premature babies born out-of-hospital, and they didn't really seem to consider going to the hospital. Most of the babies survived and thrived but at least one of them died. There was also a case of near-death where no one present knew anything about neonatal resuscitation. Personally, I feel that this underscores how important it is to have a trained birth attendant, and how important going to the hospital can be when the need is there. Of course those women had a right to make their choices, and they were willing to accept the outcomes of the choices. And, luckily, there are many more trained homebirth attendants around nowadays, so more women have more choices available to them now!

Monday, June 6, 2011

More thoughts on The Thinking Woman's Guide to a Better Birth

There were two themes from early on The Thinking Woman's Guide to a Better Birth that really struck me. You know how sometimes you read something, and you unexpectedly feel like you just got smacked in the face with a truth you had no idea existed? It was like that.

Idea #1: Doctors act based on their beliefs, just like everyone else.

One of the criticisms that the medical side often levels against the natural birth side is that NCB (natural childbirth) advocates base their positions on belief, not on facts. They seem to believe (see what I did there?) that if anyone were properly informed of the facts, they would always be on the side of mainstream obstetrics.

And, you know, that's not a 100% unreasonable criticism. I'd like to think that most NCB advocates are people who are basing their opinions on the facts - either reading the literature themselves, or reading authors who break down the literature for laypeople, like Henci Goer and many other authors and bloggers. But I've heard some things that were at best not-helpful belief, and at the worst honestly harmful, not-fact-based beliefs. Like midwives who believe that every birth can be a vaginal birth, and a woman who gets a C-section just didn't believe enough, or relax enough, or eat properly, or whatever. That's a belief, not very common but it's out there.

But the thing is, doctors are not immune to the power of belief, either! And I think realizing that answers one of the really hard questions, namely, why do doctors do things that the literature overwhelmingly shows to be useless or harmful? Why would any doctor routinely do episiotomies when we know routine episiotomies increase the risk of a bad tear? That is something that has always baffled me. And Henci Goer has an answer: belief. If you believe that birth is inherently dangerous and women's bodies cannot be trusted to work, then you do the things that that belief system leads to, like routine episiotomies and Pitocin. Who cares what the literature says when you know in your heart of hearts that most women need episiotomies?

Idea #2. The obstetric view of women is rooted in patriarchy.

Henci Goer makes the following points about how the broader culture affects our view and treatment of birthing women.
  • We (American culture in general) views technology as superior to nature. Hey, living in a high-rise is better than living in a mud hut, and medical science is better than natural cures, right? So a natural process like birth is always improved by the addition of technology. And failed technologies are hard to get rid of, unless they're replaced by another, because going from using technology to not using technology always feels like going backward. Hence why EFM keeps taking over even though it does not improve outcomes.
  • A quote from page 4: "One tenet of gender bias is that women’s bodies are weak and defective and cannot be trusted to do what they are supposed to do." That kind of thinking goes back thousands of years: hysteria, anyone? So it's no surprise that modern doctors, too, still look at the female body and think "broken, weak, doesn't work right."
  • For more fun, the reason why women are seen as defective changes, but they're always seen as defective. Back in the day, they were just weaker. Victorian women were deformed and weakened by their corsets (this is the only one with a basis in fact). Today, I've seen obstetricians argue that modern women are too weakened by civilization to effectively push out babies, that civilization has warped womens' pelvises so that babies don't fit, that our modern diet makes babies too big to fit out of their mothers, and more. All hogwash.
  • Also from page 4: the foundation of obstetrics is that babies must be rescued from their (weak, defective) mothers' bodies. You can see a ton of this rhetoric on . It's a very common view, that the womb - designed to be the perfect home for a fetus - is a dangerous environment that the baby must be rescued from.
  • If the mother's body is the problem, then she is not a part of the solution (page 4). Hence, obstetric remedies do not involve the mother doing something; they involve doing things to the mother.
  • Finally, obstetrics "values top-down relationships" (controlling authority figure, obedient and submissive mother); obstetrics "values action over inaction" (hence, "failure to progress" that is often "failure to wait"), and values traditionally masculine qualities of "control, predictability, and efficiency." (Note that by traditionally masculine, I mean qualities that our culture tends to view as masculine.) These patriarchal values - patriarchal authority figures, privileging of aspects viewed as masculine - inform the view of birth and how it is treated. 

Now, of course, there are many female OBs, so I should note that, yes, women can be part of enforcing patriarchy, too. To break into traditionally masculine fields, women have generally had to adopt traditionally masculine traits: they had to show the men in charge that they would behave like the men did, they would keep things the same, they wouldn't mess things up with all their weird feminine feelings and giggles and stuff. Thus, female OBs often have the same negative views of women's bodies that the original male OBs did. Hopefully, this will change in the future, but for now, women who break into "male" jobs have a hard time making things better for women, because they feel they cannot rock the boat and go against the male majority without endangering their own success, and indeed endangering the success of other women in the field. (Female movie producers, for example, overwhelmingly hire male directors and produce movies for men, just like their male producer counterparts do.)

Book Review: The Thinking Woman's Guide to a Better Birth

Whew, getting back on track! I've been reading, but updating. Whoops.

I recently read The Thinking Woman's Guide to a Better Birth by Henci Goer. This book seems to be very well-regarded, and for good reason. Goer does a great job of laying out the findings of a whole lot of research in a way that's easily readable and accessible to someone without a medical background.

She does have a strong bias towards natural birth, as she explains in the introduction. I appreciate that she acknowledges her biases and she is honest about them with the reader. This sometimes translates into a bit of bias that is a bit... not anti-OB, I don't want to say, and not quite hostile, but certainly suspicious.

However, this book is really well-researched, and written very clearly. I think that people who come into reading this, feeling pretty down with medicalized hospital birth but curious about the other side, can overlook the occasional anti-OB comment and appreciate the really solid research in this book. There's a ton of tremendously useful and educational stats in here.

I had a few little quibbles with the book. There were a few little inconsistencies - saying in one chapter that EFM is basically pointless, because it increases interventions without improving outcomes, but then saying in the VBAC chapter that EFM was recommended, without elaborating more on why that should be. I also disliked the style of citing sources. The main body of the text contains explanations for laypeople without citations. Then, there is an appendix at the end of the book for each chapter that summarizes the literature sources, so that you can link a specific assertion with its source. For me, as a scientist, it bothered me to not to be able to link a statement with a citation! But, maybe it is more comfortable for the general reader to read chapters uncluttered by citations and journal article titles, so maybe that is a strength of the book.

One interesting new medical thing I learned from this book - okay, two: (1) Women are given a big bolus of IV fluid, on the order of at least a liter (4 cups), when they get an epidural or before a C-section. This is to raise blood pressure, to counteract the blood pressure-lowering effect of an epidural. (2) That's a ton of water all at once, and it may be (at least partially) responsible for the problem of increased fluid in the lungs and respiratory issues in C-section babies.

Another post coming up soon on some more specific thoughts!

P.S. Can anyone tell me how to pronounce "Henci Goer"? I have no clue and it really bothers me. Hensy? Henchi? 'Ensy? Gore? Go-er?

Sunday, May 15, 2011

Book Review: The Doula Guide to Birth

Today's book review: The Doula Guide to Birth: Secrets Every Pregnant Woman Should Know, by Ananda Lowe and Rachel Zimmerman.

First of all: hey, the first author, Ananda Lowe, is a doula without children! Woo! As someone who's planning to go into birthwork long before having children, I find it very encouraging to read a book by a doula who's clearly successful, loved by her clients, and respected.

Okay, onto the book. I really liked it and, I have to say, of the books I've read so far, this is probably the first one I'd recommend to a pregnant friend, because it seems like a really great starting point. Of course, it's a book about doulas, so it's fairly set in the hospital paradigm, but it's very pro-natural-birth.

Here's what I liked best about it:
  • It gives the readers concrete tools to help them in finding the best care provider(s) and setting themselves up for a good birth. It has these nice little "Ask your doctor now!" boxes sprinkled throughout, clearly highlighted and set apart from the text, to signal "hey, if you read anything in this book, read this!" I thought that was terrific. Concrete directions for a woman who may be new to all this is surely helpful. I also liked how it wasn't one big list, it was little questions sprinkled throughout - so, a busy woman reading this over a few weeks would be able to bring up these questions as she went along in the book, instead of deluging her doctor with questions at week 30.
  • The most open-minded book I've read so far in recognizing that not all birth is going to involve a coupled mother-father dyad. This book recognizes that a woman giving birth might have a female partner, no partner, an estranged partner, a partner who isn't the father of the baby, or might even be giving birth to a baby for someone else (surrogacy or adoption). And it doesn't just give one shout-out to those things at the beginning and then spend the rest of the book talking about mom and dad; those considerations are integrated throughout the book. Very thoughtful, very inclusive.
  • It's pro-natural-birth, but in a gentle, accepting way. It's not all "omg, if you have epidural and pitocin, horrible things will happen!!" It's more, "hey, if you have an epidural and pitocin, you'll be at risk for more side effects and complications. Why not try going without them and seeing how that goes? We won't judge you if you end up getting the epidural, though. It's all good!" In that way, I think it may be very good reading for the woman who just assumes that she'll be getting an epidural. It gently says, hey, why not consider this instead?, and of course gives lots of great tips for coping with labor without an epidural, but without being too pushy or judgy.
  • At the beginning of the book, they mention that there will be a chapter on how to deal with unexpected medical intervention. "Uh oh," I thought. "Is this going to be all about, yeah, haha, you might wish for a natural birth, but you're not gonna get it, so deal with it"? But actually, it was very good! The book was really strongly pro-natural-birth and strong on giving mothers the tools to achieve that, if they wanted it. The "dealing with medical interventions" chapter was just focused on giving mothers the tools to deal with medical interventions if they came up: how to negotiate with the doctor, how to choose treatments, and how to cope with the unexpected. I thought the chapter was realistic but still hopeful. I liked their suggestions to think about, for example, if you're having a homebirth, how will you feel if you have to transfer to a hospital? How will you cope with that? It's good to think of coping strategies in advance, and hope you don't have to use them. 
One teensy-tiny criticism I might have would be that this book is very focused on first-time mothers. I suppose that's fairly reasonable: all woman who have children will have a first child, after all, but not all of them will have a second child! I also imagine that the first pregnancy tends to involve the most reading and research. (With the exception, perhaps, of woman who go for the I-trust-my-OB route the first time, have a traumatic birth experience, and then the second pregnancy is the research-intensive one - this is a story I've heard quite a few times.)

It did make me laugh a little bit, though, when the book assumed that only was it the reader's first child, but that it was also the reader's parents' first grandchild! I imagine giving this to my aunt when she was pregnant with her first child, but her mother's sixth grandchild... heh.

I felt like this book was somewhat research-lite. It definitely talked about a lot of different birth interventions and their pros and cons, but not in nearly as much detail as some other books. There were a few sections where they would mention interventions, and kinda say, well, you can do more research on this if it matters to you, but we're not going to talk about it too much here.

I thought that that was okay, though. Like I said, this book is a great starting point. It gives a broad overview of birth, birth-related issues, and how a doula helps, but doesn't go too deep. I wouldn't tell a woman to read only this book, for sure, but it's a nice place to start. Written in a very warm, friendly tone, very optimistic, and full of plenty of tools and recommendations for talking with care providers and digging deeper, I think this is a very valuable book for pregnant women.

Wednesday, May 4, 2011

Book review: The Doula Book

My most recent completed book was The Doula Book by Marshall H. Klaus, John H. Kennel, and Phyllis H. Klaus. (Did anyone else notice that all the authors have the same middle initial?)

It's a slim, reader-friendly book, weighing in at just about 190 pages, plus some helpful appendices. The writing style is a bit clinical but accessible.

This book makes a strong case for doulas, and it does so in large part by presenting a wealth of data. If you want to cite a figure for the concrete good that doulas do, this is the book for it. They bring together an impressive amount of studies and make a compelling case for doulas decreasing the need for pain medication, medical intervention, and Cesarean sections, not to mention increasing satisfaction with the birth experience, and even helping to improve mother-baby bonding so much that it leads to a decrease in child abandonment and abuse! Wow!

The book also explains what a doula is in quite some detail, and really goes into the details of exactly what a doula does. That seems like it's sure to be very helpful to someone who's curious but really has no clue about doulas. All the talk of techniques that doulas use was very interesting to me, too, as I'm looking into becoming a doula.

They have a special chapter for talking about the role of the father in birthing. First of all, the language of this book isn't very inclusive - as it always seems to assume that there is a partner in the picture, and that that partner is male. (They give a nod to this book being for all kinds of families somewhere early on, but it's all about "mother and father" from that point on. Admittedly, most families will fit that description, but just a heads-up to others.) Anyway, I thought that this book was sort of discouraging about how much a father can really do for the birthing mother in labor. On the other hand, it was a very fair point that it is a big burden to put on a partner's shoulders, to expect them to be labor experts and great labor support people, with no training, possibly no experience, and a great deal of anxiety for their partner! So that was an interesting point.

I also found Chapter 9 to be very interesting. This chapter focused on a hospital in Dublin where every laboring woman got one-to-one care from a doula/midwife (actually, nurses who were training to be midwives). I was rather amazed by the amount of intensive coaching that was described, and a little bit disappointed by how strictly they seemed to coach pushing. I guess I can't fault their methods too much: the vast majority of first-time mothers delivering spontaneously and naturally within ~8 hours of being admitted to the hospital? Impressive!

Bottom line: Great book for someone who doesn't know much about doulas, or who is skeptical about them, to learn how great doulas can be. Great for someone who wants cold hard facts without "woo." Overall, I feel like this book is really aimed at people who want to know exactly what a doula does and exactly what the benefits are. It feels a little bit like a book for doctors, nurses, hospitals, medical providers, etc. Maybe not as useful for expectant parents as some of the other books are there, but again, good for expectant parents who want "just the facts!"

Sunday, May 1, 2011

Book review: Birth Matters by Ina May Gaskin

I liked Birth Matters quite a lot. A lot of the facts about modern obstetrics were quite similar to those presented in Pushed, but Birth Matters felt much more personal and less clinical. That's not to disparage Pushed - I really liked its journalistic tone. Birth Matters isn't just a book about modern obstetrics; it delves much more into the author's personal experiences, and into midwifery.

I really enjoyed reading some of Ina May Gaskin's story of becoming a midwife. It's really quite amazing! Women in a hippie caravan, just delivering each other's babies, learning from doctors when they had the opportunity. And that became the Farm, which has some truly impressive statistics, presented in the back of the book. Like: a single fourth-degree tear out of something around four thousand mothers. A neonatal mortality rate around 1.7% - much less than the U.S. average, probably about right for low-risk deliveries. No maternal deaths. A handful of forceps deliveries. Such an amazing testament to the safety of out-of-hospital birth.

There are several really lovely, positive birth stories in the book. So nice! I felt like this book was really positive. Hopeful, optimistic, showing how good birth can be, giving hope that doctors and midwives can come together to improve birth and maternity care.

I appreciated that this book addressed the "why birth matters/why should you care" part, and took care to explicitly speak to even people without children. As a pretty young feminist, I can confirm what she's seeing, that birth is not a thing that young feminists talk or really care about. I think there's a big stigma there, this feeling that young, career-minded women shouldn't care too much about birth, in the same way that we shouldn't care too much about laundry detergent or girdles. Why we should care about birth, why reproductive choice should including how we do reproduce and not just freedom from reproduction, is so big and interesting that I think that will have to be its own post.

There's a chapter about the historical forces in the U.S. that led to the near-extinction of midwifery. Again, lots in common with Pushed here, but with some info that was new to me. For example, the point that women of the late 1800s, who were so modest, had a big problem with male birth attendants - so immodest! Doctors consciously, explicitly mounted a scare campaign to convince women that birth was terribly dangerous so that they would choose doctors. This danger was not self-evident: it had to be manufactured and demonstrated by doctors. And, of course, we know now that maternal and infant mortality rose at first when the shift from doctors to midwives happened.

She also has some good points about modern midwifery. Legislation that requires midwives to be supervised by an OB means that OBs can prevent midwifery from being practiced, even if it's technically legal. The midwife's license becomes meaningless. There's also the point about how U.S. doctors tend to see midwives as "competitors instead of members of the same team" (p. 87), which really has to change. So many other countries manage to get doctors and midwives on the same team, but it's such a struggle in the U.S.

Some fun facts:
  • The US has seven times as many births as the UK, but one-fifth of the midwives. 
  • “It’s a national disgrace that the CDC’s statistics now show that more C-sections are performed between 5:00 and 6:00 PM than at any other time of day.” (Wish I'd looked up the citation for this. This is on p. 196 of the book.)
  • (p. 212) “It’s hard to think of a profession other than obstetrics in which members must risk being punished in order to maintain a high standard of practice." (Referring to the fact that it is really hard for an OB in the USA today to support a non-interventive, physiological birth. Hospital policies want pitocin to move things along and turn over beds faster, and they want continuous EFM [external fetal monitoring] for liability reasons even though EFM has been shown to increase interventions without improving outcomes. An OB who doesn't want to routinely give pit and EFM may get in trouble with their hospital, shunned by their colleagues, and even fired.)
  • (p. 214) “When a baby dies during or after a hospital birth, that death is overlooked. No one will be punished. If, however, a baby died when the mother labored at home, it will often be the case that the midwife or the doctor or even the parents will be punished - as if their choice caused the death, regardless of what happened.” I think she's right about this. The story of Cynthia Caillagh in Pushed is a glaring example - switch "mom" for "baby" in that quote and it describes that situation perfectly. 

Sunday, April 17, 2011

Birth in sci-fi

I'm a lifelong fan of the fantasy genre, and a more recently-converted fan of science fiction novels. Since I haven't read so many, I don't have a great basis to draw from. That said, I find the topic of gestation and birth in science fiction very interesting. Often, science fiction consciously or unconsciously makes a statement about the present; it is always a product of the hopes, fears, and technologies of the time of writing.

One example that springs to mind is Lois McMaster Bujold's Vorkosigan Saga. In those books, the more advanced civilizations have created artificial wombs: the fetus is grown in a tank, and is decanted instead of being born. Everyone is very happy about this since, after all, it means no maternal mortality! When one character finds herself in the position of being pressured to actually get pregnant and carry a child in her own body, she's horrified. I won't say anything about what happens with that situation because it would be a big spoiler.

More recently, I read some books by Charles Stross, Accelerando and Glasshouse. I'm going to throw in a minor spoiler for Glasshouse in the next line - more a spoiler for the type of world it is, but also a bit of a plot hint, so if you're planning to read it and haven't yet, skip the next paragraph, I guess.

Ready? Spoiler ahead! Okay! So in one of these books, technology eventually reaches the point where they have these devices that are like the food replicators in Star Trek, only they can replicate anything. It's not stated explicitly, but based on (again) horrified reactions to the thought of pregnancy and physical childbearing, it's pretty clear that these replicators are where babies come from in this vision of the future.

I think that both of these examples are quite interesting. In a way, they're very optimistic: they imagine a world where not a single woman has to die in childbirth. They're the ultimate dream of medicalized childbirth: a world with no discomfort, pain, injury, or death at all associated with childbearing. It sounds pretty good! There is, at times, a poignant sense that something good has been lost, but there's also a powerful sense that something bad (barbaric, violent, backwards) has been happily done away with.

One could argue that books that portray childbirth this way imagine the future as a place where humans are not made to be the best that humans can be, but rather as a place where science and technology allow humans to become something better than humans. Those stories also express a deep fear of childbearing, I think, and a wish that women could be freed of that fear by science.

I wish that I had some good counter-examples. As it is, most sci-fi novels don't concern themselves much with these types of things! Also, I just haven't read enough sci-fi novels to be able to think of a lot of good examples. I can think of some sci-fi TV shows and movies that depict natural, physiological birth in a neutral or even positive way (a variety of Star Trek series and at last one movie; Farscape; Battlestar Galactica; etc.). However, I'm not sure that it's fair to compare novels and TV. Birth is great for big, dramatic TV moments; audiences are going to be much more entertained by a screaming woman in an escape shuttle than they are by a baby being mechanically replicated along with the morning coffee. Choices are being made there for entertainment value, not just for message. Of course, I think that the childbirth elements of Star Trek do fit with its message as a series, but still, not a fair comparison.

Friday, April 15, 2011

Book review: Pushed by Jennifer Block

I finished reading Pushed by Jennifer Block the other day. I thought it was excellent. Very well written; overall, I thought it put things together very well. Highly, highly recommended. Full of great info about the safety of birth and various procedures; the history of obstetrics and midwifery in the U.S. and how we got to where we are today; the legal status of midwifery throughout the U.S. and the problems that illegality causes; the terrible medical and legal abuses of women who want to make their own choices; and the incredible importance of choice and autonomy for birthing women. It was full of terrific information, extremely well-researched, lots of good citations. Block is an investigative journalist, and it really shows. I thought she did a great job of letting a lot of different voices speak and bringing together many sources.

I loved that she had so many quotes from doctors and nurses saying that birth at home is safe, and that if you want to give birth naturally without interventions, you should be at home. I feel like I get a lot of my info from one side - the homebirth midwife side, although I read plenty of CNM and nurse blogs too - so it's nice to see that other side backing up what I'm hearing. And, honestly, midwifery does need support from medicine, doctors, and hospitals; a woman's giving birth shouldn't need to be legitimized by this whole medico-legal system, but it does.

I did think that the book got bogged down a bit in the middle during the section about outlaw midwives. There was one happy birth story and one problematic one with a baby needing resuscitation from the midwest midwives, as well as the death of one of Cynthia Caillagh's patients. I thought that those stories felt unbalanced: there was so much focus on birth mishaps, midwives evading the law, and the stress of the "outlaw" life that... well, the spotlight was so much on the negative aspects and the bad things that could happen in these illegal homebirths that I don't think it made the case for legalization as well as I would have liked.

I mean, it's important to show that making midwifery illegal causes big problems. That it can cause a certain recklessness, and that the great fear of the law can interfere with giving the best possible care. I do think it's great that the author didn't shy away from the less-rosy side of the picture. However, I think it was easy to come away from those chapters focused on how problematic these reckless/radical/outlaw/whatever midwives were, and not think as much about how their legal status shaped them.

I did love the chapter about Cynthia Caillagh, who was an illegal midwife in Virgina trained by a traditional Native American midwife. I think that most people would consider her views radical but she had very good points. She expressed great concern about the fact that modern midwifery relies so much on licensing and begs for the blessing of the medical establishment. Midwifery isn't medicine but it must get folded into medicine to get any kind of legitimacy. Caillagh feels like midwifery loses out there, that traditional midwifery is very special but impossible in a medical context. I don't think that there's any way around this, and until reading her point of view I saw no problem with it. I was happy to have the chance to hear a "radical" point of view expressed very reasonably, and to get a chance to really understand it and hear it.

Some miscellaneous points from the book that really struck me as important:
  • Liked her use of the phrase "physiological birth." Because, you know, what is "normal" birth? What is "natural" birth? These are very fuzzy terms. Instead, she uses "physiological birth," defined (more or less) as the body doing its own thing: initiating labor, pushing the baby out under its own power, etc. Going through all the physiological steps.
  • Shocking how many obstetric interventions started with male OBs just doing whatever the heck they wanted to women's bodies. Things like 90%+ episiotomy rates for decades without anyone doing a study of whether they actually did more good than harm, or any good at all. And the fact that maternal mortality first increased when birth moved to hospitals? Wow.
  • Important point: The problem is not medical interventions. Medical interventions save lives in emergency situations. The problem is taking emergency interventions and applying them to every single birth.
  • Really important pont #1: On doctors claiming that C-sections are just as safe as, if not safer than, vaginal birth: "... if the trauma of the cesarean section - cutting a birth canal in the abdomen - might be equal to or less than the trauma of a modern vaginal birth, then vaginal birth, as practiced in most U.S. hospitals, is so harmful that it rivals the injury of major abdominal surgery." That is powerful. Because either (a) these doctors are so clueless that they think that giving birth the way we're designed to = abdominal surgery, or (b) interventions in hospitals today are so harmful that they are not very different from major surgery.
  • Really important point #2: You can't compel someone to take medical risks to save someone else's life. It's not ethical. This is something that's ironclad. If you have a man dying of kidney failure, and his mother's kidney is a match, there is no way to legally compel that mother to give her son a kidney. Not even though he'll die without it and she'll probably survive the surgery fine. You can't do it. Her body, her kidney. And yet, some people want to say that that woman's right to turn down procedures that would hurt her does not apply when that child is still within her body. She only has rights when that child is outside of her body. How does that make any sense? It doesn't.
  • Really important point #3: Doctors can refuse to "provide" VBACs because any doctor can refuse to provide a medical procedure that they deem unsafe. Isn't it amazing, this framing? That birth is something that a doctor does to a woman, not something that a woman does? Because last time I checked, a VBAC involved a woman and her uterus pushing a baby out. No need for a doctor to do any procedure there!
Sorry if this is a bit rough or rambling. This book was so wonderful and informative and thought provoking. I have so many thoughts swirling around in my mind now.

Saturday, April 9, 2011


I just realized that, contrary to my previous assumptions, the Jennifer Block who wrote Pushed is not the Jenny Block who wrote Open, a book about open relationships. Things somehow make a little more sense now that I know that these two books are written by two different people!

Now, of course, there's nothing wrong with the idea of a polyamorous woman going on to write a book about childbirth - I'm pretty sure that Jenny Block has a child, so it made sense in that way - but it seemed like such a big, odd change of topics that I was a bit puzzled.

About the blog / Who am I?

Well, here's my first post on this new little blog.

First things first: Who am I?

I'm blogging anonymously, so I can't get too detailed on that question. So what can I tell you?

I'm a woman in my mid-20s. I'm a physical scientist. (Physical as opposed to biological. Think physics and chemistry, not biology and medicine.) I'm a U.S. American, and a west coaster for life. I'm a feminist. I'm pro-choice. I'm scared of climate change but I'm not scared of vaccines. I love my family. I don't have any children.

I've never seen a birth in person but I want to be a midwife. I've been fascinated by pregnancy and birth from a very young age. By the time I was 7, I could define a zygote and a blastocyst, and I had strong feelings about using the words "embryo" and "fetus" accurately. Adults always told me that I should be a doctor because I was so smart, but I never wanted to be a doctor. Still don't. The fact that I could work with pregnant and birthing women without being a doctor (or a nurse) only occurred to me in the last few years. Since that moment I haven't been able to get the thought of becoming a midwife out of my mind.

Okay, enough of that. I'm bored of talking about me.

So what's the point of this blog?

I'm not sure yet! To start with, it probably won't be terribly active. Right now I'm working on reading through lots of birth and midwifery-related books, so I'll be posting reviews of those. (Next up: Pushed by Jennifer Block. Loving it so far; I'm about 60 pages in.) I'll probably also post about my thoughts and research as I look into possibly becoming a midwife. I'm still trying to decide if I'm totally crazy or not. I do hope that this blog will become a record of my journey to becoming a midwife, but we'll see!

For now, if anyone stumbles across this blog, the most useful thing is probably the "My Blog List" section over on the right. Lots of great blogs there by homebirth midwives, nurse-midwives, nurses, and other people. I read a lot of blogs.