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?