Some thoughts on Homebirth Safety

It was from my son's birth experience when I began to learn how often needless interventions are pushed in hospitals. I succeeded in a non-medicated, almost intervention free (AROM at 6 cm) birth in a hospital practice of midwives using Hpnobirthing (TM).  However I did not have supportive and respectful staff and ended up essentially fighting for the right to give birth under my own power without the midwives needlessly intervening. 

From this I learned that they are businesses who want to maximize the money that comes in and they do it by rushing women through by speeding up labor and/or cutting babies out which because it requires more equipment, more staff, more procedures bills more. The whole system is set up not to promote health and safety, but to promote efficiency and billable procedures (which includes NICU admissions).

The more I learn about midwifery, the more I see how homebirth midwives understand a great deal more about the physiology of birth than hospital birth attendants. Birth really does work best when its left alone (in 90%-ish of situations). I've lived based on that stat. There's a 90% chance that everything will be just fine at home, transfer services work for the remaining situations (and I always lived 10 minutes from the hospital I would transfer to). Midwives are trained in these situations (and since I'm studying those situations now, I'm impressed with the depth of knowledge expected from then).

One of my favorite ways to think about the safety debate is that the meaning of "as safe as hospital birth" means mortality wise. Women and infants do not have a higher likelihood of dying at a homebirth than at a hospital. Its just as safe in that way. However, homebirth is actually SAFER when taking into account morbidity (other ill health that does not lead to death but might bring a person close...) To women wanting to avoid hysterectomy, abdominal surgery, complications from surgery or anesthesia, PTSD, higher rates of infection, the manual cutting of their vaginal openings or severe lacerations to their perineums, etc: homebirth is considered much safer. Researchers down plays the morbidity thing so much. Its like they don't believe that those experiences aren't bad enough that a woman would go to great lengths to avoid them.

Increasing access to childbirth education

Earlier this week, a Los Angeles Times article condemned women for not educating themselves on childbirth options and therefore being at fault for allowing the Cesarean rate to be so high and for the interventions that happen to them when they trust their providers. 

My reaction to this article when it came out was that 1) expecting families are actively discouraged from being informed about childbirth options (by their care providers) and 2) expecting families see how pointless childbirth education is when it doesn't matter what they learn/want/say, their providers in general aren't respecting their desires and choices and in many cases actively working against the goals of the families. I also see that childbirth education is a costly expense and inconvenience in the lives of pregnant families and many women probably feel their time is better spent resting and taking care of themselves than rushing to another set of appointments.

Childbirth educators are important, don't get me wrong, but their delivery system is lacking and in many cases they are missing the collaborative relationships with care providers.

I think I had a really good idea that could address all of these issues and I'd love to talk about the feasibility of it with others.

Medical groups, doctor's offices, clinics, and insurance companies could hire childbirth educators to work in office. Their job would be to spend 10-15 minutes each appointment with families during prenatal appointments to go over options and to educate women on the process of childbirth. Rather than an additional appointment that takes 1-2 hours, short educational opportunities could be available like many clinics have dieticians and social workers.

I say get the insurers involved and require that these educators are on staff in order to make sure that providers allow them to be there. Some providers will not be difficult to convince on the virtues of this proposal but many others would. Its the ones in private practice that would be the hardest to work with.

This idea came from my midwifery training where I am basically being trained to offer short lessons in childbirth education to clients. I can see how providers themselves don't have the time to do this (and also the will) but they can contract with people who are trained and passionate about informed decision making. This is my vision for how childbirth educators can make it mainstream and break that 30% barrier.

Often that barrier is caused in part to economic factors of the families. Childbirth education is still a privilege available to those who can afford it (mainly middle-to-upper-middle-class white people). The article is flawed in saying that the blame can be put on women by ignoring the institutional and economic factors involved.

What actions would need to be taken to get this happening across the country? Who are the stakeholders who have the clout to make this happen? Grassroots advocates, childbirth educators, policymakers?

Opening the Back

Jamaican midwives having a saying that when the back opens the baby comes. This is referring to the period of time around the fetal ejection reflex where the baby moves down to crowning and birth. Opening the back occurs when the sacrum moves backward to allow more room for the baby to move through the pelvis. Its amazing to learn how much space is gained by this--up to 4 cms in some places! I had never come across it before in any of the other reading I have done on birth. I thought this is so cool, I can share it here. Especially since I can even tell a personal story about it.

I encountered this term in my copy of Holistic Midwifery Volume II written by Anne Frey. It is one of the texts in my midwifery program and covers extensively (its almost 2,000 pages!) the physiology and care of labor and birth.

I remember when this happened during Belle's birth. I even commented on it when I wrote her  birth story. I didn't know the name of it then so I'm pleased to learn about it now. At the time I described it as:

I felt tightness radiating down into my thighs and it felt like the bones of my pelvis and hip were being stretched outwards.

I later thought that this might have something to do with the hip pain that lingered after that pregnancy. I learned that it might be SI dsyfunction (sacroiliac joint) and posted about it here. Finding out that it was an actually physiological process that is part of normal birth helped me feel that the strange sensation wasn't an injury but my body working as it was designed to.

I thought at the time that when I felt my hips spread during Belle's birth that something unnatural had happened. I still think that maybe my SI issues have something to do with this spreading. It happened so quickly--it was like my SI joints abruptly slid out as far as they could like sticky slide locks on a door. Perhaps they slid more forcefully and quickly than is typical when the sacrum moves and the back opens.

This phenomenon is only observed when upright birth is allowed. When a woman in laying on her back in bed, the sacrum is prevented from moving and the pelvis does not expand in conjunction with the fetal ejection reflex.

I don't recall feeling this happen when giving birth to my son. Not surprising, since I felt pressured into birthing on my back. The only way I felt that I had been able to reposition more comfortably as he was descending and crowing was by twisting my hips so that I was more on my side.

Someday I may find more detailed description of this phenomenon. It seems like it hasn't been described or investigated by researchers enough to know what is normal "opening of the back" and what is extreme. As it is, the term is hardly known except in some circles. Hospital birth attendants and medical researchers wouldn't see it because the vast majority of birthing women they see are on their backs. Upright/vertical birth isn't even an option in many hospital birth environments.

Have any of my readers heard of this? Care to theorize with me on the possibility of normal opening of the back and extreme opening on the back?

Midwifery as A Calling

You have to check out this post at The Gift of Giving Life and read about how Mormons in the early days of their church considered midwifery a position in the church where women were called according to the inspiration of the spirit to serve the women in their congregations. Unfortunately, this practice did not persist beyond the days of birth moving to the hospital but for the time that it did exist, I can only imagine how empowering, spiritually uplifting and community strengthening such a tradition would be. 

As a Mormon by conversion, I am wistful for the days of this practice and wish that society hadn't changed so much that midwives called in each ward or take became a thing of the past. Right now in the church, there is no structure in the organization to connect Mormon (or as I prefer LDS) women with LDS midwives. I know they exist, along with a score of doulas, childbirth educators and birth junkies because I have become acquainted with many of them across the internet. 

I know that I as a birthing woman would love to work with an LDS midwife or have an LDS doula. I don't even know if there are LDS doulas or midwives in my area and I wish I did. I love the Christian midwife that I worked with during my last pregnancy but a Christian worldview was second best in comparison to a Mormon worldview. (I can clarify on this if my readers are interested). 

As an aspiring midwife and birth attendant, I feel prompted to offer my services as a doula during labor and postpartum to the women in my local congregations. In the past I have tried to get the word out that I am interested and willing to offer this as an act of service but like I said there are few ways to get this known to the local women. Meetings are structured so that there is time for very little else and the scope of the LDS church's women's organization is so broad that its hard to cover all of the many ways that relief can be provided through charity. 

I would really like to see a directory/registry/list of LDS doulas, midwives and childbirth educators that is shared on the internet for LDS women to refer to as they are looking for maternity care. In a way, it would bring back a little bit of the community that once existed in the church with Relief Society sisters literally providing relief during some of the most important and hard work of a Mormon woman's life.

Since the church is organized in geographical areas called stakes, I would love to see this list be organized by stakes. Usually a stake covers a city or town (or in some cases a few towns near each other) and has around 1,000 members of the church. Its usually within driving distance from one end of the stake to another and given the distances that I've heard some midwives travel to assist women at their births seems doable for one woman in the stake to reach any and all of the sisters when she is in labor. And there's nothing wrong with having more than one midwife listed in a stake. 

The main difference between a list like this and the former way of issuing callings is that no one is assigned to be a specific midwife or doula to a certain area. There could be a dozen midwives and doulas in a given stake (oh what a dream!) and there wouldn't need to be competition or obligation. A childbearing woman has so many options when it comes to birth attendants (hopefully) that often what she needs to make an informed choice is access to information about the options available to her. I truly think that if LDS women knew that there were LDS women near them who were trained and qualified in attending births that they would work together in many cases. What a blessing that would be to the community of sisters! 

Who's with me in creating his list? Do you know of any LDS doulas, midwives or childbirth educators in your stake or ward boundaries? Are you one? 

Or even better, does what I'm hoping for already exist?? 

Sacroiliac Joint Dysfunction

I've mentioned before that I've had intermittent hip pain since my last pregnancy. I had a spell for about a year where it didn't bother me (from August of 2009 to around May of 2010) so I thought it was something that I could just let work itself out. At some point, I realized that its become too much of a fixture in my life so I needed to do something about finding the root cause. On my birthday this year, it got really bad again so I became serious about addressing it.

I recently visited my naturopathic doctor/midwife who listened and poked around my hip and lower back to try to isolate where the pain was coming from. She mentioned the sacroiliac joint (a joint connecting the sacrum in the low back to the pelvic girdle. Its connected with ligaments and covered with cartilage). She then referred me to a physical therapist who specializes in lumbar-pelvic PT. While I'm waiting for an appointment with the PT, I've been doing some internet homework to try to figure out what is going on. With sacroiliac as a clue, I started my searches.

And this is what I found:

Another common cause of SI joint dysfunction is pregnancy. During pregnancy, hormones are released in the woman's body that allows ligaments to relax. This prepares the body for childbirth. Relaxation of the ligaments holding the SI joints together allows for increased motion in the joints and can lead to increased stresses and abnormal wear. The additional weight and walking pattern (altered gait) associated with pregnancy also places additional stress on the SI joints.

Any condition that alters the normal walking pattern places increased stress on the SI joints. This could include a leg length discrepancy (one leg longer than the other), or pain in the hip, knee, ankle, or foot. Patients with severe pain in the lower extremity often develop problems with either the lower back (lumbar spine) or SI joints. In most cases if the underlying problem is treated, the associated lumbar spine or SI joint dysfunction will also improve.

The most common symptom of SI joint dysfunction is pain. Patients often experience pain in the lower back or the back of the hips. Pain may also be present in the groin and thighs. In many cases, it can be difficult to determine the exact source of the pain. Inflammation and arthritis in the SI joint can also cause stiffness and a burning sensation in the pelvis. 1

Several things can aggravate the SI Joint too. Continual sitting or lying on the affected side will impinge nerves and skew the pelvis. Remember, the body will adopt a bad posture and accept it as normal after a period of time. The pain often worsens when riding in a car, sitting in a movie theater or putting weight on the hips while walking (for example, carrying a child). 2

As I read these findings, I was nodding along.

Pregnancy? Yes

Short leg? Yes (caused by scoliosis)

Pain in the low back, hip, thigh, and thigh, stiffness, burning, and difficulty determining the source of pain? yes, yes and yes.

Sitting or laying on the affected side aggravates? Yes

Worsened pain when carrying a child and walking? Yes (that's exactly what brought it on today, actually)

I'm still using chiropractic, yoga, massage and hip circles to address it. Hip circles, actually, make the most difference when my SI is tight and hurting. I'll have to remember to eat eggs for breakfast tomorrow and its probably time to make my grandma's famous baked custard because that's a mega dose of eggs and so good.

In addition to suggesting physical therapy, my naturopath suggested looking into craniosacral work. She also gave me a medical referral for massage. And she reminded me, which is embarrassing that I completely forgot, about homeopathic arnica for muscle soreness. I've also been seeing an Upper-Cervical chiropractor which is new and different for me than the typical pop and crack chiropractors I've been seeing.

At this point, my husband and I swearing off conceiving another baby. In my lower moments, I come close to despairing and giving up getting pregnant again ever. We even put the option of surgical sterilization on the table, which is a momentous and terrifying thought to me. In having those conversations, I realize in a new way how much I love and appreciate the children I have. I knew then that I can be happy being mother to my two and not regret having another. Still, if it is possible, I hope to recover enough that I can physically handle another one or two or three pregnancies and births. My hopes aren't so high so I can content myself with whatever that is coming my way.

Based on what Vanessa said on my blog page, I'm glad that I'm planning to put off more births. She told the story:

"That is what derailed my planned homebirth with Tess. It was excruciating and worse than any labor pain -at one point, I almost blacked out, threw up and peed myself from the pain. Thought I was in transition -except I was 1cm and 50% effac...ed. Saw an osteopath at 40+3 who tried her best to fix it, but couldn't really do anything. It took a long time to get better. I mainly saw the osteopath, but have also considered a chiropractor (and acupuncture) in case it comes up again in a future pregnancy."

I definitely hope I can avoid that. I have heard acupuncture being helpful for hip joint problems but I haven't pursued it yet either.

I'll update as I meet with and learn more from the physical therapist. I do hope that we can welcome additional biological children into our family and that it will not be at the expense of my physical well-being.

If you are interested in reading other posts that chronicle what I now know is SI joint dysfunction see the following posts (starting from earliest to most recent):

Belle's Birth Story: I describe the moment I felt my SI stretch abruptly.

Not a very interesting update: I describe the hip pain for the first time
Been Away: Started yoga at 3 months postpartum to be gentle on my hip (instead of returning to Irish dance)
Preparing to conceive again: I started wanting another baby but was feeling ambivalent because of my hip problems.
A remedy that might help my hip pain: I learned about lecithin to relieve joint pain
Check that Off the Bucket List: My husband and I took a massage class where he learned some strategies to help massage my hip when its hurting

Late Announcement

I failed to post on my blog that I bit the bullet and enrolled in midwifery school. If you've been following my Facebook page, this is old news. I just haven't gotten around to telling my blog readers about it.

After my first child was born, I got fascinated by learning about childbirth. I learned that while the physiological process is pretty simple, the cultural process of pregnancy and birth for a woman is much more complicated. Being a birth junkie became a hobby and my blog here was its product. If you are a regular reader here you know the process I've gone through. If you are a new reader, it doesn't take long to get an idea.

There came a certain point where I knew that my knowledge about birth had hit a plateau. In preparing for my second child's birth, my husband and I basically took a childbirth education class that was more like a crash course in emergency midwifery skills taught privately by our midwife's assistant. After my daughter was born, my midwife told me that if I ever wanted to attend a birth with her all I needed to do was ask.

I felt uncomfortable with that offer, though appreciative and excited at the same time. I didn't feel right inviting myself into a woman's labor because I had a compulsion to see birth as a witness rather than the subject. Attending a birth in that way would give me no official standing, no reason to be there other than voyeur. I would not welcome a person into my birthing space for that reason, I wasn't about to enter someone else's.

Perhaps though, it was my midwife's attempt to lead me into an apprenticeship. Now that I'm a midwifery student, I feel I have that official standing and the desire to become an apprentice formally. I'm hoping in the near future that I'll take her up on the offer and be available for prenatal visits as well.

Details, you ask?

I've enrolled in Ancient Arts Midwifery Institute in their Advanced Midwifery Studies certificate program. The school is owned and operated by Carla Hartley, founder of the Trust Birth Initiative and force behind the Trust Birth Conference. Its a 42 month program and an apprenticeship is not required during that time. Just in time for Christmas 2013, I will need to be done with the coursework.

The program started out as the Midwifery Homestudy Course which means that then, and now, its an independent study, apprentice based program where students get their book learning through completing the coursework and get their practical experience through apprenticeship and in person skills labs offered periodically.

Its perfect for me because I am dedicated to staying home and caring for my young children. I'm also dedicated to my sanity and developing my skills and talents. This course provides me with the balance to be anxiously engaged in a good cause though learning by study as well as being present with my children and their primary care provider. If I was able to complete a master's degree with the support of my husband while gestating two babies, I can do this program with his support as well.

I had been contemplating enrolling for awhile because I recognized the value of the education. Its very affordable in comparison to all on-campus midwifery programs. I also endorse the philosophy of practice and share the believes that birth belongs to mothers, not midwives or doctors or even the dominant culture. Earlier this summer, Carla was offering discounts to people in various places to enroll and I jumped at it. I later learned that she uses this trick to get potential students to take the step to enrollment. Clever and I'm glad she did it.

Part of the decision to enroll came because I had applied to PhD programs at the University of Washington to start this fall but I did not get in. I felt strongly that I needed some form of continued education and learning so when that didn't pan out, I saw the wisdom in becoming trained as a midwife as it would serve me in my academic career later. I think it might also help me get accepted into a PhD program in the future as well. I'm not disappointed that I'm not able to pursue a PhD at this time and I'm excited to immerse myself in birth at a new level.

My goals in becoming a midwife are not to own and operate a busy independent midwifery service. I'm not interested in maintaining a business. I'm more interested in the research, public policy and advocacy that will help midwifery become a more recognized and respected profession and provide a warning voice on the pitfalls of licensure and regulation. My birth experiences will continue to greatly inform my ideas as a birth advocate and I pray that I will never forget the primary need for the woman to consent and be the ultimate decision maker for her births. Please correct me if you ever suspect that I'm drifting from that position.

That's my hope for my future involvement in birth. To have the knowledge of a midwife which will inform academic research. When the time comes for me to apply to PhD programs again, I'll be looking at public health, women's studies, human development and public policy. Until then I'll be learning, serving as a midwifery assistant in a limited capacity and loving and enjoying my children.

I already had the chance to participate in the Basic Midwifery Skills Lab. These labs are taught a few times throughout the year in various locations across the country. In July, one was being held an hour from my home so I jumped at the chance to attend. In the lab, we were taught about the basics of midwifery practice as well as the hands-on skills of giving injections, starting IVs, suturing, inserting catheters, palpating fetuses, listening with fetoscopes, assessing blood pressure. The highlight, perhaps, was my introduction to the Vagina in a Box. I later learned that the midwifery and nursing students at the University of Washington wished that the nursing school would invest in this teaching aid. That was an indication to me that I'll be getting a better education than CNMs at one of the nation's top universities.

I met some amazing women at the SkillsLab. i even won a half price discount to the 2012 Trust Birth Conference. I've become friends with one of the women who lives just a couple of hours away from me. Together, we are planning to attend the Advanced Skill Lab being held in Oregon next year as well as rooming together at the conference.

If you've got any questions about the AAMI program, let me know, or if there's anything I left out or you want to know more about.

Responses to Survey on Unnecessary Medical Treatment

The Safe Patient Project is soliciting stories of medical overtreatment and medically unnecessary treatment. The Consumer Union asks:

Have you or a loved one had tests, surgeries, procedures or medications that you thought were unnecessary? If so, we would like to hear your story. We'd also like to know if you declined tests or treatments offered to you that you thought were unnecessary and found a medically appropriate alternative. Thanks for taking the time to do this. Your personal experience can really help us stop unnecessary and inappropriate medical care in the future, and improve the quality of care for patients.

One of the the areas in which medical overtreatment is done most is in maternity care. Its a multi-billion dollar business where each delivery costs almost triple than it otherwise could. There is evidence to suggest that childbirth in a hospital after a low-risk is overtreatment. Midwives are able to safely assist women in birthing their babies in their homes in the vast majority of pregnancies at the fraction of the cost. Choosing to birth without a medical attendant is also a valid option given preparation, planning and access to emergency services.

If you, one of my readers, have a story to tell about unnecessary medical treatment during your child's pregnancy, labor and birth, the Consumer's Union Safe Patient Project is giving you the opportunity to tell about your experiences. If your experiences were traumatic reporting on it may be triggering. There is a chance that your story will make a difference in maternity care and you'll face better and more appropriate treatment the next time you have a baby. You may also be making maternity care better for other mothers and their babies. The URL for the survey is: http://cu.convio.net/site/PageServer?pagename=spp_unnecessary_care

The following is the story I told. I'm including my responses to the question. I tried to explain as clearly as I could that I feel like the admission to the hospital in early labor was medical overtreatment. I recognize that in the big picture and in comparison to other birth experiences I may have had, its a small thing. But as I learned, it can and did have strong consequences.

1. Question - What type of medical overtreatment did you experience?

Answered: Other

2. Question - In what kind of facility did the event occur?

Answered: Hospital

3. Question - Describe your medical overtreatment experience in your own words (the space below allows you to include as much detail as you like):

I was admitted to the hospital in early labor (38 weeks pregnant) where the midwives proceeded to attempt a induction. This strategy is sometimes called a "backdoor induction" because it misleads the pregnant patient into believing that her labor is more progressed than reality and that a hospital admission is warranted. In response to this question, I'm considering the hospital admission medical overtreatment. There was no need to be admitted to the hospital at that time. The result of the admission was stress in response to the coercion used by the midwife on duty who attempted to get me to consent to an induction that was unnecessary. I felt bullied, manipulated and scared for my health and my unborn baby. I experienced PTSD as a result from what I feel like was fighting off a potential rape of my body.

4. Question - Did you report this incident to your state's Medical Board or other licensing agency?

Answered: Yes

5. Question - If yes, what was the Medical Board or Licensing Agency response?

Answered: None

6. Question - Your experience or that of a loved one resulted in:

Answered: minor injury or minor disabling condition

7. Additional Comments:

I explained above that I experienced PTSD as a result of overtreatment in my pregnancy. Often the psychological response is not classed as "morbidity" but considering how debilitating it was for me, I consider it a minor condition that had far reaching effects on my life. I still suffer the effects of the emotional trauma but felt recovered enough to not longer need treatment after 1 year.

8. Question - If you or your loved one experienced medical harm from overuse, how long did it take to fully recover from the incident?

Answered: More than a year


9. Question - Did the medical professional fully inform you of the risks of the procedure or treatment.

Answered: Did not provide full information about the risks

10. Question - Please describe additional information that you received about the risk or found out after the procedure from another source.

I was not informed that the risk of early admission to the hospital was increased intervention that could lead to a hasty attempt at induction which is associated with a higher likelihood of c-section, mortality for mother and baby, respiratory distress for the baby and NICU stay. If I had know that quickly, upon admission to the hospital that an induction of active labor would have been suggested, I would not have consented to being admitted.

It was later that I found out about backdoor induction from a labor and delivery nurse who blogged about it at:http://nursingbirth.com/2009/04/13/don%E2%80%99t-let-this-happen-to-you-24-part-1-of-2-jessica-jason%E2%80%99s-back-door-induction/

11. Question - Were there unanticipated costs associated with the medical procedure or treatment?

Answered: Yes (therapy, an extra day of hospitalization)

12. Question - Did your health insurance company pay for expenses associated with this care?

Answered: No (not the therapy)

13. Question - If you declined medical care you thought was unnecessary, what tests or treatments were offered to you that you declined?

Answered: Other

14. Question - Please describe why you thought the tests or treatment were unnecessary and declined them.

I declined the induction that the midwife attempted to force on me. She lied to me telling that she wanted to augment my labor. I after learned that using pitocin and breaking water before 4 cm dilation (and active labor) is a complete induction.

I also declined the morphine and sleep aids that I was offered. I felt that the midwife was attempting to coerce to me take them and that she did it with the intent of knocking me out so she wouldn't have to deal with me. When a woman is coping well with her established labor pattern and is not expressing any exhaustion or discomfort, the offer for pain relief or sleep aid is unnecessary.

15. Did you seek a second opinion?

Answered: Yes

16. Question - What did you do?

Answered: Pursued another treatment

17. Additional Information:

Because I was told that there was a good reason to be admitted to the hospital, I was very confused why I was then rudely told to leave the hospital when I declined the offered procedures and drugs. I continued laboring and progressed to active labor after being kicked out of the hospital for my lack of cooperation. I was then afraid of going back to the hospital fearing that I would be told to leave again, forced into intervention I knew to be unnecessary or that I would be lied to regarding the health and well-being of my baby.

In the hospital, I considered trying to switch providers to one of the OBs on staff and I learned that the OB supported and was going to sustain the midwife's plan for my labor. When I was told that I would not consent, the OB told me to leave.

At home I considered the options of not seeking further treatment or consulting with another hospital or maternity care provider. Because I was in labor and the baby would be born within hours, I could not bring myself to go to a different hospital and provider that I had not planned on working with. I was very fearful that if I even tried another hospital would not admit me. That left my other option of giving birth at home unattended by a medical professional or calling a homebirth midwife to attend me which I did not think a midwife would be willing to do without a prior working relationship with me. I was worried about the legal implications of birthing unassisted and thought perhaps my child could be taken away from me because of my neglect is obtaining proper medical attendance for his birth. I felt like my only option was to return to the hospital where I had been treated badly and hope for the best in spite of my fear.

Upon returning to the hospital, labor progressed easily and I birthed my baby unmedicated and without further intervention within 6 hours. By that time the midwife who had troubled me the day before was off shift and I didn't have to deal with her anymore. No further attempts to alter my labor were made though AROM was done with my consent. It was unnecessary at the time too but I did consent to it and did not feel pressured to do so.

In effect, the treatment I pursued was "the tincture of time." I knew that a first time labor could be slow to establish an active labor pattern that with the supportive emotional and physical assistance I could bear the labor as it progressed and that in time, the baby would be born without difficulty.

My story does not highlight the most egregious ethical lapses of a maternity care provider but yet, her treatment and tactics still were not right, not in line with the midwifery model of care and unfortunately indicative of the greater obstetric culture where its just fine for providers to withhold and manipulate information to hurry births along. I can only speculate on the motivations for why they do it and even with an explanation, the "care" cannot be excused. I truly hope that my story and others will have an impact on how patients are treated and that they are given the respect they deserve to make completely informed decisions.

A hole in the heart, a hole in the family

A little dark haired girl is wearing purple sweatpants with matching sweatshirt. Her dad, wait that's my dad but much younger, so the little girl must be me, is holding her hand as they walk through some sliding electric doors into the dim light of a corridor with an information desk and waiting rooms off to the side.

Why would this be my first memory?

I was not quite two years old. It was September of 1986 so I was 22 months old. The only reason why I know this is because that's when my brother died. Those doors opened to the hospital where my mother learned that her 38 week gestation baby was dead and that even though labor had started, she would be birthing a stillborn. Somehow, I picked up on the emotions of my loved ones and knew something was very wrong and that memory stuck.

Later my mom told me that her loss was so great that her desire to live only remained because of me.

Growing up, the explanation for why my brother died was unclear. As a teenager, I learned that he had a heart defect that, obviously, was not compatible with life. I heard different things: he had a hole in his heart, one of his arteries was not connected correctly and his heart formed inside out.

I didn't know that when I was 10, my dad had requested the medical records as well as the autopsy report. I also didn't know that I would find those records when I was cleaning out my mother's garage this summer.

Cause of death: Complete transposition of the aorta and pulmonary arteries.

Of course, I didn't know much about what that meant so I set out to learn.

I learned this defect is most commonly called Transposition of the Great Arteries or vessels. What is means is:

Babies with TGA have two separate circuits -- one that circulates oxygen-poor (blue) blood from the body back to the body, and another that recirculates oxygen-rich (red) blood from the lungs back to the lungs. Without an additional heart defect that allows mixing of oxygen-poor (blue) and oxygen-rich (red) blood, such as an atrial or ventricular septal defect, infants with TGA will have oxygen-poor (blue) blood circulating through the body, a situation that is critical. Even with an additional defect present that allows mixing, babies with transposition of the great arteries may not have enough oxygen in the bloodstream to meet the body's demands.(1)

The first question I had after obtaining that information was how did he even live as long as he did. This diagram illustrates how there is some mixing of blood in the atria (upper segments of the heart).



I also learned that in most cases TGA is not determined until after the baby is born and they are blue and floppy without pinking up over time and with treatment. This was a surprise to me because here I am learning that most babies survive birth with this condition and my brother did not.

It can be corrected early with surgery and most babies with the condition survive and unfortunately our family didn't get that opportunity. I perhaps more so than other young children have felt his loss because with his death I became and remained an only child. I often felt the hole in our family from not having a sibling and knowing that we came so close and suffered such a devastating loss that made it so.

I've also wondered if my parents could have known prenatally that the baby had a defect that was life threatening. My mom had told me after I became a mother that she had not had an ultrasound with my brother's pregnancy because it hadn't seemed warranted. In 1986, it hadn't yet become standard practice to conduct the 20 week anatomy check.

Could a routine mid-pregnancy ultrasound have caught it?

This question of routine ultrasound is still be discussed hotly in the scientific literature, as well as among expectant parents. Each couple or mother has to come to that decision for her/themselves and it will often be based on the values and perception of risk for the individuals.

My mom given her knowledge at the time decided to avoid a sonogram during that pregnancy, and none of the doctors pushed for it. Its not like now where its the exception to forgo the 20 week anatomy scan. Its within a family rights to choose one or the other. I've had to consider it myself and working through this experience gives me some more insights into the decision making process.

From what I've been able to learn about TGA, early ultrasound can detect it (2). A study using ultrasound to detect TGA prenatally started in 1986 and out of 68 fetuses with suspected TGA, 57 truly did (3). That's a pretty good detection rate. And according to the authors, mortality rates were lower when it could be anticipated before birth. They caution however that the technician must be adequately trained to detect fetal heart anomalies and the emotional upheaval of knowing ought to be weighed against nature taking its course.

I am now picturing the high-risk hell that my mother may have experienced in knowing early that my brother had this defect. Maybe it would have been discovered at 20 weeks and biweekly biophysicial profiles and non-stress tests would have been conducted to give him time to mature but then to end his gestation at the first sign of distress. If he died in utero between 32-34 weeks, that is a really early premature baby and in his case, one in acute need of open heart surgery to repair the defect.

A high chance of death anyway, a long NICU stay, recovery from a repeat c-section with a toddler at home, emotional trauma from the fear and horror of parenting a sick premie, the stress of the hospital bills--that could have been my family's alternate reality.

I've spent enough time at Solace for Mothers to know the pain, suffering and difficulty that comes from a birth experience like that. Knowing myself the trauma that comes from a negative birth experience, I can't choose which I would prefer. I know, from observation and from my own loss, the grief that comes from the loss of a stillborn baby. Would I choose that because its familiar? Because I recognize that the laws of nature are a crapshoot and sometimes babies die? That maybe facing his loss the way it happened was going to somehow be better than losing him after the trauma of a premature birth? The chance that my mother herself could have died given the increased risk of maternity mortality for cesareans over vaginal birth?

Of course, a question I've asked myself is what was the cause of the defect.

I've blogged before about the possibility that my mom's previous c-section could have contributed to my brother's stillbirth, though I have not found any evidence suggesting that a prior c-section can predict a congenital heart defect. Environmental contaminants have been named as a possible explanation (4)(5). In talking with my mother, I learned that she remembers smelling the solvents in the inks used in her workplace during her pregnancy with my brother. I already found the work of organizations like Environmental Working Group and Pesticide Action Network compelling but this further adds to my awareness of the effects of environmental contaminants. Not only do I find their ubiquity insidious but I am angered at the cover-ups employed to deny the facts and the lack of regulation and ethics that have caused so much damage already that the public is only beginning to learn about now.

I have to remind myself though, "Most of the time this heart defect occurs sporadically (by chance), with no clear reason for its development" (6).

And of course, nothing changes the reality. My mother continues to cling to me for her hope and happiness and I'm learning what being a sibling is like through watching my children. Comfort is found in the plan of salvation as taught by the LDS Church that my brother belongs to our family for eternity and that I will have the opportunity to know him in the next life. I already sense that my father, upon his death, was welcomed to the spirit world by his son.


(1) Children's Hospital Boston "Transposition of the Great Arteries"
(2) Role of Ultrasonography in Early Gestation in the Diagnosis of Congenital Heart... Abu-Rustum et al. J Ultrasound Med.2010; 29: 817-821
(3) Detection of Transposition of the Great Arteries in Fetuses
Reduces Neonatal Morbidity and Mortality in the journal Circulation 1999;99;916-918
(4) Having Faith: An Ecologist's Journey to Motherhood by Sandra Steingraber
(5) The Body Toxic by Nena Baker
(6) Children's Hospital Boston "Transposition of the Great Arteries"

Before you were formed in my belly, I knew thee

This was originally published as a response to a question asking about pre-birth experiences of knowing and sensing a child within a mother's body. I was reminded by the verse in Jeremiah "Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee."(Jeremiah 1:5). And its just fitting to think about this on the eve of Father's Day.

A couple of months before my oldest was conceived, I had this strong impression that the time was right to start the process of welcoming a baby into our family. I picked up a copy of Hypnobirthing because I had known for years that I was going to learn the technique for my preparation for birth. I prayed to know if it was right to try to conceive and felt it was.

It was not our plan at all however to try to get pregnant at that time. We had wanted to wait until we moved to our new city (just a few months away) and my husband got settled in his first year of graduate school before even attempting. Because of this, my husband was very resistant to my impression and when he prayed about it did not feel the same as I had.

Then he was surprised when I learned I was pregnant a couple of months later. For me, even though the news was unexpected, I wasn't really surprised because I had already been told that a baby was ready to come to us. Its this story that merits a complicated answer to the question, "was this a planned pregnancy?"

There was magic around us when he was conceived, and a power greater than the two of us lead us forward. We felt drawn to each other in that time and place and under those circumstances. It wasn't likely that I was fertile at the time and yet it happened, in joy and ecstasy.

As soon as I was pregnant, I knew it was a boy so I was not surprised to find out I was right. Even years before, I had had dreams of breastfeeding a baby boy. It had felt so real that as a teenage girl, I was shaken by the seeming realism. Before pregnancy, I had felt for a couple of years that my first baby would be a boy. We knew very early in our marriage that he would be given my husband's middle name.

And so it was. He is now a vibrant, strong-willed, precocious three year old little boy. He has given my life a passion, direction and drive that it was missing before and laughter everyday. Without my little boy and the experiences of his birth, I would not have become the ferocious mama I am today working for the protection of mother's and babies rights in our country. He has been teaching me balance as well as through his pregnancy, infancy and toddlerhood, I started and completed a master's degree, helped create a national then international non-profit organization and assisted the forward progress of a national service for expecting families.

A song that I feel characterizes the connection I felt with my little boy before his birth and how his being transformed my life is from the Shrek soundtrack, "It is You I Have Loved."

As a newborn, I rocked him in my arms and sang the lyrics to him and felt that the hole that had been missing in my life had been filled.

Do Birth Workers Know What Women are Reading?

Rixa at Stand and Deliver blogged recently about how obstetricians come to their beliefs about homebirth which reminded me of a question I asked myself a few months back.

Do obstetricians and L&D nurses know what women are reading about birth?

And, if they did, how would that change their practice?

Beyond the texts recommended by obstetricians and What to Expect When You're Expecting, it appears to me that many women planning hospital births are reading information on natural childbirth with books like:

Ina May's Guide to Childbirth
The Birth Partner
Hypnobirthing
A Thinking Woman's Guide to a Better Birth
Gentle Birth, Gentle Mothering
My Best Birth
The Birth Book
Birthing From Within
Spiritual Midwifery

A common thread of these books is arguments against using obstetric intervention through replacing interventions with simple strategies employed by the mother and her support people. Most of these strategies require advance preparation and knowledge regarding them though gaining this knowledge really doesn't take much time. Simply reading about it in a book, or even a website makes one qualified to change positions or to breathe deeply or soften one's jaw. It even qualifies someone present to suggest it to a laboring woman.

Now this is where I think this plays into Rixa's discussion. I'm going to theorize that one reason hospital birth workers are not supportive of homebirth (in addition the other reasons suggested by Rixa and her readers) is that homebirth is the epitome of natural birth where it becomes clear how very little knowledge and expertise is needed (except for when it is). This idea would feel like a threat to their livelihood, their career choice and might breed just a little bit of resentment towards other professionals who have not slaved through the initiation rite of medical school and residency to end up doing very similar work.

Doctors might shy away from asking themselves the question: "If birth were simple and reading a few books qualified a person to attend births, then what was the point of all that education? It can't possibly be as easy as these books say it is."

And then, as I continue on this pretend inner-monologue, perhaps hospital workers then would get frustrated with their female patients: "How could they possibly think they know enough and think that reading some silly books are going to qualify them?"

But, now I'm dreaming, what would happen if hospital birth workers read these books with an open mind? Would they be compelled to try some of these strategies or to suggest them during a woman's labor?

Are these books written compellingly enough to convince an obstetrician that maybe hands and knees for pushing is worth the try?


Or--now I'm really dreaming--what if these books became required reading for OB residents and L&D nursing students? Just so they knew what "fluff" pregnant women are filling their minds with as they prepare for birth. Perhaps, the assignment could be given with the intent to debunk the misinformation and to encourage doctors to reflect and prepare for how they will respond when women present these ideas in prenatal appointment.


And, if the less academic, popular press reading is too unpalatable for our esteemed birth workers, perhaps the expose of childbirth in America written by journalist Jennifer Block "Pushed: The Painful Truth About Childbirth and Modern Maternity Care" could be recommended first as it provides thoughtful insights into each side of the topic.

In any degree, from a pregnant woman's perspective, this would be more beneficial from dismissing them all together or pretending like they don't exist. Not recognizing their influence creates a vacuum of information, a empty divide where patient and doctor are trying to yell across but the message keeps getting lost.

However, I would hazard to guess that, if hospital birth workers could open their minds a little bit, many of them could recognize the value of the information and see how the paradigm fits together to make the idea of homebirth and non-interventive, unmedicated birth plausible and attainable in relation to relative risk and safety.

Or at least perhaps, we could stop talking past each and be on the same page.

Birth Trauma Round Up

I've been meaning to get around to this for awhile. Each day when I read news articles and blogs, I'll bookmark it if its something I want to come back to or if I have something to say about it, or agree its important and needs to be said again and again until the right people listen. Generally, the articles that stand out to me are on the topic of birth trauma. So here is an anthology of birth trauma related articles over the past few months. On analogies: Keyboard Revolutionary: An Interesting Parallel

So what does it mean when another wielder of authority says, "Do what I say or your baby will die"? Are they looking out for your best interest....or are they a bully, a rapist, an abuser, deliberately playing on your unignorable instinct to protect the ones you love in order to get what they want from you?

And when its seen like this, how obvious is it that a mother can come away from her birth experience with PTSD?

Raising My Boychick: Just Like Athletics: Exploring a Childbirth Analogy

Rather than coerce with stick or carrot, what we do in athletics (again, thinking especially of charity racing; a particularly apt comparison to birth as it is physical effort that benefits another) is cheer, support, encourage, commiserate. No one stands at the sidelines of a charity marathon yelling “give up! it’s not worth it! stop trying to be a martyr! you’re not going to win a medal!” Nobody whispers in their ear when they’re doubting, “take these drugs [that will actually make running harder], let us drive you to the finish [we'll tie you behind the car], finish in five minutes or we’ll whisk you away for surgery [for a torn ligament you don't actually have].” No one tells an athlete she can only have a “trial” of running if she has no food or drink, if she’s hooked up to machines that purport to measure how hard her muscles are working, that take her blood pressure and heart rate and temperature and send it all to the medics’ station and meanwhile are hindering her movement and reminding her she’s on a clock and she’s not running fast enough (or running too fast and they’ll “have to” stop her “for her own good”.

The analogy works well. What would happen if hospital birth attendants had this analogy called to their attention? It seems so simple, yet a strong paradigm shift is engendered in it.

On feminist activism:

Courtroom Mama: Feminism Behind the Veil

[How many women] suddenly realized that grown-ass people in a medical office were calling them “mommy” and telling them what to do as though they themselves were children. And the fact is, for a number of women of relative privilege (cis-gendered, heterosexual, middle-class, etc.), the journey into motherhood might very well be the first point of friction with patriarchy. Many of us lucky enough to not feel the weight of oppression can manage to skate by with just our carryon baggage, but add a pregnancy or a child to the mix, and suddenly you’re “actually” a woman, or rather “just” a woman.

Fertile Feminism: Mainstream Feminism and Motherhood

That’s why I’m so pleased to have discovered all the feminist mother blogs that have been springing up recently, and why I want to work with feminist mothers to help bring your voices and battles and mainstream feminism together. It’s been all too easy for childless feminists to ignore motherhood, and it really, really shouldn’t be. We need to listen, learn and become allies to mothers by not only centring your voices but using our own to advocate for mothers everywhere.

The previous two articles both discuss how stereotypical feminists (or rather the dominant cultural idea of feminism) doesn't understand the issues facing mothers in dealing with injustice in maternity care. It now appears that some "majority" feminists are becoming aware of what us feminists in the minority are facing. Like Courtroom Mama, my first run-in with patriarchy may very well have been in my first birth experience and it certainly played a large part in coming to self-identify as feminist. I too felt, before birth trauma, that feminist history afforded me a "post-feminist" spot in my world.

On cruelty:

Henci Goer: Still Cruel Maternity Wards

We have a culture of impunity in maternity wards. Once pregnant, a woman effectively cedes her right to autonomy and bodily integrity to obstetric staff who sometimes—on grounds of fetal welfare, self-protection from malpractice suits, or mere convenience—manipulate women into compliance in ways that would be considered fraud in any other venue. Without fear of being called to account for it, they can bully, coerce, humiliate, and threaten. And, yes, they can physically mistreat or even sexually assault them

It is this that needs to be exposed. In her article, Henci links to recent news stories that highlight some of these abuses. Its starting to be uncovered but it still seems to far-fetched so far from the norm, but then what is normal seems irrelevant because of its normalcy. It seems the media has not just captured the sameness of these outrageous cases with the outrageousness of the "normal" cases. The whole history of hospital birthing has been this way and its just sick.

The Unnecesarean: Women Have Right to Complain about Mistreatment During Birth

I really believe that someday, our daughters or granddaughters will be amazed that any woman was ever arrested for refusing a c/section, or operated on against her will, or prevented from moving or eating or making noise while she labored to birth her baby. They’ll regard much of what is still considered normal today as cruel, and uninformed, and backwards. And they’ll be right. But only if we keep refusing to be silenced.

It exactly this that I could not and would not believe before I contemplated becoming mother. It seemed so blatantly wrong that it seemed impossible that it could be indicative of systematic injustice. It really did feel like just being pregnant and giving birth that I was going into a dark and dirty underground system. ACOG has been labeled a cartel and for good reason.

Amy Romano @ Science and Sensibility: Patient safety, disciplinary action, and the marginalization of midwives

But whether disciplinary action is against midwives or physicians, is punishment the best way to deal with breaches in patient safety?

When this question is posed to someone who has experienced birth rape, the answer is: They have to held accountable somehow. If its not through a hefty check from their administrators, then it needs to be some censuring from their superiors. If not that, then it needs to be criminal charges. When a woman is feeling like her OB or midwife is entering her body with the same force and skillful manipulation of a rapist, yes, the provider must be held accountable. RH REality Check: The Cure for An Ailing Maternity Care System

The idea that maternity care should be evidence-based, safe, and efficient seems like a no-brainer but one key goal to note is how these imperatives lay the groundwork to minimize “overuse, underuse, and misuse of care practices and services.” We need to make sure we’re providing optimal care to all women by guaranteeing women are able to access the services they need if they need them. However (this is a big one), let’s also start from a place of understanding that pregnancy is a healthy state of being – not an inherently sick state – and so let’s also minimize the amount of unnecessary interventions that now drive up costs and place women and newborns at risk for poorer health outcomes.

It must be said: the "overuse, underuse and misuse of care practices and services" are causing trauma to new mothers, rendering it exponentially more difficult to care for their babies in their early years. Its not yet known what sort of long term effects can be had from a traumatized mother in early life, but there are studies that show that children of depressed mothers are more likely to experience depression, children whose parents experienced PTSD are more likely to experience PTSD after a potentially traumatic event. Are our children being hardwired to face life's challenges with disorder? Its not just about health care costs, its about a mother's sense of confidence in her ability to care for her children. Its about the baby's sense of being cared for and loved. Michel Odent equates these early unnecessary challenges to a threat to humankind. He even poses the question "Can humanity survive?"

Its starting to sound pretty melodramatic and that's exactly what I would have labelled it before my experience, and before I learned that I was not alone. I find its a coping mechanism to write in this manner and that I cannot be objective and unemotional when I read the stories of birth trauma at Solace for Mothers and the MDC birth trauma board. Some of it seems so fundamentally, viscerally wrong that I struggle to articulate how and why it is so wrong. So instead, I try, though my blog to illustrate, highlight and show case examples so it can become clear to others without my feeble attempts to spell it out.

What Trauma Looks Like

Warning: this post will be triggering for birth trauma survivors

Make an on-line slide show at www.OneTrueMedia.com

When watching this video, I was reminded of the pictures taken of me holding my babies for the first time after their births. They are starkly different. I've pondered over the differences before and now that I've seen this video, I feel like posting the photos to illustrate to others what trauma looks like.

After a traumatic birth, described as birth rape:





























The joy at meeting my baby comes through (and a sense of my victory over the system's efforts to control me), but look at that far away stare showing the disconnect between me and my baby. And do you see the timidity and the reservation with which I'm holding my baby boy? And how the smile doesn't make it to my eyes?

When my son looks at pictures from his birth, this is what he is going to see. I hope he never questions because of these pictures, "Why is my mama sad? Did she want me? Does she love me? Is she mad at me because of how I was born?"








And then compare, to this:









From this, and another example from a friend's blog, I see that birth experience matters. Not to the mom's hedonistic desire for self-satisfaction, but to the baby that the mother greets. I feel my babies deserve to be greeted by a mother who feels victorious, respected, capable and empowered; not one who has been victimized, disrespected, dehumanized and demeaned.

Not Letting it Happen to You Can Lead to PTSD

The blogger at Nursing Birth posted last year a series called "Don't Let This Happen to You: The Injustice in Maternity Care Series" and in one of the posts, she described a phenomenon that I had never heard about, but recognized it immediately as what was attempted on me when I was pregnant with Willem.

In my prequel, I described how at 37 weeks 6 days, contractions started at 11 pm. At 11 am the next day, I was 3 cm dilated having contractions every 6-15 minutes. The midwife at a prenatal appointment that day told me that I was in labor and should check in with Labor and Delivery to be admitted to the hospital. The midwife on call at Labor and Delivery called failed to progress and, after performing cervical exams every hour for 4 hours ,started advocating for pitocin/AROM augmentation as she called it. It was 9 pm, 3 to 3 1/2 centimeters dilated with contractions between 6-10 minutes apart.

In the prequel, I asked if this sounded like a phenomenon that you've heard of before. Do you know?

Nursing Birth taught me that this is called a backdoor induction and she defined it this way:

If a woman is 4cm dilated but is not having regular, noticeable, and painful contractions that are causing cervical change she is NOT in labor. If said woman is sent into the hospital and any interventions to stimulate contractions are started, then it is by definition considered an induction NOT an augmentation. And if said patient was not scheduled to be admitted on such day, then it is considered a backdoor induction. I knew it as soon as I read it. This is what happened to me. It is unethical and just as Nursing Birth calls it, an injustice perpetrated on a birthing woman.

Even at the time, I knew it was inappropriate for labor to be stimulated artificially and I refused. This is where my story and Nursing Birth's patient's story begins to differ. I did not go along with it with the recommendation for induction. If I had been more savvy to manipulative tactics such as this, I would have known to not trust the midwife who referred me to L&D. But then again, if I had been more savvy, I would have known that hospitals are not the appropriate place for low-risk mothers to give birth in the first place. Even then, we weren't understanding why the midwife would make the recommendation to check into the hospital obviously in early, non-progressing labor but in our excitement, we decided to trust her. To our detriment.

Because in my experience, I then learned what PTSD is like. I'm not faulting Nursing Birth for leaving the story off as she did, but I have something to add to it. If you fight the system, even if you win, which is not likely or common, you will still lose. You will lose a sense of being human, the feeling of being respected and treated like the person deserving of dignity that you are. Such dehumanization can have indelible impact on the psyche.

The converse is true, letting it happen to you, can lead to PTSD. But not knowing it is happening to you seems to be a protection. It appears to me that the mother, Jessica, in the story was unaware at the unsavory practice that she was being subjected to. So what is worse? Not knowing you've been victimized, or knowing the feeling of violation because you do know you've been victimized?


........

After I had begun to process my birth experience, I wrote an email to the referring midwife telling her the outcome from her recommendation. To my surprise, I received a conciliatory email in response.

After I learned the term backdoor induction, I was upset for a couple of days. I talked through it with my colleague from Solace for Mothers and felt better sharing the stress with someone else. Since, I've intended to blog about it, but I'm only finding myself able to do so after writing the prequel and being triggered by the previous article I wrote about.

Sharon with Solace for Mothers asked me the question, "What are you now going to do with that knowledge?" I answered that I would write a letter to the hospital saying I knew what they did and emphasize how distasteful and unethical the practice is. I have not done that yet, because I'm struggling to find the words to express how and why that is so wrong.

So, I'll ask my readers, after telling my story in a letter to the hospital and midwifery supervisor, how do I support my claim that practicing backdoor inductions is an unethical practice?

If I could do it all over again Part 1: Preparing for Childbirth

I've learned so much from becoming a mother and my blog is somewhat of a catalog of that learning. Since I posted my review of Birth as an American Rite of Passage, I've been thinking about what I know now that I wish I had known before Willem was born. So much of it comes from what I wish I had read. I have often thought that if someone had told me that I could come away from giving birth traumatized by having to fight for an unmedicated birth, I wouldn't have believed them. I would have needed to read the right books to be fully convinced. I think I've now found a reading list that would have convinced me if I were to have read them while I was pregnant the first time.

Birth as an American Rite of Passage by Robbie Davis-Floyd

This has been a very influential book for me. Framing the obstetric culture in terms of technology over nature was a very helpful framework for me to see the potential battle that birth can be between a mother and hospital workers. If I had read the book while pregnant the first time, I would have know that I was in the wholistic camp, believing that a woman's body is capable of working properly to birth a baby. Viewing birth as a rite of passage also likely would have illuminated the spiritual aspect of birth in a way might have compelled me to view the upcoming event as a spiritual event as well. The women stories in the book also very clearly describe common hospital practices that upon reading, I would have known I wanted to avoid. Homebirth was clearly shown by the mothers stories to be one of the only viable ways of really avoiding those practices.

Rediscovering Birth by Sheila Kitzinger

The strength of this book comes from the cross-cultural descriptions of birth practices, as well as covering the history of childbirth. Kitzinger places the natural process of birth as the foundation of the book and so when describing the migration from homebirth to hospital, it becomes very clear to the reader how unnecessary a hospital birth is in the majority of births while respecting their usefulness is certain situations. As a first time mother, I had had no exposure to the cultural context of hospital birth. I believe, like circumcision, if I had known the history behind the practice, I would not have been accepting to engage in it. This book also highlights the spiritual and emotional aspects of birth, which as I've said, would be very helpful for me.

Pushed: The Painful Truth About Childbirth and Modern Maternity Care by Jennifer Block

While Rediscovery Birth examines the history of the way childbirth has been handled across societies, Pushed examines the current issues confronting childbearing women in our society. Like Birth as an American Rite of Passage, I believe I would have clearly seen the incongruent care being given to childbearing women and how that can lead to avoidable harms. Block gives a sense of the whole picture that comprises all the parts of maternity care and how each part in interrelated from hospital administration to insurance companies, malpractice lawyers, midwives and law-makers. I feel that the book shows very convincing how women can be painted into a corner when it comes to making decisions for birth. As it was so extensively researched with up to date information, I believe I would have been very convinced by Block's reporting.

Gentle Birth, Gentle Mothering by Sarah J. Buckley

Buckley describes the biology of childbirth and describes very well the type of environment needed to allow the process to occur most successfully. I feel that her presentation of the physiology defines why privacy, familiarity and no intervention is so important in childbirth.

From this book, I also would have learned the whys of babywearing and been introduced to the concept of elimination communication, which I may have been intrigued enough to try it as soon as Willem was born.

Ina May's Guide to Childbirth by Ina May Gaskin

If I could have read one book on how to cope with and prepare for the physical sensations of childbirth, this would have been it. It would have been very helpful for me to know about "the sphincter rule," the value of cuddling and "smooching" during labor, "horse lips" and maintaining a relaxed mouth and throat. The Hypnobirthing preparation I did do during my first pregnancy was helpful in learning how to relax and breathe but I feel that Ina May's Guide covers that very well, with more applicable information for the continuous motion often helpful during labor.

Also the normalcy of home and out of hospital would have been reinforced and added to how convinced I would have been to avoid the hospital.

A Thinking Woman's Guide to a Better Birth by Henci Goer

Not only is this book convincing for why common obstetric practices should not be routinely employed, it also works to prepare a woman who may need to have a hospital birth for whatever reason. I think through reading this book in conjunction with the others, my confidence in my knowledge of what I want to avoid would have been bolstered and I also would have been prepared to deal with the hospital if I had needed to.

If I had read all of these books relating to childbirth during my pregnancy (or before), I still would have needed to convey the information to my husband. He is more difficult to convince than I am when it comes to information that it outside of cultural norms or claims to be scientific in anyway. Like I found between my pregnancies, he did learn a great deal from the times when I stopped reading and couldn't help but tell him about the frustrating, funny, interesting fact that I had just learned. That strategy went a long way, but it did come to a point where he told me to stop talking about birth (more because it reminded him of the trauma he experienced from Willem's birth). Because of his limited time as a graduate student, I would have needed to pick one source of information on childbirth to share with him.

The Business of Being Born produced by Rikki Lake and Abby Epstein

This documentary provides a DVD format and covers all of the main points of the books I've listed. Its animation of the "technocracy's cascade of interventions" is useful in the quick way it describes the drawbacks of hospital birth. The history of hospital birth provides enough information to see just how money driven, patriarchal and unjust hospital birth's origins are.

My husband has seen the documentary and though he was convinced by the information regarding what is wrong with the hospital based maternity care system, he still was not completely convinced about a homebirth. HIs preference would be to fix the hospital system so unmedicated birth is the norm, but I think even he realizes that is not going to happen in time for births in our family. He accepted the homebirth option because he didn't see a better way, in the moment, that I was comfortable with. I think this is what is called "opting-out." Even still, I'm not sure whether he would have been convinced regarding homebirth without first witnessing the down-right abuse I experienced in the hospital giving birth to our first child.


All of the books, and the DVD, I discussed in this post are available on the amazon associates store that I posted at the bottom on my blog. There's reading list widgets for blogs or there's shopping directly from a blog, I chose the latter--saves time for the reader. That's also my explanation for why I didn't link individually to each item or post pictures, its all there, just below the post.

Review of Birth as an American Rite of Passage

I just finished reading "Birth as an American Rite of Passage" and I found myself wishing that if I had read just one book to learn about what giving birth in an American hospital would be like, I wish this book written by medical anthropologist Robbie Davis-Floyd. Through the words of women in response to interview questions relating to their birth experience, readers get a very realistic view of what obstetric culture is like and the expected role of women birthing in hospitals. I often said that if someone had told me what giving birth in a hospital is like based on culture, medical ideology, current practices, etc., I would not have believed them because it all sounds so very irrational, paranoid, conspiracy-theorist and unethical. However, after reading "Birth as an American Rite of Passage" I think I would have been convinced through Davis-Floyd's analysis and the selected quotes from women's birth stories. She clearly describes the "technocratic model" that predominates our current culture and how it renders women as objects who malfunction who are not to be trusted and who threaten the very premise that our world can be saved by technology.

In the article I recently wrote for the Exponent, I quoted the author's definition of technocratic birthing rituals and I'll also include it here:

“The term technocracy implies use of an ideology of technological progress as a source of political power. It thus expresses not only the technological but also the hierarchical, bureaucratic and autocratic dimensions of this culturally dominant reality model—dimensions that are immediately visible in many realms of post-industrial American life.”

Davis-Floyd goes on to state:

“According to the technocratic model of birth, the human body is a machine. The medical system [which is inculcated by the technocratic culture] has done a thorough job of convincing women of their defectiveness and dangers in their specifically female functions”—pregnancy and childbirth foremost.

Through reading the book, I've also come to have a greater understanding of why women are so steeped in our culture and why non-technocratic birth is unlikely (as 98% of women in the US give birth to babies in the hospital, and only 1% birth at home). Indeed, when as I became a mother, I too felt the obligation to follow the dominant culture. If only I had know the historical underpinnings of hospital birth and read this book, I may have been able to be convinced that birthing in a hospital was not the way I wanted to welcome my child into my arms.

I was pleased to read that Davis-Floyd recognized and named trauma as a result of birth experiences; however, the symptoms of post-traumatic stress disorder were misidentified as mild postpartum depression. In my research on PTSD resulting from childbirth, the earliest citations I have found declaring the diagnosis of PTSD were from 1995--before the first edition of the book was published. However, I am disappointed that in the revising for the second edition, the author did not update sections on trauma to reflect the new diagnosis.

Also I felt a category of women's experiences was missing. Davis-Floyd stated that of the 100 women she interviewed for the book that women either fully accepted and embraced the technocratic model of childbirth, they rejected it entirely or they were somewhere in between. To give the benefit of the doubt, there is a chance that the reason why my missing category was not included was because none of the women in her sample would have matched it. The in-between categories included:

• Women who maintained conceptual distance from the technocratic model by achieving "natural" childbirth in the hospital (15%)
• Women who maintained conceptual distance from the technocratic model by placing technology at the service of the individual (10%)
• Women who found conceptual fusion with the technocratic model with cognitive ease (42%)
• Women who found conceptual fusion with the technocratic model during birth by experiencing cognitive distress, e.g. trauma (9%)

And now, because you are wondering what this missing category I am referring is: I feel she left out, or did not have a woman in her study matching the profile, of a women who maintained conceptual distance from the technocratic model by achieving "natural" childbirth in the hospital with cognitive distress.

For this was my experience, I was able to attain the ideal unmedicated, low-intervention birth in a hospital and the detriment of my mental health.

Perhaps it could be argued that my experience would fit into the last category of finding fusion with cognitive distress, but I did not find fusion. And if someone wants to state that I did, because I consented to AROM at 5 cm, I'm not listening...

An interesting correlation can be mentioned however, that the percentage from Davis-Floyd's study of women who experienced cognitive distress is the same commonly cited percentage rate of PTSD after childbirth--9%. Making her omission of PTSD as a sequelae of childbirth, even more disappointing.

So in conclusion, this book is a very persuasive case for birth as a initiation rite for women as they transition to motherhood and current obstetric practice as a vehicle for gaining compliance and reinforcing the dominant cultural view of technology reigns supreme. If I were to create a list of influential, informative books for future mothers, this would be near the top.

To end, a quote from the book that summarizes why birth is so exceptionally profound and important to me:

Her baby constitutes for her a powerful symbol of her motherhood, her individuality, her new family, the beauty and wonder of nature, and the perfection of her own body and her procreative powers.