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.

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.

The Prequel: My Traumatic Birth Experience

Although my birth story is often cited on my blog, I have never written out the prequel to the story. My traumatic birth didn't start in early labor, it actually started weeks before.

When I was in week 34 of my pregnancy, I was working part-time at a preschool (9am-1:00 pm each day). I had a commute and prep time before class started so I was waking up at 7 am. I'm not a morning person (if you ever notice when most of my blog entries are posted you'll know that I'm a night owl). I was constantly tired in my pregnancy. I'd get home from work and have to take a long nap each afternoon just so I could function the next day. One day, I had to rush away from work for a prenatal appointment, but that day had already been a struggle. I was fighting nausea the whole day (strange for the third trimester) and had thrown up 3 times, once as I was getting into the car to head to the appointment. Already feeling tired and sick, I encountered unexpected traffic which was making me late to the appointment. I generally get very stressed when I am late to something so the combination of being impatient, stressed sick and tired was not going well for that appointment. I then parked rather far away from the clinic and had to walk (more like jog since I was worried about being so late).

That sets the stage for what happened at the appointment. In typical technocratic style, once checked in, I was weighed, pee collected in a cup, blood pressure assessed. Would anyone like to guess what my blood pressure was after my previous hour?

168/88

The midwife comes in and goes over the results of the glucose intolerance test from the previous appointment. The values were higher than normal prompting a discussion regarding gestational diabetes.

As an aside, I knew the results were going to be skewed because I was unable to handle the glucola being the only nutrition in my body at the time. Rather than sweating it out since I felt very close to passing out, I snacked on my ever handy blood sugar stabilizing snacks I carried around with me. The good news is that I didn't pass out on the way to the lab, the bad news is the false result on the test.

It already was not a good day to hear news like that, coupled with the way the midwife said it. She seemed very unaware to my stress level and was not sensitive to how concerned I was regarding the way in which she stated it and my frustration with her for not consenting to the 3 hour fasting test as a follow-up. If I had had such a negative reaction to the 1 hour test, having eaten lunch just before that appointment, how in the world would I cope with a overnight, drink the glucola on an empty stomach after waking up even earlier than usual and then waiting 3 hours test?

So after that conversation, the midwife plunged right into, "...and your blood pressure measurement from earlier indicated that you have pregnancy induced hypertension." If you have a copy of William's Obstetrics handy, or any other prenatal care textbook nearby, you'll find that the minimum criteria for a diagnosis of PIH is a diastolic value of over 90. In the same paragraph in William's it states that some practitioners like to make the diagnosis when a woman's diastolic is elevated 15 points above her baseline, which would have been true in my case, but if one were to continue reading, one would see that William's states that is not a recommended procedure for diagnosis.

I was visibly upset by this time at the appointment and receiving no assurances, compassion or comfort from the midwife who was speaking to me. I called my husband and in tears told him what was happening. He at the time had been having a conversation with his advisor and when he heard my husband say, after looking at his phone, "Oh. Its a number from the medical center. It must be Jenne probably calling from her prenatal appointment right now," said, "That means something is wrong. Go. Now."

He ran over to the clinic (on campus) and we sat down with the midwife. My husband was surprised at how the midwife was handling the situation because based on what she was telling him, he didn't see that she was making a reasonable assessment. She counseled that I go on immediate bedrest and cut salt out of my diet entirely. Although we were not entirely trusting her judgement, we decided that bedrest was better safe than sorry. We spent the next week trying to get a better sense of the risks of PIH (by this time they had dropped the concern of GD) and we couldn't get a better sense of their concerns based on the information they had given us. We consulted with a number of the midwives and nurse's assistants on staff and we basically got, "PIH can lead to preeclampsia and preeclampsia can mean that the baby dies and the mother can stroke out and die."

We did our own homework and read up on what we were being told, and it didn't add up. I still stayed on bed rest and attended the non-stress test appointments that were scheduled twice weekly. But we knew that what was happening was not as serious as they made it out to be.

A couple of weeks later, at an appointment with another midwife in the practice, I was told, "In all my 20 years of being midwife, I've never see a woman with blood pressure like yours go into labor on her own without being induced." Not only does that say something about her practice style, it also says something about her knowledge.

Up until this point, in my prenatal care, I had tried on a number of occasions to discuss with the midwives policies relating to the birth. Each time I had been told that we would discuss it later. I had never had a satisfactory discussion about my desire to have an unmedicated birth using Hypnobirthing. The midwives did not seem interested in discussing it.

Now at this appointment where I'm being told, they'll basically pressure me into an induction whether I like it or not or whether its indicated or not, I felt like I needed to run away from that practice. But I was 35 weeks pregnant with my first baby, living in a big city that I wasn't familiar with having moved there less than 6 months before, and not very knowledgeable regarding birth options. I thought, if a midwifery practice is going to be this unpleasant to work with, how could working with an OB be any better? We considered and discussed transferring over care to the OBs in the practice, but I was scared of the medical mindset. I wanted midwifery care, but didn't know enough and felt that I didn't have even time to find out about out of hospital options.

So I stayed, like a domestic abuse victim in a violent, toxic relationship.

A friend volunteered to be my doula to help protect me from the unwanted advances of the hospital staff. Having made those arrangements, I told myself that I would hope for the best and pray that labor started on its own before the threat of induction became more real.

In week 37, after 3 weeks on bedrest, and having made it to "full-term" I asked my husband what the soonest time would be okay with his schedule as a first year graduate student for the baby to be born. He said that after Thursday Jan 25 all his tests would be done and that weekend would be an okay time.

Bedrest was, in some sense, a blessing. At the time I was enrolled in my M.Ed program and I had work to do. I spent the month of bedrest doing assignments and getting started on my thesis. It was helpful. But the drawbacks were also considerable. I felt myself getting weaker the longer I stayed inactive and immobile. I'm pretty sure the baby moved into an unfavorable position and further exacerbated the scoliosis in my spine. I started getting headaches and being dizzy, which just made the midwives want to say I told you so since those are indication of progressing preeclampsia, but its also a sign of weakness as a result of inactivity and a lack of salt in the diet. I believe these factors contributed to the long labor (38 hours) as well as the hours of back labor (17 hours worth). Add that to being a first time mom, going into labor earlier than it would have likely been otherwise at 38 weeks, its not surprising that I had a long early labor. It would have been very helpful to know of Ina May Gaskin's teachings for husbands and wives to; as she calls it, "cuddle and smooch" during labor.

We made it to that Thursday, and we decided that we would try out the strategy of starting labor via intercourse and what I've jokingly heard referred to as "prostaglandin application." And then we prayed. We prayed that labor would start and the baby would come, so that we would be protected from the providers that at this point we did not feel safe with. We then fell asleep and I was woken up 4 hours later by menstrual-like cramps coming every 15 minutes.

I let Peter sleep but I couldn't. I was so excited and so relieved that labor had started on its own. At six am, I couldn't keep my excitement to myself anymore and I woke Peter up. We talked, we were happy and we decided that it was just be stupid to go to the hospital at that point because we knew for sure that we were going to avoid going to the hospital too early. We then discussed if I should go to the scheduled non-stress test at 11 am. We decided to keep the appointment, if not to avoid the within 24 hour cancelation fee. But before, I wanted a big breakfast. So like a runner getting ready for a marathon, we went to IHOP and I throughly enjoyed my breakfast feeling exhilarated that not only had I thwarted the mid-witch, I was going to meet my baby.

At the appointment, we knew it was too early to go to the hospital, even though I had been contracting for close to 11 hours at that point (still 6-10, sometimes 15 minutes apart, easy to manage). The NST showed that I was having irregular contractions and my cervix was dilated 3 centimeters. We were surprised when the midwife at the clinic called up the Labor and Delivery and told us that we would be checking in. I thought it was still too early, but went with the recommendation.

Then we enter what I call the flight pattern period of my labor. Labor and Delivery said they were full, they could take me so I should go home. At home, I got a visit from my visiting teachers--they thought it was very strange that I was in labor and welcoming them over and how calm I was dealing with it, but it was early labor and it was easy to handle. After calling and checking with Labor and Delivery a couple of times, they were still busy. So I waited. All I wanted to do at that point was to go into my labor space and focus, turn inward--what I called at the time "holing-up." I couldn't do that at home knowing that I'd have to leave. (This is about the time that homebirth started sounding appealing but completely out of the question since it would have been completely unplanned). We went out to lunch, basically tried to distract ourselves and stay near by the house and the hospital in case we got the call saying we could come in.

At 4 pm, we were finally able to get into Labor and Delivery. No progress. Contractions still 6-10 minutes apart. Hourly vaginal examines commence. We walk the halls of the hospital. At the gift shop, we find a mini set of bowling pins with a marble to "bowl" with. We buy it in celebration of the anniversary of the day we met three years to the day before at the bowling alley in the BYU student services center. Looking back, we should have just gone to the bowling alley and bowled through early labor.

At 9pm, 1/2 centimeter progress and the midwife starts talking options. She offers 1) send me home with an Ambien to sleep, 2) give me morphine, move me to another room in the hospital (not L&D) and make sure I'm sleeping or 3) pitocin augmentation and breaking water.

Is this starting to sound like a phenomenon that you've heard of before?

As I sat on a birth bath and handle contractions as they come, we refused, refused, refused. My husband tried to talk to them but they refuse to talk with anyone other than me. We countered with, sure, its reasonable to clear the LDR room for another mother in labor, but we'd refuse the morphine and go to another room to let labor progress on its own. Its surprising how hostile the midwife was to that. The room was only offered if I accepted medicinal sedation. At the time, that felt so dehumanizing. Like I was being viewed as a dying horse that needed to be take out back and shot to be put out of its misery. Or that she wanted to make me the hospital's prisoner, but instead of using shackles, she was going to use drugs (hello, 24's use of medical torture?) An OB was called in and we were told, "You have no more options. Its time for you to leave. Get out."

As we pack up and get ready to leave, we look for a nurse, or a midwife or the receptionist at the check-in test to find out when they would like us to call back or at what point to return, and there's no one around. So we leave, feeling neglected and confused.

Go figure, that once at home, labor picks up pretty quickly and intensely. I started having a hard time finding a comfortable position. I could lay down comfortably and I had been upright for so long that my legs were tired. I started having back labor and it was difficult to support myself on the birth ball. My husband and doula tried to get some sleep. They gave up pretty quickly and then helped me into the bathtub. The water was too shallow, and not hot enough, the tub walls hard and uncomfortable. So I lay hurting, cold and shivering. I start to get frustrated and despondent. I call L&D and I'm told that I can come back in and get checked for progress but I might be turned away again. I'm gun-shy at this point and I'm too afraid to go back in, too upset with the insensitive way I was treated earlier, knowing that the same midwife would still be on the shift. I found that she was going to get off shift at 8 am, so I became determined to stick it out.

We get to the hospital at 8am and she's still there. She does the triage exam which I've blocked from my memory. All I remember from that is spots of blood on the floor of the triage room that did not belong to me.

That's a good point to stop and refer you to birth story that I wrote soon after Willem was born, and have edited slightly since then.

In the next few days, I'll post regarding some insights I've learned since experiencing this.

Applying the MCFI to virtual maternity care

I'm finishing a project where I analyze whether maternity care providers provide mother friendly care based off the Coalition for Improving Maternity Services Mother Friendly Childbirth Initiative so this technique for analyzing birth care is at the front of my thoughts still. So when I came across this segment of RoboMom, I could not help by apply the MCFI steps to what I observed.


Based on the segment, these are the steps that I see were broken:

Step 1 A, B & C: Husband, family members, doula and midwife were not present.
Step 4: Freedom of Position was not encouraged or allowed.
Step 6A: IV and Electronic Fetal Monitoring were used; both procedures which are not supported by research.
Step 8: Baby was not given directly to mother for skin to skin contact, bonding and breastfeeding. Baby was unnecessarily moved across the room for newborn exam.

Also referring to the preamble of the MCFI which contains something like The Birthing Woman's Bill of Rights, it appears that the birthing woman's preferences were not respected because the "voice" for her did not grant assent to her leg being supported in the human stirrup.

It is unknown from the segment whether the birth was medicated or not and if it was the case that mother felt encouraged by hospital staff to accept pain medication, Step 7 was also broken. Also unknown was whether this labor was augmented or induced by Pitocin which would have been breaking Step 6B.

Good news, an episiotomy was not performed. And it appears that the mother was allowed to push when she felt the urge and was not coached (strongly) by the providers present.

Lastly, and this may not a fair critique since who knows how lifelike this robot is, the doctor should not pull on the baby or placenta while they are being delivered. Such practices have a strong likelihood for doing more harm than good including increasing the likelihood of hemorrhage, retained placenta, perineal tears and physical trauma to the infant. If this were a real situation and the doctor did that, it could also be coded as negatively abiding by Step 6.

This is a project that I would really like to do using footage from TLC's Baby Story. If you think this sounds like fun, let me know. I don't have access to TLC or full episodes, so if you have recorded episodes or know if you can by seasons online, tell me.

I even have the spreadsheet to quickly code for each principle and step for the MCFI on hand!

Revisiting Birth Plans

I'm always on the look-out for birth plans that catch my attention for using a novel technique or strategy that in some way can garner cooperation and respect from hospital workers when parents try to communicate their needs. Since there is such a disparity between practice and evidence in birth services, most of the time, women who prepare birth plans are trying to get the evidence based practices employed in their births rather than what is on the contrary typically done during hospital births.

Below is a birth plan a mother shared with me recently. The reasons I think it is worth sharing are:

• It recognizes the need for intervention in some situations and does not overinflate or minimize the risk of birth. Perhaps by framing the topic with "birth in inherently dangerous" hospital workers will be more receptive to reading the desires of these parents. While recognizing the risks and dangers, it emphasizes the fact that birth is typically normal. This balanced view, I hope, will earn the respect of birth workers.

• The parents include the reminder that they have the right to informed consent and given concessions when consent might not be able to be obtained, while at the same time remaining firm that consent is necessary.

• The father is explicitly stated as medical proxy if the mother at some point becomes unable to make decisions for herself, or even if she wishes at some point to grant the proxy to her husband verbally. This shows in a clear manner that the husband is involved and needs to be respected in the case that he states any decision.

• Hospital staff are not obligated to support the provisions listed in the birth plan, but are merely stating that they have read it. This should be less threatening than the typical birth plan which generally presents a document asking hospital workers to make some sort of commitment to upholding the provisions; something that most workers are very hesitant to do for fear of liability.

I understand that birth is inherently dangerous, and, if the situation warrants it, interventions can be good, even lifesaving, that being understood, the vast majority of births are a normal, natural process that need little more than ‘the tincture of time’ to reach a safe and healthy end.

I understand that, at any time, my written or witnessed verbal consent may be given and will override any previous non-consent or refusal. I understand that in a true emergency there may not be time to fully explain or receive consent for a life saving procedure, and I will not attempt to interfere with life saving interventions. I expect every attempt will be made to give me any information possible before, during, or immediately following any emergency situation.

My husband and I, as legal guardian and rightful biological parents of Baby (last name here) have the right to informed consent and to choose to consent or refuse any and all medical interventions or procedures given to our child, both before and after birth. I, as an adult of sound mind and legal rights, have the right to informed consent and to choose to consent or refuse any and all medical interventions or procedures to my body, before, during, and after labor. My husband is my chosen medical proxy for all medical and legal decisions should I be unable to make decisions on my own behalf.

_____________(patient/mother)

_____________(medical proxy/father)

I/We do not consent to:
Ø Artificial rupture of membranes (AROM) before full dilation and effacement
Ø Induction of labor prior to 42 weeks by any means physical or medical
Ø Augmentation of spontaneous labor by any pharmaceutical means
Ø Epidural or other pharmaceutical pain management
Ø Continuous electronic fetal monitoring (EFM)
Ø Frequent pelvic exams
Ø Episiotomy
Ø Cesarean Section
Ø Coached pushing
Ø Immediate cord clamping or cutting
Ø Formula or glucose water for infant
Ø Separation from infant
Ø Eye salve for infant
Ø Vitamin K shot for infant

I/We will:
Ø Eat and drink as my body demands during labor
Ø Labor and deliver in any position comfortable
Ø Allow intermittent fetal monitoring using a Doppler or fetoscope
Ø Allow rupture of membranes if waters have not naturally broken by full dilation and effacement to avoid a birth in the caul
Ø Allow pelvic exam at least once per four hours of labor provided consent is obtained before each exam
Ø Use water, heat, cold, massage, movement, change in position, and other non-pharmaceutical means to cope with labor pains and to help labor progress naturally
Ø Push as my body demands, making every attempt to inform provider when I am ready to start and when I am pushing

I/We expect/demand:
Ø My husband will be there for labor and birth unless life saving measures require all non-medical personnel be removed.
Ø Immediate skin to skin contact with infant unless life saving measure makes this impractical: Baby is to be taken from my womb to my stomach or chest, depending upon length of cord. Any vitals or physical check of baby can be accomplished while baby is on my chest. If cord is extremely short, too short for baby to be safely placed upon my lower abdomen, every attempt will be made to retain cord connection for at least 60 seconds before clamping and cutting.
Ø Cord will be left intact until it stops pulsing: Baby and mother are to remain connected unless life saving measure makes this impossible, many life supporting measures can be safely and readily done with cord intact, allowing baby to continue to receive oxygen and blood through the cord, which has been show to increase positive outcomes.
Ø Placenta will be allowed to birth normally: Cord traction and forced delivery of placenta has been shown to increase risk of hemorrhage, we will attempt to nurse, try nipple stimulation, and continue to push during contractions as my body indicates until placenta is delivered naturally.
Ø Baby is to remain in room: Baby will not be separated from mother/father, all vital checks, physical exams, and other medically indicated newborn procedures can be done with baby in the room, after a reasonable amount of direct skin to skin bonding we will allow baby to be weighed and, if agreed upon, washed in room by nursing staff/hospital staff as needed.
Ø To be consulted and given full information on all procedures performed on baby:

We consent to standard weight/measurements and heel prick for state mandated blood testing, however, we expect to be informed when these things or any other procedures or tests are about to be done, we may ask for a delay or more information before continuing.

Signing does not indicate personal or medical agreement, opinion, or recommendation, it indicates only that signee has read the document.

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Mothers and Fetuses: Whose Rights Trumps Who's?

One of the fears facing homebirthing and unassisted birthing mothers is a transfer to the hospital where their motives and "fitness" as a mother are called into question by hospital staff; sometimes resulting in CPS taking the newborn from its mother and the mother faces criminal charges. Another fear is the court-mandated Cesarean where a women is forced into a surgery that maybe against her wishes.

Lorna A. Turnbull discusses these issues in the article "The Legal Characterization of Pregnancy and Mothering: Does Mother Know Best?" in the Spring/Summer 2001 issue of Journal of the Association for Research on Mothering.

She states that the legal system has historically relied on a medical model of pregnancy that dictates the behavior and decisions made by a women. The state has then attempted to regulate pregnant women's behavior through criminal prosecutions or by allowing civil actions against the mother.

"The medical model removes the power of women with respect to their pregnancies and places it in the hands of doctors, or in some cases, the state. The model allows women to be depicted as self-interested or incompetent. The standards of medicine become the norm against which a pregnant woman's behavior is judged and a woman who decides against the norm of medical science is cast as irrational and selfish. A woman who defies the truth of medical knowledge becomes a bad mother, one who has declined to put the perceived needs of the foetus ahead of her own concerns."

Homebirthing and unassisted birthing mothers know this frame of reference all too well. By choosing to birth a home with or without a professional who is not a doctor, women are considered to be flouting what the medical establishment has deemed proper behavior for birthing women. The American College of Obstetrics and Gynaecologists have repeatedly decried the dangers of homebirth calling mothers "selfish," "irresponsible" and "incompetent." Conversely the vast majority of mothers who do choose to birth their babies at home do so beleiving that it is within the best interests of their baby and themselves; as to not be exposed to the risks attended with hospital birth. Ironically, the evidence based research of the most appropriate care for birth aligns with homebirth practices moreso than hospital births for low-risk women. Yet women are still being framed as unable to understand medical practices and then stupid and irresonsible for choosing to go against those practices. It seems that we still live in a world of "doctor knows best."

Rixa of Stand and Deliver also gave a talk discussing Risk, Responsibility and Safety at the 2008 Trust Birth Conference.

Legal Rights to Informed Consent in Birth

This article from the Seattle PI "High rate of C-section births is health concern for women" was a breath of truth and reality of what women are facing with birth.

This is the first time, in a news media outlet, that I've seen hospital practices framed as coersive and trying to manipulate women's birthing choices. And the first time I've seen the abuses of the fields of obstretrics frames as a health issue, as well as a legal issue regarding reproductive rights and patient's rights.

One particularly persuasive quote from the article, says:

Such reasoning inappropriately views a pregnant woman's decision about her and her baby's needs as suspect, and it ignores her legal rights as a patient. All pregnant women, whether they view birth as a natural event only rarely needing medical intervention, or whether they willingly accept medical assistance with the birth process, have the legal right to informed consent and to direct the experience of bringing their children into the world.

The issue needs increased awareness. It goes beyond the talking point of VBACs and coerced Cesearans although those are grave concerns that need to be addressed. Please post comments to the PI article.

Birth "Think-Tank"

The Tatia Oden French Memorial Foundation is currently partnering with doulas and childbirth researchers and birth activists in forming a birth "Think Tank". The purpose of the Think Tank is to gather information, perspectives and solutions to the state of childbirth in the US, which now focuses on the "medical" model of childbirth. We hope to change the direction of birthing in the US and bring it closer to its natural state. Understanding HOW childbirth evolved to where we are now .... and the educating women regarding natural childbirth. If you would like to join us please contact us at momoden@sbcglobal.net

I found this today on Tatia Oden French Foundation website. Through the course of my graduate students, I had begun to wonder if the birth activist community needed a think tank to further the work of improving maternity services through research, advocacy and policy.

For those unfamiliar with what a think tank actually does, here is the definition from wikipedia: "A think tank (also called a policy institute) is an organization, institute, corporation, or group that conducts research and engages in advocacy in areas such as social policy, political strategy, economy, science or technology issues, industrial or business policies, or military advice."

I am most familiar with think tanks relating to issues regarding early care and education (since that is what my graduate degree is in) but as I've been transitioning from preschool issues to birth issues, I've realized the birth community can benefit from the coordinate efforts of a think tank created for the purposes of correcting what is wrong with the way birth is treated today.

This blog post is a call to other researchers and activists to consider what your role can be in assisting in the organization and efforts a birth think tank. As I find out more information, I will post.

Unlocking Birth Plans

When I was pregnant, I thought of a writing a birth plan for a hospital birth was like a cafeteria, you had choices--you could take and leave what you wanted. That's when I developed my birth plan based on the real life example of others. I wrote all the things I wanted with provisos about all the things I didn't want. It was three pages, complete with a very nice letter to the nurses, midwives and doctors I would be working with.

Then after I discovered what hospital birth is really like, I heard birth plans being maligned. I learned that birth plans aren't typically read but are often scoffed at before they are thrown in the trash. But information still promulgates that birth plans are useful tools in having individual desires, wishes, cultural and religious values being respected; while others state that birth plans are useless.

I've been trying to figure my through this chasm of opinion. I wasn't quite prepared to throw away the birth plan idea all together, but understood how they often do not have the effectiveness that families desire. One solution I've heard touted is a birth plan should take up no more space than a 5 x 7 index card with easy to read font (no 7 pt business). I didn't understand how that was possible, based on the number of birth plans I'd read and the one that I too composed in preparation for birthing in a hospital.

Recently, in the book "Pregnancy, Childbirth and Your Growing Latter-day Saint Family" written by a registered nurse and certified childbirth educator, I read an example of what a index card birth plan would look like and I began to see how this would be plausible. I will attempt to reproduce what I found:

Room: Labor, deliver, and recover in same room at local hospital
Other people present: husband, doula (a woman who provides professional labor support), and maybe mother
Food and drink: light foods, juice, water as desired
Fetal Heart Rate: intermittent, with initial 20 minutes electronic monitoring, then hand monitored every 15 to 5 minutes as needed.
Pain Relief: relaxation, breathing, comfort measures, shower, hug and kisses from husband!
Labor Stimulation If Needed: walking, changing positions, nipple stimulation
Labor and Birth Positions: mother's choice
Pushing Techniques: short (limit to six seconds), spontaneous bearing down
Perineum: try to prevent tearing with support, gentle pushing, no episiotomy
Cord Cutting: father cuts cord after pulsating stops
Immediate Baby Care: baby held by parents for first hour and given opportunity to breastfeed
Feeding and Contact with Baby:feeding on demand with 24 hour rooming-in

I had to see it to believe it, but that fit on a 3 x 5 index card (admittedly with probably 8-9 pt font). It concisely described a family's desire to have "as natural a hospital childbirth as possible." Having seen the example, I can see how it can be adapted to an individual's wishes. In the space remaining on the line regarding immediate baby care, I would make a note refusing the Vitamin K shot, vaccines and erythomycin). I would make use of those blank lines and add no artificial nipples of formula supplementation; supported squat, upright pushing positions; warm compress and counterpressure on perineum, etc.

But there you have it, a short, concise, fit in the palm of your hand birth plan. They do exist.

Becoming A Transitional Character

I learned about transitional characters in a family studies course in college. The term mostly was applied to breaking the cycle of abuse or alcoholism in families, but I recently realized that it can be applied birthing traditions in families as well.

The definition of transitional characters was originally given by Carlfred Broderick in his 1980 book called "Marriage and the Family" (currently unavailable on amazon).

A transitional character is one who, in a single generation, changes the entire course of a lineage. The individuals who grow up in an abusive, emotionally destructive environment and who somehow find a way to metabolize the poison and refuse to pass it to their children. They break the mold. They refute the observations...that "the sins of the fathers are visited upon the heads of the children to the third and fourth generation. Their contribution to humanity is to filter the destructiveness out of their own lineage so that the generations downstream will have supportive foundations upon which to build productive lives.

A few weeks ago, my mother and I were talking about the history of birth practices (or the generational transmission of birth, if you will) in our family. I know my birth story. I was born via Cesarean section at 39 weeks 4 days for being breech and for the convenience of having my father in town, since he needed to leave for work around my due date. My mother was born in a hospital in 1953, so we can assume that twilight sleep was used on my grandmother. Unfortunately, we cannot ask her for her birth stories of my mother and uncles since she passed away in 2006. That means we also cannot ask her what she knows of her own birth. She was born in 1921 in rural California, so its kind of toss-up if she was born in a hospital or on the ranch where my great-grandparents lived. Now my great grandmother was born in San Francisco in 1904. Hospital birth was still relatively new then (using a reference from the history of birth presented in the Business of Being Born), so she may have been born at home, but since it was a big city, there's also the chance she was born in a hospital.

Together, my mother and I couldn't come up with anymore information on the topic, so we started thinking of who in our extended family might have known. We contacted my grandmother's cousin who is currently the matriarch of the family. She was unable to give me anymore information other than she's pretty sure that both my grandmother and great-grandmother were born in hospitals.

So with that information, I pretty much am left to believe that the last 100 hundred of birthing history in my family has taken place in hospitals. If my readers are familiar with my story, my first child was born in 2007 (103 years after the birth of my great-grandmother) and his birth was enough to prompt me to "return" to homebirth. I had hoped that my history would have afforded some homebirth stories of my women ancestors but I was disappointed.

However, that affords me the opportunity to be the transistional character for birth in my family. It wouldn't be the first time. On my father's side, I'm a transitional character for stopping the transmission of emotional, verbal and sometimes physical abuse, so my efforts in parenting and my marriage are to overcome the tendencies and examples set by my father and his parents. This does raise the question of the history of birth on my dad's side. I know both my father and grandmother were born in hospitals, but I don't know anything about where my great-grandmother was born. I can ask my grandmother's sister who is still alive. I will update this blog when I've been able to converse with her on the topic.

Looking forward to the future, I plan to birth the rest of my babies at home, barring a medical need to birth in hospital, and this will start the tradition of homebirth in my family. I hope that my children will know and remember how they and their siblings were born so that they will too will expect to birth their children at home, in a safe, supportive, loving and gentle environment.