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Archive for the ‘Midwifery’ Category

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“I can’t afford a doula,” said a pregnant woman to me recently who was only a few weeks away from giving birth. “And, anyway, my husband is going to be there.” We chatted a while about the kind of birth she was envisioning. This was her first baby. She had a strong desire to avoid a cesarean and to give birth without drugs. She really didn’t want a “huge needle” in her spine.

This mother had clearly done her research and knew that many of the interventions that are so common in American childbirth are unnecessary. She had a lot of statistics at the tip of her tongue and we discussed many of them. I could tell she was determined to beat the odds, even though when you think about these odds, you probably would not bet against them in Vegas!

Eighty-three percent of American women receive pharmaceutical drugs for pain during labor (despite polls that show that most women say they would prefer NOT to do so). Ninety-one percent of American women lie on their backs or just a bit propped up when they are pushing out their babies. Forty-seven percent have bladder catheters during labor (which means they are NOT walking around). The list of interventions goes on and on. (These statistics come from the study “Listening to Mothers III.)

When I asked her how she thought she would avoid these common interventions, she said, “Well, I’m informed. I’ve done my homework.” She imagined herself just saying “no” to these interventions during labor.

This is when I asked whether she’d considered hiring a doula and she told me she couldn’t afford one. I asked how much the doulas she interviewed cost. She had not interviewed any doulas, but she’d “heard” that they cost $1,000.

In my town, only the most experienced doulas charge $1,000 as birth doulas and the real going rate is somewhere between $350-700. So her data on this point was inaccurate. But this woman’s tone indicated that this line of inquiry was closed. She was just not open to the idea of hiring a doula in these last weeks before giving birth and I could tell that continuing that conversation was not an option.

But if she had been open to the conversation, this is what I would have said to her:

It’s possible that you will have the kind of labor that never gets really hard. You might pay $1,000 and realize at the end of the day that you and your partner could have handled that birth without any outside help at all. It does happen. I have met such women before.

It’s possible that you will have the most amazing labor and delivery nurse who reads your birth plan and gives you a lot of labor coaching because she is a strong believer in natural birth. Even at the moment when you say, “I can’t do this anymore. Get me an epidural!”, this nurse will say back to you, “You’re doing great. Just focus on this contraction.” And you will focus on this contraction and the next one and after a few minutes that feeling like you can’t do it anymore fades away and you start to feel the urge to push. This also happens. I have met such women before.

It’s possible that your midwife will maintain a calm and protective aura in your room and never let you know that there is a resident just down the hallway who is watching your baby’s heart rate monitor and suggesting all kinds of interventions. This happens. I have watched it happen in hospitals in my town.

It’s possible you will be able to speak calmly and rationally throughout your labor. It’s possible that you will be able to interact with your hospital staff very rationally and weigh pros and cons of interventions on the spot. It’s possible that when the obstetrician says something like, “I’m a bit worried about your baby and I’d like to get some more information. I’m going to break your bag of waters and put in this internal monitor,” you will be able to say, before the next contraction hits you, “Oh, thank you so much for your concern. Is my baby in real danger right now? Could you tell me the pros and cons of this procedure?” And the obstetrician will patiently wait at your bedside while you handle an intense contraction that lasts a minute and a half. When you’re back to yourself, the doctor will touch your arm gently and explain the particular situation with your baby (who is not in imminent danger) and the pros and cons of breaking your water and using an internal monitor. Except that the explanation will be interrupted by four more contractions. But you have the best obstetrician in town, who will patiently wait through all of these contractions. You will be able to ask specific questions about parts you don’t understand. You will ask about alternative ideas. And you will be the kind of woman who is still able, after all this, to say politely, “No, thank you. After considering your explanation, I don’t want to do this right now. Let’s wait a little while longer.” It’s possible.

Although I want to tell you that I have not really met more than a handful of women who can do this during an active, strong labor.

This is where women who want natural births without unnecessary interventions often end up “giving in” and later regretting it. They are deep in the physical work of labor and they can’t really (and shouldn’t really!) concentrate on logical conversations. All the intellectual information we have gathered during pregnancy really does us almost no good when we are in labor because we are not really able to access much of our intellectual knowledge during labor. It’s much easier to say, “Yes,” during labor than it is to articulately say, “No, thank you.”

We imagine ourselves as our everyday Self in labor. Our everyday Self may be a strong, educated, and even opinionated person who is able to advocate for herself. But our Labor Self is a different self. Our Labor Self is strong and educated in a very different way, in a sensual, physical way. Labor Selves rarely articulate themselves well in full sentences and well-considered arguments.

You don’t pay $1,000 (or, more often, $500) for the labors that are easy and that you could manage without help. You pay $1,000 (or, more often, $500) for the possible times that having a doula changes the game.

So, if we are playing the Vegas odds, let me tell you that while it’s possible you will have that easy kind of labor in which your doula is really unnecessary, the odds on it are not very good. Maybe 3 in a 100. But the chances that a doula has something to offer you in labor that turns out to be important? Well, those odds are worth betting on. I’m going to put that at about 89 out of 100 or even higher.

In case she is needed, what will she be needed for?

Maybe for fifteen hours of squeezing your hips because when she squeezes your hips during a contraction, the pain changes from unmanageable to just manageable. But.only.if.she.squeezes.your.hips.EVERY.TIME.

Maybe she will help you walk around the hallways when your labor seems “stalled” at six centimeters and the hospital staff say it is time to think about a cesarean for “failure to progress” and it turns out that getting moving helps your labor a lot and you are eternally grateful for your doula’s insistence on walking before agreeing to the cesarean.

Or back to our scenario of “rational decision-making” during labor. It might feel like you paid $1,000 for her to whisper to you, after the doctor explains the pros and cons of the intervention, “I know you’ve heard what this doctor has said. Do you want a minute to discuss this with your partner?” And you nod your head. The doctor leaves the room and your partner is able to ask you, without a lot of eyes and ears around, “I know how important doing this naturally is to you. Do you want me to tell them we don’t want to do this and we want to wait a few hours?” And you can nod your head. You don’t have to say any words. You have a team that knows what you want, a team that knows how to create a situation in which you are likely to get it, and that does not expect you to talk rationally.

Let’s be honest that most women in America will not pay even one penny for this kind of support. Around 94% of American women, in fact. Maybe for these women paying $1,000 (or $500!) is not worth it for these “moments.” They are happy enough to go along with the routines of the hospital and have the kind of birth that the hospital staff guides them toward. If their labor is medicated and no one suggests anything “hippie” like walking around or using a shower to manage labor pain, if they end up with an unnecessary cesarean, they are pretty OK with it. They choose the route of “going with the flow” and that route works well for them.

But if you are the kind of woman like the one I met at the park the other day, the kind of woman who has done her homework and knows the statistics, who wants to beat the hospital intervention childbirth odds, then I would roll my dice with a doula. Every time.

photo by Salvatore Vuono

If you want to read more about ‘Listening to Mothers III” you can find a report here:http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-III_Pregnancy-and-Birth.pdf

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Brazil ImageBrazil has a cesarean rate that is, depending on the year, the highest in the world. Their rivals include Taiwan and China, but not the United States. Here we hover around the 33% mark, but in Brazil about half of all babies are born by surgery and in some urban, private hospitals the rates are in 70-90% range.

To put this in perspective, if we took a 20% cesarean rate as “normal” (and I do not think that is normal!) as a 2010 World Health Organization report did, several million Brazilian women are having unnecessary cesareans every year. That report calculated a world-wide excess of 6.2 million cesareans annually and half of those are in China and Brazil.

(http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf, p. 8).

Why is the cesarean rate in Brazil so high?

If you ask Americans, they tend to blame Brazilian women.  Almost invariably, the first ideas we Americans have are about how the WOMEN must want more cesareans, how the women must be more used to surgeries (since they have so many more plastic surgeries than American women), how the women must be more concerned with keeping their vaginas tight and beautiful, how the women must not be willing to undergo labor.

But when I ask Brazilians in the United States, they tell me the same things that American women tell me. They say things like, “My doctor told me I didn’t have enough amniotic fluid” or “My baby was too big to be born vaginally” or “My baby was in distress.” In other words, Brazilian women understand their own cesareans as medically-necessary, even though statistically it can’t be true for most of them. (The same phenomenon occurs in the United States, I find.)

A 2014 article in the Atlantic confirms this. That article concluded that the medical system is not set up to support laboring women who are aiming for vaginal births (much less unmedicated vaginal births!). In hospitals where 70% or more of births are by cesarean, women who aim for vaginal birth are nuisances to the schedules of doctors and nurses. And it is a self-fulfilling prophecy that doctors and nurses who are skilled at cesarean birth become less and less skilled at managing natural labors.

All of this adds up to a fascinating cultural picture that I am eager to learn more about. So I am headed to Brazil at the end of May for a two-week crash course in all things birth in Brazil. I will be in Florianapolis with Ana Paula Markel, doula trainer extraordinaire, and in Belo Horizonte with my Portuguese teacher, who has promised to introduce me to young women and their families who are in the thick of this childbearing conundrum.

I’m so excited! If you are Brazilian, Brazilian-American, or an American who has given birth in Brazil, I want your stories!

Here are two articles if you’re interested in more.

http://www.theatlantic.com/health/archive/2014/04/why-most-brazilian-women-get-c-sections/360589/

http://www.pri.org/stories/2014-05-14/brazil-half-all-mothers-have-c-sections-whether-they-want-it-or-not

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So, I wish I wrote this about the cesarean rate. And I wish I made all the great graphics to go with it. But, even though I didn’t write it myself, I’m in love with this piece. It’s really helpful for answering the question I get all the time, “So, why do you think the cesarean rate is so high?” I can talk, talk, talk about all the reasons, but this piece just quickly runs through the reasons and more importantly gets to WHAT WE CAN DO actually.

Let’s get to it!

http://www.toprntobsn.com/bringing-birth-back/

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Waves

Surfing the waves of contractions, photo by Folkert Gorter

Active labor.  Contractions are hard and occasionally whipping up higher than expected. Massage and hip squeezing isn’t working. The birthing mother’s voice is getting higher and tighter.

As a doula, sometimes in these situations I reach for a visualization. And for active labor, there is no better metaphor than waves. There are so many ways to use this metaphor. Here’s an outline you can use and embellish as you like on the spot.

Here comes the wave… Take a deep breath… Now dive under this wave and through it and through it…. and now you’re coming out on the other side… swim up… Take a breath… Let it go

It’s OK if there are moments of silence in between your words or sentences. You don’t have to be talking the whole time. Speak slowly and use a low, calming voice. If she follows your lead, her own imagination will be filling in most of the details. You are just there to give her a bit of guidance. By focusing on this image of a wave, she can more easily let go of other thoughts that might have been causing anxiety (like, “How much longer will this go on?” and “I’m afraid of the next one.”) Our minds will fill with thoughts if we don’t give them something to focus on.

If you’ve never talked someone through a visualization, it can feel strange to do it the first time. I think we fear that everyone will look at us strangely and wonder why we have started talking in a sing-song voice about waves. In reality, my experience is that everyone in the room is usually happy that there is something besides pain and, often, the blips of machines on which to focus. Often the birth partner and nurses in the room will quietly take part in visualizations and, if it appears to calm down or help the birthing woman, they will even take it up, adding their own voices to the visualization. You may feel funny at first, but if you give it a real try, I guarantee you will be pulling this trick out in a lot of births.

What’s your favorite visualization?

 

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Russia Breastfeeding article

This looks like strikethrough text, but click on it! It is the link to my article about breastfeeding and “low milk supply” in Russia. We are so used to our own cultural context that we can forget that we ALL see pregnancy, birth, breastfeeding, and parenting through our own particular culture. As a breastfeeding conference is underway in my favorite city (Toronto!), I thought I would share this article I wrote a while ago about my experiences in Russia.

Things have changed in Russia since I did fieldwork there in 2000-2001, but I still think it is valuable to understand how others in the world think (or thought) about women’s reproductive bodies.
You can also get to this article by clicking on the words ‘Related articles” below. That brings up the Google link!
by C Gabriel – ‎2003 – ‎Cited by 2 – ‎Related articles

THE EFFECTS OF PERCEIVING “WEAK HEALTH” IN RUSSIA: THE CASE OF.BREASTFEEDINGCynthia Gabriel. The state of Russian health has declined.

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I see my main job not as a doula, but as a public advocate whose mission is to mainstream natural birth. That doesn’t mean that I PREACH about natural birth (unless I am preaching to the choir at a doula or midwifery conference). I’ve found that preaching doesn’t get me very far when I am talking to the uninformed, underinformed, or people who actually disagree with me. But I do try to take advantage of situations in which it makes sense to tell positive birth stories and bring up my profession as a doula. Just saying the word can be a powerful catalyst in a room of people who’ve never heard it.

I watched it happen today, except it was not me who said the word. It was a college student, just explaining to other students in a class why he had missed class the day before.

His wife is a doula. She had been attending a birth for twenty-four hours. He had to stay home and watch their toddler.

I teach anthropology at a working-class state university in Michigan. My students are a DIVERSE group, though they are usually poorer and come from more disadvantaged backgrounds than the students at the fancy state university (University of Michigan).  That tiny spark — a man saying the word “doula” to fellow students — resulted in several conversations right there in front of my eyes. I didn’t start the conversation. I just stood there, basking in the glow of people talking about birth and realizing that there are more options than they knew. Ripples. Seeds planted.

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I just read a blog by a woman who was trying to decide whether to hire a doula in her second pregnancy. She eloquently captures that inner dialogue that I bet a lot of women have about this question: Is a doula a luxury or a necessity? In her blog post, she talks about her unease with consumerism. Do we need to buy things to be happy? Do we need to spend money to regain our confidence in our own birthing bodies? You can check out her blog here: http://mothershavefeelingstoo.wordpress.com/2012/08/29/doulas-necessities-or-luxuries/

In this post, I want to offer one idea in response to the Mastercard-buy-more-to-be-happy-consumerist problem we all live with in the First World. One of the problems with consumerist culture is that we mistakenly believe that the THINGS we buy are what gives us pleasure. In fact, the things we buy are things that real humans made, transported, sold. It is their WORK that gives us pleasure. When we buy services (massage, health care appointments, a haircut, or doula services) this is more evident than when we buy objects.

When we remember that it is human’s work that we are paying for, not just “things,” we can make wholly different choices about spending money. We can spend money and stop being a “consumer” if that makes sense. We can USE money to connect with other humans. So often we do the opposite. We use the fact that we are paying someone money for something like a haircut or cleaning our house or taking care of our children as an excuse to treat them differently than we would a friend or relative. We all do it. (Be warned: Sometimes when I try to treat someone I am paying for a service more humanely than they expect, they act as if I am crazy.)

As a doula and as a woman, I value so-called women’s work — no matter who does it, men or women. Long ago as a teenager learning about women’s work in history I vowed that I would pay childcare workers fairly even if they themselves did not charge a fair amount (which is true in our area. Our babysitter charges an absurdly low hourly rate and doesn’t charge for sick days: hers or ours!). A more accurate term I learned in graduate school is “reproductive work” — which is all the work that is (usually) unpaid if it happens within a family. It is the work that is necessary to reproduce ourselves everyday (taking a shower, mending clothes, cooking, doing dishes, gardening, etc.) and to reproduce another generation (childcare, etc.)

Because of larger cultural and global forces outside of any one person’s control, we are not able to do all the reproductive work inside families anymore. In my case, a big factor is that my parents, my husband’s parents, and all our siblings (eight in all) live far, far away from us. The closest is a ten-hour drive; many of them live across the globe. Many of my friends rely on their extended family for SOOO much help. My best friend here sends her two kids to her in-laws overnight every Saturday. [An aside: I can’t imagine having a night off of children to spend with my husband free of charge every week. When we do hire a babysitter, we have to go out of the house. I would love to stay at home and sleep at home with my husband with no kids in the house!] Just because I would prefer to have much of this reproductive work done inside my family networks doesn’t mean that is the best way to do it in 2012.

In general, I try hard to be thoughtful about using money and when I pay for reproductive tasks I find I am even more thoughtful than when I am buying plain-old commodities like new running shoes. I want to be thoughtful when I am buying running shoes, too, but I find it is easier to be thoughtful when I actually meet and interact with the human who is doing the work. Because when I pay for reproductive work (cooking, cleaning, childcare, doula work) I am asking someone to step into the shoes of my relatives. I am asking someone to care for me/my loved ones. Money is just the vehicle that allows someone else to have the time to do this work that I do wish my sister, my mother, my grandmother could do for me. But they can’t. So I am using money as a tool — not a substitute — for connecting to real humans.

It’s not a perfect solution to our consumerist culture. But being clear that money is really a metaphor for human time and that what we buy is human work — not “things” — makes me more thoughtful about my choices. And the surprising conclusion I come to when I think this way is that I want to spend MORE of my money on things like doula services and home-cooked meals and less of my money on things like technological gadgets.

What about you?

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