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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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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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A group called The Unnecesarean pointed out today that anesthesiologists, themselves, are aware that WALKING in labor (“ambulating” in medical terms) reduces cesarean rates. Though I am an advocate of natural hospital birth, I share the goal of reducing unnecessary cesareans. It seems to me that if “walking epidurals” are known to reduce the risk of cesarean in women who want epidural anesthesia, we should be offering these more often. (Please know that I say that with the belief that no woman should be offered anesthesia in labor that she does not want. Women who want a natural birth deserve FULL support for this!) As “The Unnecessarean” points out, the anesthesiologist quoted in this article is blunt in admitting that it is “easier” to manage laboring women in bed. But labor is not about ease. It is about birthing the next generation. It is worth the hard work of women AND hospital staff!

Here are some excerpts and a link to the article. Thank you to The Unnecesarean for pointing this out.

Most notably, only four of the patients who received a walking epidural experienced hypotension compared with 44 patients in the nonambulatory group. Only 113 in the walking group required bladder catheterization compared with 187 in the nonambulatory group. Motor block was seen far less frequently in the ambulatory group (14 vs. 145 patients in the nonambulatory group), and cesarean delivery was less common as well (53 vs. 65, respectively).

On the other hand, patients who received walking epidurals reported more pruritus and required more interventions, as demonstrated by higher total PCA volume and use of rescue doses of ropivacaine. The duration of labor was unaffected.

“Even with the benefits to the patient, walking epidurals are not used very often because they are more time-consuming in terms of patient management,” said study leader Shaul Cohen, MD, professor of anesthesiology at UMDNJ, in New Brunswick. “It’s much easier to keep them in bed with a Foley catheter. And it’s an insurance issue. Insurance companies pay for care not quality of care, and they won’t pay for the additional time and staff required by walking epidural.”

Dr. Cohen added that the increased use of cesarean delivery—nearly 45% of laboring women in New Jersey now undergo the surgery, he said—makes it more difficult, if not impossible, for obstetric anesthesiologists to offer patients the walking epidural approach.

Others in the field have a more tempered view of its benefits, however. “There is no ‘ideal’ epidural infusion regimen for labor analgesia,” said David Wlody, MD, chief of anesthesiology at the State University of New York-Downstate Medical Center, in New York City, and a specialist in obstetric anesthesiology. “Different patients, anesthesiologists and obstetric providers will have different expectations regarding pain relief in labor,” said Dr. Wlody, a member of the editorial board of Anesthesiology News, who was not involved in the latest research.

“Some patients may be willing to tolerate a greater amount of discomfort if it means enhanced ability to ambulate, while others will desire more pain relief at the expense of increased motor block,” Dr. Wlody added. “It is the responsibility of the anesthesiologist to balance these often conflicting goals in order to provide the best outcomes and the highest degree of patient satisfaction.”

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Clinical%2BAnesthesiology&d_id=1&i=May+2013&i_id=956&a_id=23112#.UaSyPv1c7Q0.facebook

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Hello pregnant women!

Fewer of us than ever before are signing up for traditional childbirth education classes. You know, those old-fashioned classes that meet in person. With a teacher. And maybe a textbook. Perhaps “class” reminds you of high school. Or college. And you do not want to be in SCHOOL any longer.

Besides, everything you need to know about birth is on youtube. Right? OK, well, then. Maybe it’s on Parenting.com? Or Childbirth.org? Or the American Pregnancy Association? Or WhatToExpect.com? 

Oh, dear. There’s a lot of websites that offer “childbirth information.” And the information they offer conflicts. A lot. More importantly, the information is not well-tailored to your unique situation.

No, problem, says the modern mama-to-be. I know how to get information tailored for me! I will jump into some chat rooms or join a website and ask my specific, individualized questions. Then the magic of the Internet will quickly provide me with the answers I need.

This is, indeed, how the majority of American women are preparing for childbirth. But childbirth is a very different process than researching what car to buy or whether or not to cut bangs this week (Michelle says, “Yes!”). Preparing for childbirth on-line is sort of like preparing for a triathalon on-line. There are good tips out there, but we all know that the REAL preparation is occuring off-line in what I would call “real life.”

Childbirth is a unique life event and probably nothing you have ever done in your life (except give birth previously!) can serve as a good model for how to prepare. I don’t know of any other event that requires the combination of social (how to interact with hospital staff and birthing professionals well), emotional, relational (negotiating the needs/wants of partners and parents and siblings), intellectual, and physical that birth requires. Many people compare birth to endurance sports events like marathons, but the fact is that few marathoners have to negotiate important medical decisions with doctors while they are running.

So, what you get in childbirth education classes that you CANNOT get on-line is the opportunity to practice in the presence of an experienced guide. When you READ information, it does not stick with you nearly the way it does when you have practiced what that information tells you to do. As Yogi Berra said, “In theory there is no difference between theory and practice. In practice there is.

You learn SO much by getting to ask a question and having a personal INTERACTION about your question. You get to practice — try out — different ideas in this safe place that is not yet your labor or your baby’s birth. In this place, you get to practice thinking and feeling and relating different ways. You have a teacher, who has probably been at a number of births and seen some of those ways play out in real life, who can guide you in your thinking and feeling and relating.

Childbirth education classes are not really about information. The “facts” are readily available on-line. It is the practice of trying this idea and then this one or, hey, maybe this one that makes this information useful for you. When you are in labor you do not need theoretical knowledge. You need very, very practical knowledge.

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Reposting my all-time favorite post. Because I love my job! Every so often I get a bug to become a better-paid birth professional. Doulas are just not the top earners in the birth field, sad to say.

And part of me is a real midwifery geek. I know I would love learning to become an obstetrician or a midwife or a labor and delivery nurse. I love learning about blood vessels leading to the placenta, about how to guide a breech baby out, about how to diagnose an ectopic pregnancy. Really. GEEK is the only word for the thrill I get from reading about such topics.

But when I am at a birth (as I was a few days ago) I have this fabulous role. This birth brought it home. Everyone else in the room at this hospital VBAC birth was focused on getting a recalcitrant baby out of a woman’s body as fast as possible: cutting her vagina open, attaching vacuum suction cups to the baby’s head, and adjusting various accoutrements to keep track of the baby’s heart rate (which was low and not coming up in between contractions… thus the drama and concern).

In contrast to the midwife, the L&D nurse, the obstetrician, the resident, and the neonatal team, my job was to remain full of trust in birth. My job was to help the mother stay connected to her calmest, most trusting place inside herself. I was allowed to smile and tell the mother that we could all see dark, curly hair as her baby’s head crowned. Everyone else was 100% focused on getting this baby’s head OUT. Fast. The mother and I were able to concentrate on this baby’s individuality. (Her previous babies had blonde hair.)

When the baby was born, the neonatal team whisked him away because of the heavy meconium. (Yet he was FINE immediately. At one minute he had an Apgar of 8. So much for all the panic!) No one but me noticed that the mother was panicked without being able to see or or hear or touch her baby.Of course, after all that drama when she didn’t hear a cry right away, she was afraid her baby was not OK. I was able to stand in the middle of the room and relay news about how her baby was waving his arms and legs and his skin was a beautiful, healthy pink color. All the birth professionals were busy, with important jobs for which they went to school for many years and for which they get paid fair salaries.

But would I rather learn how to measure a cervix or help a mother find her inner power? I am so, so glad that there are birth professionals out there who answer, “I want to measure the cervix.” Without these professionals, birth would not be as safe as it is today. Yet I am happy when I remember that my greatest joy is not measuring blood pressure or fetal heart tones, it is in aiding a woman have the experience that makes her feel like she is a powerful, amazing mother who can do anything. This is a feeling she gets to keep for the rest of her life.

Helping women smile when they remember giving birth. That is a doula’s job.

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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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Summer Doulas

It is March. I am sending in my daughter’s form for her first sleep-away camp this summer (she is ten and SOOOO excited!). As I look ahead at the summer, I realize that I will not be able to be a doula most of the summer. AGAIN. It is so hard for women who have babies in July and August to find doulas who will be in town. I am going to be gone two weeks in July and at least ten days in August. This must be a big problem for all doulas and for all moms-to-be who want a doula in the summer. What did YOU do?

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