In reply to “2 sides of the story”

I received a comment on my last post, “Introducing the Mid-Columbia Birth Network” that I wanted a chance to reply to in detail. Go to my last post and read the comments there, then come back here for my reply. As it turns out, I don’t disagree with the commenter on the bulk of what they have to say. Actually I think we have quite a bit in common in our beliefs. I have no idea who this person is in real life, but chances are I’d bet we’d have a lot to not our heads in agreement over.

Like the commenter, It bothers me quite a bit when doulas, midwives and others prone to more uninterventive birth beliefs lump obstetricians and nurses into the “evil” category. I don’t for a minute believe that doctors and nurses are out to get women, wielding their evil epidural needles and their Pitocin bags as tools of torture and misogyny. I know obstetricians and L&D nurses personally and respect them immensely, although I won’t always agree with everything they practice (just as a group of nurses or a group of obstetricians might not agree on everything either).

It might surprise the poster that I have great memories of my own personal experiences with childbirth, but that they occurred at a local hospital with an obstetrician attending both times. I had planned epidurals – the first at 3 cm (it was an intense 5 1/2 hour labor, and I was just sooooo scared), and the second at 7 cm (I was able to cope the second time much better, partially because of the one-on-one support I received from the labor nurse assigned to my care).

That is not to say that there are not a ton of things I would change about the way I gave birth, knowing what I now know. (I have to wonder if I would still have a uterus if I hadn’t have chosen an epidural, consented to an episiotomy, and pushed with all my might during second stage, that resulted in uterine prolapse.) But I continue to learn about pregnancy and childbirth with every client I take, from every birth professional I meet (whether or not they share my own paradigm), and with every book I read. I do have to honor the person I was at the time of my births and remember that the hospital staff honored my wishes for what they were, and that I was treated with the utmost respect.

Doulas should never guilt a woman into not having an epidural. I never tell a woman if she should have an epidural or not. What I do is use the Pain Medications Preference Scale to assess where a woman’s desires are for epidural or other drugs. Then I help her achieve them. For a woman who strongly wants to avoid an epidural, if she says “I want an epidural!” during labor, I might bring up other things she might try, such as a bath or a massage or a change of position, or I might say “how would you like to try five more contractions and see how you feel after that”. For a woman who knows she wants an epidural as soon as she can have one, I might even tell her when she is a strong active labor pattern that it would be a good time to have her epidural now if she would like one. It is all based on her personal needs. Although I’ll tell her what the risks are with an epidural (which really, they are minimal), I have zero preference for if she has one or not.

I agree that my numbers from the World Health Organization I referred to on my last post are not stand-alone evidence to support a less interventive model of birth. As the commenter suggested, it is very hard and often unethical to perform randomized, controlled studies to determine how well a country is doing on maternal and fetal health as the topic is very complicated. However, I still think it is a valid part of the equation. I have a hard time believing that the countries that rank ahead of us don’t struggle with drug abuse during pregnancy or lack of prenatal care in similar numbers to our own country’s. It is interesting, however, to note that of the countries that the World Health Organization has labeled as “developed” countries, our country ranks toward the bottom on each of the lists. These countries can afford good health care, good drug education programs, and so forth as well as we can. Whatever the answer is, whether it be fixing the methods of birth or the health of women in general, I hope we can work toward finding the solution.

However, there is other evidence that shows that our current methods of obstetrical care might not be serving women in their best interests all of the time. Like most doulas I know, I try to keep up with what the medical evidence says so I can provide my clients with the best third-party information I have (and as I’ll expand on, let them make their own decisions with their practitioner about what is the best course of action FOR THEM). When I first started keeping up with the latest obstetrical research, I thought for sure I would find that there is solid evidence on both sides of the fence. And I vowed to support the evidence, whatever it said. I am finding that most often, the evidence I see coming through the obstetrical research news wire, shows a less interventive approach than what I currently see in the settings in my local hospitals is statistically the safest option for both mothers and babies with normal pregnancies, or at “worst”, shows that doing something and doing nothing carry about the same risk therefore the mother could choose the gentler approach if that is what works best *for her*. I often use the Cochrane reviews as a source of balanced medical research. Cochrane shows me that many interventions used in my area hospitals show no medical benefits or are actually more risky than doing nothing. For instance:

routinely breaking the bag of waters during labor actually does more harm than good

the use of continuous External Fetal Monitoring (EFM) did not reduce incidences of cerebral palsy (the primary reason EFM is used) but instead had a significant increase on the rate of the need of Cesearean birth or assisted vaginal birth

early skin-to-skin contact had greater benefits to a baby warmer alone (in a normal birth scenareo, fetal assessments can occur directly after birth just as easily on the mother’s chest, or even be delayed for an hour or so)

delayed cord clamping improves baby’s health

the risks and benefits of home versus hospital births are about equal

induction of labor before 41 completed weeks of a normal pregnancy has no medical benefit

there is not enough evidence to support using active vs. conservative management of fetal distress is a benefit

benefits to giving birth off your back include less pain, better fetal heart rate, less forceps deliveries and less episiotomies

there is not enough evidence as to the safety of misoprostol for induction of labor

If there are sources of information that I need to be checking for quality sources of obstetrical research, I sincerely want to know. I don’t want to ever give a woman information that isn’t backed by solid research.

The commenter mentioned many anecdotal stories of medical technology saving the day. I absolutely agree that these things happen all the time . I also absolutely believe that a less interventive method can save additional lives. I have many anecdotal stories where I have seen this happen or heard of stories where this has happened at births attended by people I know.  I also have seen and heard of countless stories where women were seemingly coerced into doing something that actually had the same or higher risks as the more gentle alternatives.  Or were made to feel inadequate or shamed by the medical staff.  Or were not given full medical information on which to make her own decision – or even told what was about to happen to her.

Doulas are not medical professionals, so we do not direct women what actions to take with their pregnancy. I try to present both sides of the information fairly and completely and always let the woman and her care provider make the decision together. Sometimes that means that I have to give information against my own personal belief system. I’ve given the pros along with the cons of routine use of an enema in early labor when it came up with a client, and I’ve given my unconditional support when a woman has chosen an induction based on no medical reason but because she was tired of being pregnant. But in the end, I always realize this is not my birth, it is hers. I haven’t lived her life, haven’t walked a mile in her shoes. Truly, although I might make a different decision, I feel only good will and understanding to the women I serve.As doula certified by DONA, I operate under both their “Standards of Practice” and “Code of Ethics” and it is clear that my job is never to perscribe, but to support:

“The doula should make every effort to foster maximum self determination on the part of her clients.”

The reason, though, that I and others have founded the Mid-Columbia Birth Network isn’t to attack practitioners who make decisions different than our own. (And if I see that happening, you can be sure I’ll voice my opinion to stop it.) When I said I might be a “pain in the ass out of the labor room” that was poor wording on my part. What I meant was that the Mid-Columbia Birth Network will probably be *perceived* as a pain in the ass. I sincerely hope not. I hope local obstetricians and nurses join us in our quest to improve birth outcomes and treat women as individuals in their care. We believe that the medical model of childbirth has been given over and over to women, but the less interventive midwifery model of childbirth is not so well known. We’d like to give a woman information so SHE can make her decisions based on more than pure trust in whatever her caregiver says. We’d like her to be a partner in her own care.

I should point out that when I say “medical model” and “midwifery model” I am only using those words for lack of better ones. Of course there are many doctors who operate by spending longer appointment times with their patients, who are interested in them in a holistic way (emotional health, family health, etc.), and who suggest such techniques as squatting for pushing, eating and drinking during labor instead of IV fluids, and intermittent monitoring. And of course there are midwives who practice more in line with I call the medical model – keeping labor on a timeframe with use of Pitocin or other drugs, using Cesarean birth liberally, and having shorter appointment times. And when, occasionally, I say “natural birth”, it is also because it slips out occasionally. See my older post on that subject. I try to use a term like “unhindered” or “physiological” or “mother-friendly” (refering to the Mother-Friendly Childbirth Initiative) when I am trying to get my point across – yet sometimes the old language sneaks in as it is so prevalent in the doula community.

I hope this clears things up. I think we agree on much. I’d love to hear what your thoughts are.


9 Responses to “In reply to “2 sides of the story””

  1. 1 Gollum February 4, 2008 at 7:14 pm

    I believe fertility drugs increase the number of multiple births (e.g., twins, triplets, quadruplets, …).

    I believe multiple births increases the number low weight babies.

    I believe low weight in a baby is a risk factor for cerebral palsy.

    Have fertility drugs increased the number of cases of babies born with CP?

  2. 2 Karen February 4, 2008 at 8:30 pm

    Like you, I’m a doula. I serve the laboring woman. I hold the space for her. My personality, my philosophies, my preferences – none of those matter in the room where her birth happens – only she matters. Will she look back on this time and know she was supported each step along the way? That is all I ask myself.

    I sometimes where my activism hat – at BirthNetwork here in CT, when I was in the birth play, sometimes even as a teacher of Childbirth Education. I will play the role of advocate in the labor room – but never activist. Like you, I know the time and place for all these things. My most important role in that room is support and I cherish it, as you do too.

  3. 3 single mom ~ left of the middle February 5, 2008 at 9:26 am

    I know there are doulas and midwives who are very judgmental, and are very one sided. When choosing a doula or midwife or even an obstetrician, a woman must decide whether that particular provider is going to be judgmental, or give them the kind of care/support they are looking for. Women must be advocates for themselves. Kristina is not the kind of doula to judge. I have never felt that she has judged any of my choices, and she has been nothing but supportive. Each mother to be, and care provider have their own views, personalities, and experiences that they are bringing into the labor room. The important thing is finding the right doula and midwife/OB for YOU.

  4. 4 2 Sides of the Story February 7, 2008 at 7:23 am

    I wanted to respond to some of the comments posted.
    In regard to Gollum’s questions. You are right about fertility drugs increasing the number of multiple births. The reason for that is that most fertility drugs or fertility methods increase the number of eggs available for fertilization. With a greater number of eggs, the greater possibility that at least one will become fertilized. So, if you have 4, 5, 6 eggs, available for fertilization – you take the risk that they all will get fertilized.

    As far as you questions regarding multiple births and cerebral palsy, I found a website that might better answer your questions. Here’s the link
    I hope that helps.

    In regard to Karen’s comments. I personally am not a doula but I work in the Neonatal Intensive Care Unit and throughout most areas of the hospital (ER, Adult Critical Care, Intermediate Unit, Medical floor, Surgical Floor, Pediatrics). I attend all high risk deliveries. I find it interesting that so many of us have similar opinions but express those opinions very differently. I think that is where forums like this help to clarify what one is thinking so that as a community, we can work together for what is best for our patients and their families instead of against each other.

    In regard to Single Mom~Left of the Middle. You are right that you must choose carefully who your care provider is. Especially when you are going to work so closely with this individual for at least 9 months. Use your intuition. If you don’t feel comfortable with who you have chosen, find someone new. Your care provider should be willing to work with you, answer your questions, address your concerns and make you feel confident enough to trust him or her. If a provider won’t take that time with you, find someone new. Remember that every patient has a bill of rights. Look for it the next time you are in a hospital. Here is a website link to an example of that those Bill of Rights are.

    And as I have said before, ASK QUESTIONS! A lot of information or comforts are available, you just have to ask. Unfortunately, not everyone informs their patients of the kind of options they can have but the have to ask for. So keep asking questions until you are comfortable.

  5. 5 2 Sides of the Story February 7, 2008 at 8:17 am

    In regards to Kristina’s response.

    The situations I brought up in questions in my first response was to point out that the fact that statistics can be made to support a particular side, it depends on the test subjects and the conditions of the study. More information about how the study is conducted and who was tested helps me understand the statistics better. For instance, testing all healthy women may yield different results from testing all women who may have circumstances arise that affect the outcome no matter what birthing method is used. So it wasn’t that I was trying to put down the statistics but gain more information about it.

    Another point I would like to make is that medicine is a ‘practice’ and not an exact science. We learn from a particular disease or situation and do what works the majority of the time. Unfortunately, there is always one person who reacts differently to a particular illness or situation. It is a constant learning process. We are constantly reviewing our treatment methods to see how we can improve upon them.

    As medicine moved from the dark ages and medical break throughs occurred, the medical community felt the need to save everyone. But that lead to new problems such as end of life issues. Now we have learned that it is ok to allow a patient to die with dignity instead of keeping them a live forever and ever. The medical community used to be very strict on visiting hours and who could visit and everything looking so sterile. Now, we look for non-medical ways to help promote healing. For example, I work at a ‘Planetree’ hospital. That means that there are no set visiting hours (except when report is given to protect patient privacy), any family member can come visit you (including your pets), music, and massages are available, religious leaders are encouraged to visit as well as having clergy on staff who respond to all emergent situations to help families, we have a healing garden as well as a non denominational chapel (we have even taken our patients on a ventilator down to the garden) and many other things all to help promote healing. We no longer kick families out during resuscitative efforts but allow them to be in the room if they so desire. Even our birthing rooms have changed from the past to try to make the room closer to a home environment. Is the system perfect? NO. But that is why we encourage input and are constantly reviewing and looking for ways to improve. It is essential to healing. And does the change happen quickly, not always, it takes time. (some times too long)

    Even out medical treatments are constantly changing. We test methods or treatment and then review and review and review. If the results aren’t what we want, we go back to the drawing board and try a new method. And the public probably doesn’t see all the changes that occur but also realize there are strict rules governing how we treat our patients. You can see that process when a new drug comes out. It takes years before we see a new drug available because it has to go through so many testing processes. Our sue happy society has prompted that process. If it is a good drug the process takes too long. If it is a bad drug, they didn’t test it long enough.

    I’m glad that you keep up on the latest medical news so that you can provide the best advice and care for your patients. But I wanted to share with your readers the fact that medicine is ever evolving and not just in the areas of medicinal treatment but non-medical treatment as well.

    And as I have said before, choose your care provider carefully. I have been on many deliveries where the physician is very good about helping the mother have a positive delivery and does what he can to avoid episiotomies and c-sections. I have also been to deliveries where I wondered if the physician knew what he was doing. I’m sure there are also doula’s and midwives out there that are fantastic and some that you wouldn’t recommend to anyone. It becomes an interview process to choose someone who has your best interest in mind.

    I also want to briefly mention that not all women, though they enjoy their baby once it is here, do not enjoy pregnancy or actually giving birth. And that’s OK. Just because it is a wonderful and miraculous process, it’s ok if someone doesn’t like it and voices her options that she doesn’t like it. And if she does have an opportunity to express her dislikes, it provides an opportunity for those who do enjoy it to suggest what might make it a better experience for her next time.

    I do have another thought. We put a lot of education into the pregnancy and the birthing process but sometimes I think we forget to educate our women about what happens after birth. How long it takes for your milk to come in, the help available for nursing mothers (not all babies get the hang of it right away), how you will feel afterwards, etc. I think that was a bigger eye opener for me when I had my first baby and wish I had a little better education in that area. Postpartum depression is a prime example of some of the education needed before the baby is born. We should be more proactive about making sure our mothers have a positive experience beyond the birthing room.

  6. 6 Agatha February 7, 2008 at 12:03 pm

    Following on from the last comment, I’d be interested to learn more about postnatal care in the USA.

    Here in the UK we visit the mother at home for ten days postnatally. That is… if she gives birth in the hospital & leaves at say, 8am, then we’ll probably pop by that afternoon to see how she is. If she is discharged at night or late afternoon, we’ll be by in the morning to see how things are going. Same for a home birth.

    We visit on days one through ten, sometimes daily, sometimes just 3 times – it all depends on the woman. We usually discharge on day 10, but can discharge up to 4 weeks postnatally if a woman needs more support. We then hand over to a health visitor, who visits a few times a year for up to 5 years.

    We run baby weighing clinics for, well, baby weigh-ins. We also run breast feeding peer support & baby cafe’s.

    How does that differ to the US?

  7. 7 Kristina February 7, 2008 at 1:36 pm

    Agatha – here in the US, almost all women give birth at the hospital so I’ll discuss what happens there with regards to postnatal care.

    Once the baby is born, the care of the couplet is transfered to a different nurse – still working for the L&D unit, but is assigned to mother-baby care that day. She works to provide comfort to mom if she’s had any lacerations/episiotomy/cesarean, instructs mom on how to wash baby, and helps out with getting breastfeeding going soon after birth and troubleshoots any issues that come up. She watches for illness in mom and baby. For a first-time mom she might give more hands-on teaching/assistance with baby care. She should talk about the differences between baby blues and PPD. Our local hospital has a PPD support group however that is not well known. (It’s listed as a resource on our birth network site, however.)

    At the hospital I usually go to, we have lactation consultants on staff M-F during normal “office” hours. A mom usually will stay in the hospital for one to two nights after a birth – if it was a cesarean birth she’ll stay an extra night or two. Chances are unless she gave birth late Friday, the lactation consultant will stop in to mom’s hospital room. They talk not only about breastfeeding and how things are going but will often discuss baby care basics such as Dr. Harvey Karp’s “Happiest Baby on the Block”‘s five S’s (swaddling, side/stomach position for cradling, shushing, swinging, sucking) and how not to operate on any timeline, how to tell if your baby is getting enough to eat, etc.

    It really depends on the nurse you get – some are very pro-breastfeeding but some really push the formula to be on the safe side, even if iron levels, etc. all come back within the normal range. I’ve heard of nurses telling patients that formula is the same thing as breastmilk.

    When Mom is discharged, she is offered a free gift bag from either Similac or Enfamil that contains various goodies and also a big can of formula. (Whether or not mom has chosen to breastfeed exclusively this is offered.) Often this leads to Mom beginning supplementation with formula at home for convenience factors or fear something isn’t going quite right with supply or whatever – when in actuality everything is perfectly normal. Often that leads to mom’s supply not having a chance to build properly in those early weeks and then supplementation becomes more and more necessary. (This is not even mentioning the formula ads in magazines, mailers, baby fairs and television.)

    Free phone support and clinic visits to the lactation consultant are available after mom is home. (Too bad more women who wish to breastfeed don’t take advantage of this before they pop off the lid of the free can of formula.) They’ll weigh baby before and after a feeding, check her latch, troubleshoot and/or answer any questions mom might have about supply issues, how often to feed, etc.

    As of this moment we do not have an active local La Leche League chapter but I’m hoping to change that soon. 🙂 Our hospital offers breastfeeding education as part of their three-day prepared childbirth series (so much to cover in three days!) but does not have a separate class just about breastfeeding.

    After hospital discharge, the next time mom sees her provider (usually an OB), it is in week six. Breastfeeding is discussed as is mom’s and baby’s health and mom’s mood is discussed and PPD/baby blues is screened for, usually informally unless there are obvious signs.

    Once the six week visit is up, that’s usually the end of the assistance in a normal birth scenario.

  8. 8 single mom ~ left of the middle February 8, 2008 at 9:13 am

    I wanted to mention, that I gave birth at the hospital you are referencing on a Tuesday… and I asked to see a lactation consultant because I really couldn’t get baby to latch well… and they told me one wasn’t available. The only assistance I really got with breastfeeding was right after delivery from the labor and delivery nurse, and at the 3 day nurse check… at which time she said that baby wasn’t hardly getting anything when latched on to the breast without the shield… so to keep using the shield. Then she casually mentioned that WHO recommends 2 years of breastfeeding as a minimum. I called WIC… and the nurse who said she would help me PP simply said that the shield was not recommended.

    I guess my point with all this, is that there is very little support to mothers PP… and I really think that that has a lot to do with the high post partum depression rate. After the birth of my first child two years ago, I didn’t even know what the baby blues were.(and I took the class you referenced as well) I was completely surprised when all the sudden I was crying for no reason. I think that something needs to be done to change this. Not only for the health of mothers but for the health of babies as well.

    Breastfeeding does not come naturally, and many women don’t know other women who have done it successfully. Grandmas who breastfed don’t live in the next room anymore to help out the new mom. Most of our grandmas (or mothers) probably exclusively formula fed. I had never seen another mom breastfeed until I joined a local AP group in my area.

  9. 9 Agatha February 21, 2008 at 10:30 am

    Sounds very different to us.

    Here, mothers who have had a normal vaginal delivery with no significant blood loss & a good weight beby will go home in 4 to 6 hours. They stay in longer if the babe hasn’t fed or if there was meconium or pyrexia, maybe they’ll stay in 6 to 8 hours, & one the pyrexia is under control, off they go!

    A c-section means a 3 day stay, sometimes more, sometimes less.

    We don’t teach bathing as we recommend no baths for a week, just topping & tailing… things like that are all taught in antenatal classes anyway. We do spend a lot of time, both in the hospital & at home, on breast feeding support. Sometimes we’ll be in a house for a few hours, getting it right.

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