Things to Read

Trust Birth?

Virginia Bobro, co-owner and senior trainer for Birthing From Within, shares her thoughts about trust and birth, coupled with excerpts from Pam England’s new book. Originally shared on the Birthing From Within website. 

Instead of focusing on the adage, ‘Trust your body,’ trust that you can meet whatever challenges come your way. – Pam England

“Trust Birth” and “Trust Your Body” are common cliches, often tossed around casually in many childbirth circles, and also sometimes hotly debated, especially among those who have had or have witnessed difficult births. But what does it really mean to trust? And how might trust be helpful or unhelpful for pregnant people in their preparations for birth and parenting? Using excerpts from Pam England’s new book, Ancient Map for Modern Birth, let’s think a bit more deeply about the role of trust in childbirth preparation.

We know that hope and optimism are good for our bodies, minds, and relationships, and this remains true for expectant parents as they look forward to meeting their baby and moving into an exciting new stage of life. A positive outlook can reflect and build inner strength, courage, and resilience. It’s certainly true that expectant parents who feel relaxed and hopeful about birth and parenting are likely to enjoy pregnancy more than those who don’t. When expectant parents are mistrustful of themselves or others, they often feel overwhelmed by anxiety or paralyzed by a sense of hopelessness, rendering them unable or unwilling to ask for or receive help. They may research or plan obsessively in an attempt know and control all potential outcomes, or, on the flip side, they may give up and sink into inaction, feeling that nothing they do could possibly make a difference.

The potential pitfalls of excessive mistrust and pessimism are relatively easy to see; what may be trickier to understand is that excessive trust and optimism can also present significant difficulties in the form of complacency or passivity. If a parent is committed to thinking, “Everything will work out,” “I trust birth,” or “I trust my body,” then what is their motivation to take a childbirth class, or learn how to cope with pain, or ask questions, or explore fears? (Avoiding thinking or learning about cesareans, for example, is a common side-effect of unbalanced optimism – one that might verge on naïveté in this era of the 30% cesarean rate.) This is equally true – and equally risky – for those committed to unquestioning trust in their doctors or midwives. In all of these cases, the concept of “trust” closes the door on growth and curiosity, blocking opportunities for building knowledge, flexibility, and inner strength.

Let’s also keep in mind that phrases such as “I trust birth” or “I trust my body” may have very different meanings for people who have experienced birth than they do for people who haven’t. Often this nuance is missing when the phrase is used or debated. Thus, if a midwife or doula tells a first-time parent that they can safely trust the process of birth, the parent may mistake that statement as an implicit promise about the outcome of the birth: “If you just trust enough, then your birth will be easy and uncomplicated.” (And what an attractive and appealing idea! Who doesn’t want the “secret recipe” to a perfect birth?!) Most birth workers have no intention of conveying such a simplistic meaning when they talk about “trust,” but parents often internalize it in this way. This miscommunication becomes problematic if the birth is then hard, or long, or complicated – as births often are – and the birthing person feels confused and ashamed of what they may interpret at their failure, and betrayed by the person who encouraged them to “trust” in the first place.

In Chapter 6 of Ancient Map for Modern Birth, Pam England writes,

“This kind of birth trauma may be lessened by being mindful about the language we use to inspire, support and educate pregnant [people]–in particular by avoiding absolute language or outcome-focused messages. It is essential that any conversation about trust and birth be honest, compassionate, and realistic, not idealized, horrific, or oversimplified…Trusting your body is helpful and important; the problem arises when you believe that if you just trust enough, or in the right way, that you will have an ideal or natural birth. No amount of trust or preparation can guarantee an easy birth.”

That’s why, in preparing for birth and parenthood, it is so important to really feel into the concept of trust and what you are telling yourself about yourself as a birthing person and parent. How do you know whether you are trusting enough or too much? And what, exactly, ARE you trusting when you “trust birth?” Are you inspired to learn and grow, to think about the edges of the experience, to mobilize inner and outer resources to cope with unexpected challenges? Are you interested in paying attention to the messages from your body and your intuition? Are you willing to grow fearless about facing the unknown?

You may want to dive a bit deeper into the Trust pool, and ask yourself these questions:

How are you trusting that birth is, at its essence, a Mystery– unknowable and uncontrollable?

How are you trusting that you can access resources, internal and external, to help you cope with the intensity that birth can bring?

How are you trusting yourself to ask for and receive help and support?

How are you trusting that your body (no matter how carefully you take care of it) is fallible, imperfect, and surprising, and that your body has a wisdom all its own that may never be completely understood or explained?

How are you trusting that you are doing your best in each moment, and that the outcome of your birth does not reflect your value or worth as a human being or parent?

Look within, reflect on these prompts as you take a walk, eat a nourishing meal, or fall asleep. Share your thoughts with your partner, friend, or birth companion. Perhaps you will feel inspired to journal or paint your images of how you are trusting birth.

20 Reasons to Sign Up for a Childbirth Class at 20 Weeks

This wonderful article comes to us by way of Birthing From Within San Antonio & Mentor Nikki Shaheed

Original Article

As your belly grows and your sweet baby puts on the ounces, there are many exciting milestones! The first time you feel those tiny feet kicking, making it to the second trimester, wearing maternity clothes, and making a visit to your doctor or midwife, to name a few.

There’s another important milestone when you reach twenty weeks – the midway point in your pregnancy. As you round the bend to the second half of your pregnancy, it’s time for your attention to begin looking forward to the birth.

The twenty week mark is the perfect time to seek out and register for a childbirth class. Here are twenty reasons to enroll in a childbirth class at 20 weeks:

1) Have time to find a class that works with your schedule.
Beginning your search now can allow you time to look around for a class that works for your and your partner’s schedule, or to make short-term adjustments to your schedule in order to be able to attend.

2) Have time to find an instructor who’s a good fit for you.
You may have a particular learning style that works best for you, or a particular personality that you mesh well with. Checking out different websites and calling a few childbirth educators can help you get a feel for the person you’ll be spending several hours with and find someone with the philosophy, experience, and personality you’re looking for.

3) Have time to research different kinds of classes.
Some classes are only geared toward a specialized type of birth, while others are intended for people in all settings and birth types. Different classes can have a different emphasis or focus or set of beliefs about birth that they operate from. Starting the search for your ideal class (or classes) at 20 weeks can allow you to peruse the many kinds of childbirth education that are available and choose the one that feels like a good fit.

4) Learn what to expect in a hospital, birth center, or home birth.
Finding out about standard procedures in your intended birth space can help you to better navigate the healthcare system during pregnancy and birth.

5) Learn how to cope with pain.
Independent childbirth classes help birthing people understand a variety of ways to deal with labor pain and help partners understand how they can help.

6) Enough time to take more than one class.
With so many childbirth preparation options available, you may decide that you want to take more than one kind of class. Getting the ball rolling at 20 weeks gives you ample time to take in all the classes you need or desire.

7) Time to establish healthy practices during pregnancy.
Many classes teach families about sound nutritional choices for pregnancy, or postures or exercises that can help facilitate birth. The sooner you sign up for a class, the sooner you can find out about, and start engaging in these practices that are good for baby and good for you.

8) Be ready in case baby is born before your due date.
While many babies come after their due date, some decide to come earlier. Anywhere between 37-42 weeks is a normal time for a person’s labor to begin on it’s own and deliver a full-term baby. It’s a good idea to have completed your class series by the 37 week mark at the latest, if possible.

9) Understand the needs of the postpartum period.
Families need support and guidance as they transition to life with a baby. Learning about the needs of postpartum moms, partners, and babies during pregnancy will give you a chance to put a support system in place while you still have the time and energy to do it.

10) Acquire labor tools before the birth.
You may learn really cool things about how a birth ball or rebozo or essential oils can help you during labor. Getting a head start on classes also means leaving yourself enough time to gather the helpful tools you learn about in class.

11) Have conversations with your partner about the kind of support you want.
Figuring out what kind of help, words, and touch you may want from your partner in labor is an important part of childbirth classes. They may speak a different “love language” than you. Attending classes together can help you get on the same page so they can better meet your needs as you bring your baby into the world.

12) Referrals for doula, midwife, OB/GYN, IBCLC (breastfeeding support), chiropractor, birth center, hospital, pediatrician, babywearing educator, etc.
Childbirth educators are well connected in the birth and baby community and have a long list of resources available to help you deal with the many needs that may arise during the childbearing year, from finding a provider who specializes in the kind of birth you want to getting assistance with breastfeeding to finding a pediatrician for your baby.

13) Build confidence.
Getting ready to go through labor can be overwhelming and even a bit scary. Learning about the process and specific steps you can take to help you cope through it can help you feel more confident as your baby’s birthday approaches.

14) Build trust with your partner.
Parents who attend birth classes together build a foundation of trust together. The birthing person can trust that their partner has heard the same information that they have and can help remember things that are important as they drift through the hazy mental space of Labor Land. Trust promotes oxytocin – the hormone that also causes contractions!

15) Time to read or research.
You may hear about interesting books or videos from your childbirth educator or even your fellow classmates. Getting an early start on classes leaves you time to read, watch movies, or research any other important topics that come up during your class.

16) Reduce stress of the prenatal checklist.
Parents have many tasks to complete before the birth of their child, from gathering information about childbirth to buying baby clothes, and for some, even moving into a bigger house or apartment. With so many things to do, finding and enrolling in a class (even if it doesn’t start for a couple more months) will help reduce some stress for you as you check things off your to-do list.

17) Learn about the labor environment and establish boundaries/invite helpers.
As you learn about the needs of a laboring mother, you may find that it’s really important to you to have a certain loved one at the birth with you, or that you feel that you’ll really need privacy. Whatever the case, exploring what helps a mom work through labor in a class will give you a chance to make arrangements to have the support you need and set boundaries to keep out the kind of energy you don’t need.

18) Begin building your community of support as parents.
Taking group childbirth classes gives you a chance to meet other parents who are at the same stage of life as you. Some people find long-term family friends in their birth classes who support each other as each of their children go through the same developmental milestones, struggles, and triumphs.

19) Help older children adjust to being cared for by someone other than parents.
If you have older children, taking a little time each week to go to a class together while your child stays with another caregiver is a good opportunity for kids to learn that there are other people in their life they can depend on besides their parents. That flexibility will serve you well postpartum when your child can be entertained by another adult for a while so that you can rest or care for the baby.

20) You are worth it. Your experience is worth it.
Sometimes parents feel like a birth class is a big investment of time, or money, or birth. Having a baby is something that only happens once or a few times in a lifetime, and creates memories that a woman will hold on to for the rest of her life. Being as prepared as you can be for a huge, life-changing event is a sound investment. You are worth this investment. Your birth experience matters and you matter.

A note about gender-neutral language

As someone who falls on the ‘queer’ spectrum, and who has a non-traditional relationship style, I have been making a conscious effort to increase my use of inclusive, gender neutral language; in my classes, on my website, and in my writings. I recognize that my earlier blog posts may not use inclusive language, nor acknowledge the wide range of possibilities of who may be giving birth, infant feeding and caring for and in a family with, the birthing person and newborn.

Unfortunately, the birth world is an aggressively gendered space; and even with awareness of the issues on a personal level, it took more time than it should have to be aware of the need for gender inclusiveness on a professional level, and I apologize for any missteps I have made.

All birthing people deserve compassionate, inclusive classes to prepare them for the adventure ahead.

Dates in Pregnancy

No, not the romantic kind (Although those are also important in late pregnancy for ‘you’ time!), we’re talking the sweet dried fruit of the date palm.

A recent research study found that women who ate 4-6 dates daily in the last 4 weeks of pregnancy, are more likely to:

  • Have a more ‘favorable’ cervix when labor starts
  • Have intact membranes for longer during labor
  • Go into labor spontaneously
  • Have a shorter first phase of labor

The date fruit has an oxytocin-like effect on the body, leading to increased sensitivity of the uterus. It also helps stimulate uterine contractions, and may reduce postpartum hemorrhage the way oxytocin does. All that in a little fruit! Snazzy!

Yummy ways to eat dates

  • Chopped up as a topping on cereal, salad, yogurt or icecream
  • Stuffed with soft cheese (like blue, chevre or feta) and broiled- these can be wrapped with bacon, too
  • By themselves as a substitute for candy
  • Blended into a smoothie or milkshake
  • In baked good like breads, pies and cake

Birth isn’t always awesome…

The article “Monstrous Births: Pushing back against empowerment in childbirth” is making the rounds, and some are taking exception to it. But here’s the deal- she’s not wrong. Birth isn’t always awesome.

Birth is always, on some level, a transformative event; because who you are when you begin, is not who you are after the baby is born. How that transformation manifests is different for everyone.

Birth can be empowering, transcendent, orgasmic, beautiful, sweet, calm, touching, tender, powerful, exhilarating. It can also be terrifying, harsh, confusing, overwhelming, rushed, frantic, chaotic, painful, messy, sorrowful, ‘monstrous’.

And, here’s the super-duper important part: Birth can be any of those things, in any combination, no matter where or how you give birth.

A cesarean birth could feel empowered and uplifted.
A home birth could feel confusing and painful.
A normal ‘natural’ birth could feel beautiful and overwhelmingly scary.
A high risk, intervention filled birth could feel transcendent and chaotic.

All of these are real and valid birth experiences.

We, as birth workers must remember that we are not in the birthing person’s head and body. What might seem empowering to us, may seem terrifying to someone else. What might seem limiting to us, might be uplifting to someone else.

When we promise (explicitly or subtly) emotional/spiritual experiences based on place or type of birth, we are literally making promises we can’t keep, because we can’t tell someone how they are going to react to the reality of their birth.

If we say “Birth is the most empowering experience of your life!” and they come out of birth feeling low and confused- what story will they begin to tell themselves? Will it be positive self messages, or will they be wondering where they ‘failed’?

When we (explicitly or subtly) assign positive emotions & images to one kind of birth and negative emotions & images to another kind of birth, we are assigning value to those births, and by extension the people who have them.  What message does that send to the person who has the ‘wrong’ kind of birth? What message does that send to the person who had a negative experience in a ‘good’ birth, or a positive one in a ‘bad’?

The bottom line is that we can’t predict or control which births are “empowering”, and which births aren’t, and we need to respect every person’s birth experience, even if it doesn’t mesh with our own beliefs or values.

The Cesarean Rate- What it means, why it exists, and what to do about it.

This article was originally written in 2013 in response to a Jezebel post, and has been updated for 2016:

The headline was, to say the least, shocking- “PREGNANT WOMEN EVERYWHERE ARE BEING BULLIED INTO HAVING A C-SECTION”, followed by a short article detailing all of two incidents, where intimidation and legal action were used to effect a cesarean section.

Beyond that, the article was low on facts about surgical birth, so we’ll look at some basics:

The World Health Organization had originally cited an ‘acceptable’ cesarean rate of 15%- that was withdrawn in 2010, citing a lack of “empirical evidence” and “…cesareans should be available to any woman who needs them.” (low tech countries may have been using the suggested rate as an excuse to avoid providing needed interventions), but many still use that number as a benchmark.

The United States cesarean rate for 2015 was 32.2%, little changed from 2010, indicating a plateau after years of steady rise- the rate in 1996 was 21%. (When the rate was first measured, in 1965, it was 4.5%)

This means that, of all the pregnant women in the US, of all demographics, almost 1/3rd of them will give birth surgically, as opposed to vaginally.

That is a significant number, and puts the US in the upper range of cesarean rates worldwide. In addition, cesarean section is the 2nd most used surgical procedure in the US, after angioplasty & heart imaging.

“Isn’t Cesarean birth safer than vaginal birth?”

Pause for a moment to think about the implications of this question. On the surface it seems to be a reasonable thing to ask, and there are clearly cases where the use of a cesarean section is safer for mother and baby than proceeding with a vaginal birth.

But, in the absence of medical need, what that question asks is “Is a major surgical procedure safer than the biologic standard of birth?” Bluntly, is it safer to cut a woman open than it is to use the opening provided?

While both vaginal and cesarean birth hold risks, cesarean birth holds significantly more:

  • All of the complications and risks associated with any surgery; including infection, blood loss, adhesions, injury to other organs, longer recovery time, longer hospital stay, need for repeat or corrective surgery, etc
  • Scarring to the uterine muscles & abdominal wall, may cause increased pain during healing, and limit activities.
  • Risk of hysterectomy
  • Limitation of options for future births
  • Increased risk of placental complications (some life threatening) in future pregnancies.
  • Increased risk of ectopic pregnancy
  • Negative reactions to associated interventions like anesthesia, catheters, etc.
  • Physical limitations inhibit contact with and care of infant even after returning home (1 in 14 had pain at the incision site 6 months later)
  • Significant separation immediately following birth, separation from support if they go to the nursery with the baby.
  • Complex emotional response to birth that may inhibit or complicate infant care.
  • Higher likelihood that the infant will be premature in development.
  • Increased post-delivery interventions for the infant.
  • Infant is more likely to experience breathing difficulty & low APGAR scores
  • Possibility of injury to infant.
  • Possible negative impact on breastfeeding
  • Evidence for increased health issues in infant development following cesarean

The risks of a vaginal birth (NOT including those caused by any interventions or pre-existing conditions) are;

  • Spontaneous injury or trauma to the perineum, anus & urethra
  • Need for sutures following episiotomy
  • Increased tenderness in the vagina and perineum
  • Blood loss
  • Infection
  • Infant scalp molding & bruising

As you can see, there is much more risk to mother and baby, in the short and long term, with having a surgical birth.

“Is the increase in surgical births saving the lives of mothers and babies?”

That is the whole reason for the existence of the cesarean, isn’t it?

First, you need to understand that the USA does not collect maternal mortality information as part of the National Vital Statistics System. When looking at the data from the Centers for Disease Control, the numbers are based on voluntary yearly reporting by 52 US regions (states and territories) using information gleaned from submitted death certificates. Since there is no standardized national death certificate, the actual cause of death related to pregnancy may go unrecorded, some pregnancy related deaths may be unreported, and all of the information is subject to human interpretation when it is transcribed.

This is what the numbers show for Maternal Mortality:

  • The Maternal Mortality Rate (MMR) in 1987 was 7.2 deaths per 100,000 live births- .0072% -less than one hundredth of one percent.
  • In 2008 the US official numbers set the MMR at 15.5% deaths per 100,00 live births, in 2012 it dropped to 15.9. (The spike in 2009 and 2011 to 17.8 is directly attributable to the H1N1 epidemic.)
  • Compared to other countries, we rank approximately 34-40th depending on the source of the data often the US’ numbers in these surveys are estimated based on various data sources, including the CDC numbers.

Birth by the Numbers is a website focused on collating and examining this data, and is an important resource when looking at and discussion our national maternal mortality and cesarean rates

The updated for 2014 Birth By The Numbers video discusses national statistics clearly:
https://www.youtube.com/watch?v=a_GeKoCjUQM

BBtN also discusses cesarean birth rates in specific detail, looking at each of the common reasons given for cesarean increases, and comparing those to what the actual data says (hint- the data usually doesn’t support the argument…) :
https://www.youtube.com/watch?v=M_SKMMs2qfM

Sidebar: In California, when they began to examine their rising MMR, they needed to standardise the information that was being reported, so they could not only find the MMR, they could figure out how to address it. Interestingly, using the same data available to the CDC, they came up with different US MMR numbers- Their national number for 2013 is a disturbing 22.0

Since collecting cleared data, and institution policy and law reforms based on that data, California has been able to reduce their MMR from 16.9 in 2006, to 7.3 in 2013 https://www.cmqcc.org/focus-areas/maternal-mortality/california-and-us

So the maternal mortality rate can be reduced; with standardized data collection and focused, targeted policy change.

What about Infant Mortality? Here’s those numbers; based on the UN’s World Populations Prospects Report (using 5 year averages):

  • Between 2000 and 2005, the IMR (deaths per 1,000 live births) was 6.9, a low from all the previous years.
  • In 2005-2010, that number was 6.8, not a statistically significant change.
  • That ranks the US 34th of 182 countries; 33 countries have better IMRs

If mortality rates aren’t going down when the cesarean rate is going up, then why are so many women having cesareans?

In popular discussion, most people think it is one of these:

  1. Maternal Request- more mothers are making a fully informed choice to have a cesarean for non-medically indicated reasons.
  2. More women have a medical need for a cesarean, due to multiple gestation, fetal weight, age, weight, health issues, social status or race.
  3. Doctors are concerned about liability and malpractice.

But, when those points were looked at closely, few of them held up as true:

  1. In a survey of 1600 women who gave birth in a hospital, only 1 said she requested the cesarean. The Listening to Mothers surveys find 1% or less maternal request cesareans. Research in other countries has had similar results- women aren’t requesting non-medically indicated cesareans.
  2. The cesarean rate has risen evenly across the board, for all demographics. No one type of woman has a significantly greater rate of increase than another (Several demographics have higher rates than the national average, but their rate of increase has been the same.). The same holds true for multiple gestation and birth weight.
  3. A comparison of studies shows that fear of malpractice liability has only a small to moderate influence on cesarean rates.

So, if those aren’t the smoking gun, why is the cesarean rate going up? Birth By the Numbers clearly implicates changes in the way the US practices maternity care -both medically and culturally- as the cause of the increase in the cesarean rate since 1996; and this holds up under deeper examination.

Cultural Presentation of Birth & Access to Care

Women in the United States women are not exposed to physiological birth. That is, birth that happens without even routine medical intervention. What is presented culturally as ‘the usual’ is a high stress, high intervention experience to be feared and endured. Modern ‘reality’ shows use editing and music to emphasize drama and danger in birth. Use of medication and interventions is seen as inevitable and preferable.

Physiological normal birth is culturally portrayed as abnormal and undesireable. Unmedicated vaginal birth is out there or “XTREME”, something those hippy anti-science weirdos do. Women who express a desire for that standard are brushed off, mocked, or reacted to in a condescending way. Evidence of women having positive (even pleasurable) no-to-low intervention births are dismissed as outliers or unusual.

Birth is singled out as an isolated (usually medical) happening, rather than being integrated into a woman’s social & emotional life.

Surgery (even non-birth related) is seen as an accepted and expected part of life, even for non-medically indicated reasons. Culturally, we are bombarded with messages encouraging us to seek out interventions.

Women are not encouraged or supported in ‘comparison shopping’ for childbirth providers.  Outside factors like insurance coverage determines who a woman will be served by, rather than her needs and preference.

Childbirth education is seen as a luxury, and is usually limited to less than 30 hours of ‘crash course’ in the last 6 weeks of pregnancy. Private, unaffiliated classes are paid for out of pocket. Classes offered by hospitals or insurance often focus on policy and procedure and available interventions, rather than preparation for normal birth variants.

Non-medical support in childbirth is expected to be provided by a layperson, often a partner or spouse, with minimal exposure or training in support skills. The partner or spouse’s needs (physical, emotional and spiritual) are unaddressed by our culture.

There is a clear correlation between socioeconomic status, and cesarean rate that “…cannot be accounted for by differences in maternal age, parity, birth weight, race, ethnic group, or complications of pregnancy or childbirth.” Lack of access to adequate prenatal care, lower quality care provided in areas of poverty, and provider attitude towards ethnicity and poverty all contribute to higher cesarean rates.

Medical Management of Birth & Provider Training

A culture of intervention exists in many hospitals; more support & encouragement is given within the policy and peer structure of the hospital for the use of interventions (even when those interventions may not be evidence based) with all births- often interventions (like an IV, or Electronic Fetal Monitoring) are instituted immediately upon admittance. Very little support is given to providing non-interventive care to mothers.

The use of multiple interventions has a known cascade effect- the more interventions that are used in a birth, the more (and greater) interventions that are needed, often leading to surgical delivery.

Staffing limits and inhibits support and care- even the best nurse is hampered by having multiple women under her care at one time; interventions that should be intermittent or limited are prolonged by staff absences, women are left alone without professional support & information for long periods of time.

Increased use of ‘hands off’ monitoring & telemetry separates providers from the patient, reducing them to a set of numbers. Major decisions can be made based on those numbers alone, even before they are interpreted by a trained professional.

Dr. Neel Shah, Assistant Professor at the Harvard Medical School, has found that things as simple as how a hospital’s maternity ward is physically laid out may impact cesarean rates: https://www.youtube.com/watch?v=9-X-S8EHkFg

Modern obstetric students are trained in fewer hands-on procedures for managing normal birth variations; things like external version, vaginal breech birth, twin birth management, perineal massage etc. are not covered, or covered only briefly.

Obstetrics training uses a strict medical model of care, often focused on crisis intervention & procedure, rather than the wide spectrum of physiological birth.

Personal preference, practice style, and attitude towards interventions impact the care provided.

The system of payment for childbirth procedures tacitly supports provider speed and convenience- a provider will be paid less for spending a large amount of time supporting a woman through physiological birth, than they will be for a surgical birth.

The hospital environment encourages high turnover of patients, cesareans may be encouraged where waiting is a medically acceptable option.

Physician organizations may overstate the benefits of surgical birth, the risks of VBAC, and overlook evidence that contradicts long standing practices.

Hospital rules or provider preference may actively prevent or inhibit a woman from attempting a Vaginal Birth After Cesarean. There is evidence that some women may be given a medical reason for VBAC refusal, even when there is no clear medical indication.

The threshold of when a cesarean should be used has changed, even when populations haven’t. Even when there is a change that supports low-intervention birth, it can take many many years for systemic change to be implemented.

Cesarean Birth Awareness

Women are not given full information on the risks surgical birth pose to mother and child  Cesarean birth is not accurately represented as major abdominal surgery, with the recovery period and limitations that abdominal surgery imposes.

Many women feel coerced or shamed into having a cesarean section. In the Listening to Mothers survey, 25% of the women reported having been pressured by a professional to have a cesarean. Review of websites discussing cesarean birth find many similar results.

Women are in an altered state of consciousness during birth; in addition to the diminishing of higher cognitive function in labor, a recent study found that oxytocin, which is the primary hormone released in labor, also increases a woman’s feeling of trust; this may lead to women agreeing to procedures they might not approve otherwise.

Many women have reported the use of fear & threat based language surrounding the birth of their child. Phrased such as “Don’t you want your baby to be healthy?” and “Something bad might happen if we don’t (insert intervention here).” Many low-intervention birth professionals call it “playing the dead baby card”, where the specter of death or damage is held over the parents’ heads if they don’t follow doctor orders.

Now that we know there is a problem, what do we do about it?

There’s a few things that need to happen:

Change the culture of intervention in the hospital & provider mindset
This is both the most crucial piece, and the most difficult. Women can know all about why and how to ‘avoid’ a cesarean and have all the data about cesarean rates, maternal mortality, etc… but until the hospitals and providers are willing to recognize their role in the cesarean rate (and not continue to place the whole burden on ‘risky populations’ or ‘maternal health’), and make significant changes, then women as consumers of a service can only do so much.

Increase women’s access to & exposure to physiological birth
If women know what the wide range of ‘normal’ is for birth, and are educated in the appropriate uses of birth technology, they are less likely to accept interventions that are not medically indicated.

Increase women’s understanding of the appropriate and compassionate use of interventions
Interventions themselves are not the ‘enemy’, and have appropriate, timely and compassionate applications in childbirth. Rather than an ‘natural’ vs ‘intervention’ model that teaches avoidance and distrust, women should understand what the tools are, and when to recognize (and even request) their use, without guilt or fear of ‘failure’.

Increase women’s access to doulas/trained labor support
Multiple studies have shown that continuous labor support by a trained professional has a profound impact on the outcome of labor, birth and the postpartum period. With the average cost of doula care hovering around $500, the potential savings for both public and private insurance coverage vs. the cost of cesareans is in the millions of dollars.

Build a system of cooperative, socially-focused care with midwives as the primary provider
In the countries with the lowest infant and maternal mortality rates, midwifes are the primary care providers for normal, low-risk pregnancies, with referrals to obstetricians if complications arise. Many studies have shown that midwife-attended births are safe, with fewer medical interventions and significantly lower cesarean rates. (As an aside, the USA is the only country that differentiates between midwives who have had previous nursing training, and those who went into midwifery directly.)

Increase childbirth preparation/education to 9+ months
Can you imagine if a runner, preparing for the Boston Marathon, only trained for 2-3 hours a week, one day a week, in the 3 months leading up to the marathon, all while going through significant physical changes? That’s what we expect from pregnant women, when we recommend they take childbirth preparation classes at all. Increasing class time can:

  • Give women a better understanding of the process of pregnancy, labor & birth. Many women have limited time with their care provider, so questions and concerns can be glossed over or forgotten- full pregnancy education can fill in that gap.
  • Build a pain-coping mindset beginning early in pregnancy, so that coping skills are ingrained and reflexive, rather than ‘crammed’ for like a test.
  • Prepare women not only for the many facets of physiologically normal birth, but help them be aware of and ready to adapt to the unexpected or unwanted.
  • Prepare women for the postpartum period with increased information and support in self-care, infant care, and physiologically standard infant feeding.

De-stigmatize, legally protect and fund out of hospital birth
Study after study shows that a planned home birth attended by a trained professional is a safe option for many women, yet few women are exposed to this option. Even in studies that have shown a higher relative risk to infants, the overall risk is still less than 1%- just like a hospital. When a women does discover the option, they often find they will need to pay out of pocket, and they are faced with social censure and ridicule. In some states, choosing home birth with a trained midwife may result in parents and/or the midwife facing legal action.

Bring back the VBAC
A controversial position paper in 1999 from the American Congress of Obstetricians and Gynecologists (a voluntary fraternal and lobbyist organization) said that Vaginal Birth After Cesarean should be “offered” with “emergency support immediately present.”. This paper was accompanied by an editorial by a Dr. Greene stating that VBAC was dangerous, and there was widespread media attention. This had the effect of causing absolute bans in 28% of all American hospitals and de facto bans in an additional 21%; which in turn caused the VBAC rate to drop from 23% in 1996 to 10% in 2010.

In 2010, the NIH held a “Consensus Conference on VBAC”, finding that the risks of VBAC were minimal, and had not changed in the time since they first became widespread in 1980. And while the ACOG followed that conference with a ‘revised’ position paper, the general availability & support for VBAC in hospitals has not appeared to change significantly- there is a slow increase, but the US still has the lowest VBAC rate of all industrialized countries.

The Bottom Line

Major abdominal surgery should only be happening when there is a clear medical indication for it. Obviously, no one disputes this.

The fact is that nearly 1/3rd of pregnancies in the USA end in this major surgery, costing millions of dollars a year, and having as yet unknown impacts on thousands of children. The only way this will change is by demanding accountability and change from providers and facilities, and through increasing awareness & education Not just for expectant mothers, but for our whole society- asking ourselves if this significant deviation from the physiological standard is really beneficial, how is it impacting our culture, our economy, our standards of care, and why are we allowing it to happen?

The advent of awareness of this as a consumer and national expenditure issue (illustrated by the 2016 Consumer Reports series of articles on childbirth and cesareans) rather than just a ‘pregnant woman’ issue, may be the thing that finally makes the difference.

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CDC Data:
http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

This infographic gives a clear picture of the 2011 data:
http://www.facethefactsusa.org/facts/more-us-mothers-dying-despite-expensive-care/

Consumer Reports
http://www.consumerreports.org/doctors-hospitals/childbirth-what-to-reject-when-youre-expecting/
http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

Socioeconomic Status:
http://www.ncbi.nlm.nih.gov/pubmed/2747759

http://www.jstor.org/stable/10.1525/sp.2012.59.2.207

Amnesty International’s “Deadly Delivery” report:

http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf and 1 year follow up http://www.amnestyusa.org/research/reports/deadly-delivery-the-maternal-health-care-crisis-in-the-usa

Other:

Maternal Mortality in the United States: A Human Rights Failure

http://www.indexmundi.com/g/r.aspx?v=2223

Oxytocin increases trust in humans Michael Kosfeld1,5, Markus Heinrichs2,5, Paul J. Zak3, Urs Fischbacher1 & Ernst Fehr1,4

Systematic Reviews-Continuous Support for Women During Childbirth

Doulas Save Money

CNM/CM-attended Birth Statistics

Trends in midwife-attended births in the United States

Listening to Mothers III- Survey & Report

Best Evidence for Choosing A Place of Birth

2010 NIH Consensus Development Conference on VBAC

ACNM Response to ACOG VBAC 2010

ICAN. (2009, February 20). New Survey Shows Shrinking Options for Women with Prior Cesarean.

Align Your Birth Team

Birth is a physically and emotionally vulnerable time for many, which makes having a birth team that shares your beliefs and values about birth an important task of birth preparation. Take some time to do the following exercise:

List everyone who will be present at your birth, in the birth room with you.

Consider the following:

  • Does (or has) each person you’ve invited support and nurture you in your life?
  • Do you feel emotionally and physically safe and unselfconscious with each of the people listed?
  • Do you know each of their attitudes and beliefs about birth?
  • Do you know how each expects to participate in your birth?
  • What is their motivation for being present?
  • Do you feel they can respect you and your birth space?
  • How do you feel about them being there?

Now, make a list of everyone who will be at the birth location, but not in the birth room.

Consider the following:

  • What is their motivation for being present?
  • How do they expect to participate/stay informed about your birth?
  • Do you feel they can respect you and your birth space?
  • How do you feel about them being there?

Last, make a list of people who won’t be present, but will be informed when you go into labor

Consider the following:

  • What is their motivation for being informed?
  • How do they expect to stay informed about your birth?
  • How do you feel about informing them?

You may find, after considering these lists, that there are friends, family members, or even care providers that may not feel as ‘in tune’ with your birth purpose as you‘d like. How do you navigate bringing your birth team more into alignment?

Aligning Care Providers:

  • Open a respectful dialogue with them about their practice, and what differences you are seeing. Ask them questions about areas or procedures you may be confused or concerned about- if you find that there isn’t time for these questions at a routine appointment, consider making an extra appointment just to sit down and talk.
  • Consider what impact your birth location has on the expectations & attitudes of the providers; what options can you realistically explore to bring things closer to your beliefs?
  • If you find that your provider or birth space just won’t ‘click’, what are your options?

Aligning Friends & Family In The Birth Space:

  • Mindfully explore and let go of your expectations of behaving a certain way in front of people. Birth in awareness of what you need, rather than tailoring yourself to the judgement of others (including your inner judge!).
  • Sit down with them and have clear expectations and guidelines for being a visitor to Laborland. Give them a copy of the Welcome to Laborland handout.
  • If they have an expectation that they will be part of your birth, and you are uncomfortable with their presence, what other role or task of birth can you give them to allow them to actively participate? Examples could include ‘hosting’ the candle circle, preparing the home for when you arrive post birth, caring for other children, collecting and preparing postpartum meals.

Aligning Friends & Family Outside The Birth Space:

  • Pre-plan how will you manage information flow from the labor space, to those waiting for news. Designate a ‘news anchor’; the person who’s job it is to carry news from the birth space, out to the waiting room and beyond.
  • Put together a Labor Candle Circle for those who want to know when you go into labor.
  • Find roles or tasks of birth/postpartum for them to do; postpartum laundry, meal prep, house care, bringing games to the birth place for people who are waiting around to have something to do.

When You Need To Say “No”:

  • Acknowledge that they want to be a part of your birth, that being present or participating is important to them.
  • Thank them for their energy and caring, let them know it means alot to you that they want to be a part of your birth.
  • Gently but firmly set your boundaries. Ex.: ”We have chosen to only have the two of us in the birth room.”
  • Give alternative outlets. Ex.: “Instead, would you please be in charge of our Labor Candle Circle.”

 

Mindfully bringing your birth team into alignment helps create a supportive, uplifting environment for labor, birth & postpartum.

Portions of this article were drawn from the out of print Birthing From Within Keepsake Journal 

 

Using Your B.R.A.I.N.

B.R.A.I.N. is an acronym that can help parents to gather information from a care provider or birth attendant when a procedure or intervention has been proposed.

B: BENEFITS
How will this help labor/birth? Why is this being proposed? What is the intended outcome?

R: RISKS
What risks are there to this procedure? What does the procedure involve? Does it lead to/require other procedures? Are there side effects?

A: ALTERNATIVES
What are some other things we can try first? What have other people tried that might work? Is there any medical reason we couldn’t try X first? Is there any medical reason we can’t wait another (time period)?
Don’t say: “Could we…?”, that allows them to give you a yes/no answer.

I: INTERVAL and INTUITION
We need to have some time privately to discuss what you’re telling us and make a decision, thank you.
What is your gut telling you? Are you making a decision from fear, or awareness?

N: NEXT BEST THING
Looking at the information, what is our next best step?
We are going to wait for (time period), then revisit your recommendation.
We want to try X for 30 minutes, then we’ll try your recommendation.
We would like a second opinion.
We are consenting to the procedure.
We are choosing to decline the procedure.

The Dec. 2015 Home Birth Study & Understanding Risk

Many of you have seen the NYT article about the new home birth study. And, if you were a brave soul, you read through the comments, wherein a large number of people did the predictable anti-home birth flailing, this time carrying a red flag reading “This shows babies are 250% more likely to die! Make it illegal! Selfish mothers!”

Except that’s not what the math shows, at all.

First of all, lets look at the numbers the article gives- for hospital births, 1.8 deaths per 1000. For home births, 3.9 per 1000.

Now we look at what is called “Relative Risk”: The number that tells you how much something you do, such as having a home birth, can change your risk compared to your risk if you have a hospital birth. Relative risk can be expressed as a percentage decrease or a percentage increase. If something you do doesn’t change your risk, then the relative risk reduction is 0% (no difference). If something you do lowers your risk by 30% compared to someone who doesn’t take the same step, then that action reduces your relative risk by 30%. If something you do triples your risk, then your relative risk increases 300%.

3.9/1000 is a roughly 117% relative increase from 1.8/1000. Not 250%. (a 217% relative increase would be 5.9)

That means the actual relative risk is 117%.

That still sounds like a scary number, right? If you have a home birth there’s a 117% greater chance of infant death, oh no!.

Except now we look at “Absolute Risk”: The number of percentage points your own risk changes if you do an action.

1.8/1000 is .18% and 3.9/1000 is .39%, that means that there were .18% deaths in hospitals, and .39% deaths at home.  the absolute increase is .21%.    Put in layman’s terms:

The absolute increased risk of infant death in home vs hospital shown by this study is less than 1/4 of 1%. The risk of infant death in both cases is less than 1%

No matter where you give birth, there is a less than 1% chance your baby will die- and the risk in a home birth is a whopping .21% higher than in a hospital.  Not as scary as the detractors would have you believe.

 

Use your HSA/FSA to take childbirth classes!

Did you know that Childbirth Education is covered under most Health Spending Account or Flexible Spending Account plans? This means you can take a class, and have it paid for! The easiest way to do this is to ask your teacher for a detailed receipt for your registration fees that you can then submit to your plan for reimbursement.

Some teachers may be able to process your card on site, but you will still want a detailed receipt, in case your plan asks for documentation.

Check with your plan, or talk to your educator to find out if this is an option for you!