Between Worlds: A Birth Story, Part 3

When we left me, I was kneeling on the bathroom floor brushing my teeth. I was still needing to find a comfortable position. We tried putting a stack of pillows on the floor so I could kneel leaning forward on the bed, but that didn't work for me either. Kim suggested I get on the bed and lean forward on the birth ball. That position was perfect. I used the ball to help me rock, sometimes back and forth, sometimes side to side. I started saying "peace" out loud during the pressure waves. Kim said that when I had gotten off the birth ball, the waves had suddenly gone from about 6 minutes apart to 3 minutes apart. They also let me know that Lorri was in about 25 minutes away, and Kristin was coming and bringing the assistant, Kelly, who was a nurse. I felt some strange sensations above my pubic bone--I wonder if it was the baby's head rotating or moving down. I suddenly wanted my t-shirt and pajama pants off, so I took them off, and was wearing my swimsuit top (which I had put on under my shirt after my shower that morning) and some mesh panties I found in my birth kit. Then, I sat up on the bed. It seems like a strange choice of position, but it was really comfortable at the time.

My midwife Lorri arrived. She said she would check my vitals before I got in the tub and went to get supplies. I got off the bed to go to the bathroom and then Lorri came back and took my blood pressure and temperature, and listened to the baby’s heartbeat, and all was well. I got in the tub. The tub was big and deep and I loved how I could get into all different positions in it. I took off my headphones and we played Hypnobabies out loud because I didn’t want to accidently get anything wet that wasn’t supposed to get wet. I reminded my team about the video camera, and my husband filmed me in the tub, including one pressure wave, and then went out of the bedroom and filmed the other people in the house The water in the tub was pretty hot, but I like hot water, so I didn’t really mind, until I had a few pressure waves in the tub and got really hot during them. Kim brought me a cold washcloth to put on my neck to keep me cool, but eventually I just had to get out. I think I went to the bathroom again, and then I was leaning on the side of the tub during a wave and I felt the need to yell at the peak of it. Lorri heard this, and came in. I told her I thought I was feeling pushy. She said to just try to let my body do most of the work and only push when I couldn’t help it. She asked if the water was too hot and I said yes, so she and my husband dumped in a few bowlfuls of cold water. I got back in and the temperature was much better.

Kim was filming now, and my husband knelt near the tubKristin and Kelly must have arrived around this time and came into the room and set stuff up. They were behind me and very unobtrusive. I remember turning around to make sure they were there a few times, because I guess knowing they were there was reassuring for me.

I remember reading once that in some tradition somewhere (I can't remember where), the birthing woman is thought to have to travel to the underworld to claim her baby. The beginning of pushing was definitely the most challenging part for me. Feeling that much power moving through my body was overwhelming, and I didn't quite know how to respond to it. At the peaks of the waves, when I couldn’t help pushing, I would vocalize loudly, because that seemed like the best way to release that intensity. I changed positions a lot, and loved the ease of movement in the water. I usually knelt low in the tub or was on all fours between the waves, and often during them, I had to go to a high kneel and throw my arms around my husband. He gave me Hypnobabies cues which helped me relax better. I remember apologizing for getting him wet. At one point, I was on hands and knees and lowered my face so close to the water that my bangs got wet.

Soon, I felt the baby’s head coming down and I said something like, “The baby is coming out! The baby is coming out!” It was almost like I didn't really expect the intense part to actually end, but the baby moving down meant it was definitely going to. Lorri, who was next to the tub on my left, turned to my husband and asked if he wanted to catch his baby, and he must have said he would because she started giving him instructions on how to do it. I switched from kneeling to a deep squat. With the next wave, pushing just happened. I roared, and the head became visible. I remember saying something about how excited I was that we were almost there. As the head crowned, I leaned back, letting my legs float forward in the water and my head rest against the edge of the tub, supporting myself with only my arms and head, while the rest of me floated. With the next wave, the head was out, and with the one after that, I eased the shoulders out, and out came our baby at 8:39 pm!

My husband lifted the baby out of the water, and I sat down in the tub and took my baby into my arms. He looked to see if it was a boy or girl, and exclaimed, “It’s a girl!” I was shocked because I had myslef convinced it was a boy! She gave a small cry and then got quiet and looked around.

My mom brought our two older kids in. It was neat for them to get to meet her so soon after she was born. Our son, who is 21 months, was a little more interested in the water, though, and put his hand in it (someone washed his hands), and he wanted to take his pajamas off and get in, too, but we didn't let him. The cord was short, so I was limited to holding her against me with her head on my chest, just out of the water. Lorri encouraged me to talk to the baby, so I babbled to her about all kinds of things as we waited for the placenta.

I had to push pretty hard to get the placenta out, and the membranes were trailing and full of clots. Then my husband cut the cord and Kristin helped me get out of the water and into the bed with the baby and then the baby had her first nursing. No one but me held her for over an hour after the birth. It was so peaceful and wonderful. When we weighed and measured the baby, she was 6 lbs 11 oz and 20 inches long. And perfect.


I was amazed at how minimal the damage to my body was. I didn’t tear with my second birth either, but this was even better. My vulva wasn’t even swollen and the little bit of soreness I had went away in a few days. I think it was mostly because I did mother-directed pushing this time and because the water acts as a big warm compress.

One of the names we gave our new daughter is shared with my mother-in-law’s sister, who passed away a few days later, in my mother-in-laws arms, soon after she arrived at her bedside. I am struck with the similarities between their transitions, one into, the other out of this world. I am so blessed to have been able to give my daughter a transition into this world that was gentle and loving as well as safe. Perhaps when we come out on the other side, we will be gently lifted into peace and parental love.

End? No, the journey doesn't end here. Death is just another path, one that we all must take. The grey rain-curtain of this world rolls back, and all turns to silver glass, and then you see it . . . White shores, and beyond, a far green country under a swift sunrise. -Gandalf the White, Lord of the Rings: The Return of the King (film version)

Between Worlds: A Birth Story, Part 2

Thrilled and terrified at the same time, I woke my husband up in a panic and told him I needed his help to handle these waves. I texted my midwife and she said to let her know when they had been consistent for about half an hour, and I texted my doula, Kim and told her that I was ready for her to come. The time stamp on that text is 3:35 pm.

I grabbed the Hypnobabies Birth Partner Guide and opened it to the birth prompts I went to the music on my phone and turned on Easy First Stage. I wanted to get into hypnosis as fast as I could and make this easier. I switched to the relaxation music for a while and we tried the birth prompts, but it wasn't really working for us, so my husband suggested I go back to Easy First Stage since I had found it so helpful in our last birth, and he would just do the "Relax" cue during the waves. I was sitting on the birth ball leaning forward onto our bed. I felt like the ball needed more air in it, so I asked my husband to blow it up for me. It was much more comfortable when it was fully inflated. My doula got there and she timed the waves and gave me encouraging words. My husband brought me some headphones and suggested I try using them to help me focus. At first I said no, but then I decided to try it and he was right, it did help. She and my husband were kind of tag teaming making sure the kids were okay in the other room. I stayed in "OFF" between waves, except to talk or to drink my poweraid. This helped me get deeper faster. For some of the waves, I would switch to "CENTER" and bounce gently on the ball, because it felt better. As I got deeper, I tended to stay in "OFF" and breathe deeply and use my peace cue. It didn't completely relieve the discomfort, but it helped enough that I felt calm, relaxed, and in control. This was Kim's first experience with a Hypnobabies birth. She was very impressed. I finally found my confidence, just in time.

After it had been about half an hour, someone called Kristin to let her know these things were not stopping. She said the other midwife, Lorri, was on her way, and she'd also be coming shortly. I stayed on the birth ball, except to go to the bathroom, which was just a few feet away. Whenever I got up, I would have extra pressure waves that were not as strong. Whenever Kim heard me start breathing deeply, she would write down the time, then come put her hand on my shoulder. My mom called at 5:40 pm. I told her I was in labor. She had been up very early and traveling all day and wanted to go to bed, but I kind of wanted her to come over and take care of the kids, so she said she would come. She came over and that freed up my husband and doula to both stay with me.

At some point, I noticed my legs were starting to feel stiff from sitting in the same position on the ball. I let my support team know that I wanted to change positions. We tried putting pillows on a chair so I could kneel leaning forward onto the bed, but when the next pressure wave started, that wasn't comfortable and I got up and did the slow dance position with my husband. When that one was over, I exclaimed, "Nausea!" my husband asked if I wanted a bucket and I said yes, but then I just walked to the toilet and threw up there. I heard my husband explaining to Kim that in the past, vomiting has been a sign that I was getting very close. They asked me how I felt, and I said I felt better after throwing up. My husband gave me my toothbrush with toothpaste on it and a cup of water so that I could brush my teeth and rinse my mouth out. My team decided to check with the midwives again, to make sure they'd be here soon, since it looked like I was in the transformation phase.

Between Worlds: A Birth Story, Part 1

At about 5:00 am on Wednesday, December 7, I woke up to a leaking sensation. It felt like a period, or rather, it felt just like when I leaked amniotic fluid before my first birth. I got up and put on a pad and laid back down. At about 6:30, I felt a gush. Not a gush like all my fluid was coming out, but a definite gush. I texted my midwives and let them know this, and that I was not having pressure waves yet. I woke up my husband a little while later and told him that my water broke but it could still be a while before the baby came. He said that he would stay home from work. I also texted my mom, who told me she would get a flight for the next morning, thinking that if I had the baby that day, she would be there in time to take care of everything I would need postpartum. My midwife Kristin called and said she would come take my vitals and give me a Doppler so I could keep an eye on the heartbeat. She came by and she also drew some blood because she was planning to do a re-check on my iron level at my appointment on Friday. She instructed me to eat and drink well, to rinse with a hibiclens solution whenever I used the bathroom, and to take my temperature and check the hearttones every hour and just let her know when pressure waves started. She said she thought it would probably be that day.

My husband spent the day cleaning up the house, buying food for after the birth, and doing last minute homebirth set up preparations. I helped a little, but didn't want to wear myself out. Pressure waves started by that evening and were about 10 minutes apart for a while. Around 10:30 pm,still thinking the baby would come that night, I decided to try lying down and listening to Hypnobabies to try to get some rest, or at least get myself into hypnosis. I ended up in and out of sleep all night because they spaced out, but didn't completely stop. I had my ipod on a playlist of Hypnobabies tracks so that it would just keep playing while I slept. I probably would not have gotten any sleep at all that night if I had not had Hypnobabies to listen to. The pressure waves were manageable when I was awake and listening, but when one would hit while I was asleep and I was woken up by it, it was extremely uncomfortable.

I got up around 5:00 and took a shower to see if that might do something, but waves were very far apart, so I ended up going back to sleep for a while. Husband was up around 7:00 am. I was kind of getting frustrated with the waves because they seemed to be far apart but strong when I was lying down, weak and close together when I was standing up, and seemed to almost completely disappear when I was sitting. I told him I was having some fears about being able to handle it because the waves seemed stronger than in my last birth (my theory is that the difference had something to do with my water not breaking until 9 cm plus last time) and I think with them being so far apart, yet so strong, I wasn't able to get deeply into hypnosis like I had with my last birth where waves started consistently 10 minutes apart and gradually got closer and closer together. I also was a little worried that it could still be a long time before active birthing started and I would be exhausted from not getting enough sleep by then. I was conflicted--I wanted birthing waves to come consistently so that I would have energy for the birth, but I also was a little afraid of the birthing waves. I asked my husband to give me a priesthood blessing for strength and comfort and to help me know what to do.

We could tell the kids needed to get out of the house (preschool group had been cancelled both days that week, so they had been home all day most of the week), so my husband took them to the store with him to get some things. It took a while to get them ready and get out of the house, and there were a few other things he needed to take care of. We ended up needing to eat lunch before they could go. Before they left, he was also on the phone with his mom. His mom's adopted sister had recently gone into a coma due to a brain infection and she was given a very small chance of survival. My mother-in-law wanted to go to Tahiti to be with her family during this difficult time, but did not have the funds. We offered to help pay for a plane ticket for her to go. My husband wanted to get out the door with the kids, so he had her talk to me to get our credit card information and she and I had a sweet conversation. There I was, with my birthing in limbo, waiting to bring a new life into this world, while she knew she was waiting for one to leave it. Perhaps my child and his or her great aunt were both delaying their transition. Maybe there is a place between our world and the world of spirits, and they were both there, together?

After I got off the phone, I decided a nap was a good idea (it was early afternoon by this point). I got in bed and listened to Hypnobabies again. I think I did the Fear Clearing track. I knew I needed that. I got some sleep. I woke up and my husband and the kids came home. I decided to try some activity to see if it might kick start things. My husband tried to take a nap himself. I mopped my kitchen floor. Then,I stood in front of the mirror in my kids' bathroom and remembered something I had learned at the Dancing For Birth&trade Training Workshop: asymmetry. Asymmetry of the pelvis can help position the baby and bring it down. The move I started doing wasn't exactly one we learned in the training, though it was sort of similar to the mighty mama (sumo) move--I alternated raising each knee up, quickly, one and then the other, over and over, and then a strong pressure wave came, and a few minutes later, another. They were strong and they weren't stopping. This was it!

Its a Girl!

Baby Girl born at home in the water at 8:39 pm on 12/8/11, 39 hours after my water broke. 6 lbs 11oz, 20 inches.

Pregnancy Update: 38 weeks

Yep, still pregnant! I apologize for my absence. I have been busy, and I also haven't had the laptop I usually use, and have been accessing the Internet from either my phone or the iPad, both of which are a little harder to blog from than an actual computer.

The day after Thanksgiving, my husband and I left the kids with my family who were in town at the beautiful cabin my parents rented an hour away from our house so that we could have Thanksgiving with everyone without me having to travel so late in my pregnancy, and we went to my 37 week midwife appointment. We learned that the baby, who had been head down for weeks, had suddenly flipped to transverse lie! This is a pretty unusual thing for a baby to do at this point. My midwife gave me sone suggestions to try to encourage the baby back to head down. I knew there was a small chance that the baby might not turn back before labor, and as I thought about this on the drive home, after a nice lunch at a restaurant with my husband, I felt peace about it. I knew that if I had a cesarean, yes, it would be a challenge for me, but I knew that if it happened, I felt strongly "that all these things shall give [me] experience and shall be for [my] good." (Doctrine and Covenants 122:7). I have gained valuable lessons from each of my children's births, both the good and challenging parts, which I wrote about in last year's Thanksgiving post. I expect to learn from this birth, but have no expectations about what those lessons will be.

The night after my appointment, I put ice above the baby's head and a warm pack above my pubic bone. I felt a whole lot of movement and then felt my belly. I felt a bulge under my ribs, a firm area below it, and what felt like a head in my pelvis. For the next week, I checked often, and it continued to feel the same, and kicks were on the upper right and hand movements near my left hip. My midwife confirmed it today--baby is right occiput anterior!

I am still working on completing preparations for the birth and the baby. Most of the important stuff is done. I finally got the birth tub bleached out and brought into the house. I am starting to look forward to meeting this child face to face, but I may never get to a point where I feel completely ready!

Pregnancy Update: 36 weeks!

I really have been in denial about this baby coming! Two nights ago, I had some serious feeling pre-birth pressure waves (Hypnobabies lingo for false labor), and I think that made me finally start to accept that this is really going to happen!

I have had two midwife appointments since I posted my last pregnancy update. At my 32 week appointment, I learned that the results of my glucose screen were excellent. I also learned that there had been a mistake with the tube the blood was drawn in for the CBC I had drawn at the same time. I decided to re-draw it because I really wanted to know what my iron level was. The midwife and I discussed the supplements I was taking, and she told me the vitamin D I was taking (2,000 IU) was probably not high enough. A recent study found that routine supplementation with 4,000 IU in pregnant women (ten times the current recommended daily intake) resulted in no harm and better outcomes. Considering that my level was very low in my prenatal blood work (and that was in the spring time), I need to be taking a much higher dose, so I have upped it to 10,000 IU a day.

A couple days later, my midwife let me know the results of my CBC--my iron was low. Not dangerously anemic low, but low enough for me to feel tired. I started taking Floradix, and feel so much better. I realized that the amount of sleep I was needing to function (about 9-10 hours in a 24 hour period) was not normal, and I have so much more energy now. I am keeping my house clean while busy with preschool and Hypnobabies and feel like I'm staying on top of things pretty well! I took it in my last pregnancy when my iron came back a little low at the same time and I thought it increased my energy level then, too. Why didn't I start taking Floradix earlier? Probably partly because Floradix is really expensive...

My 35 week appointment was a nice, long one. We talked about everything we need to do to set up for the birth. I asked about placenta encapsulation, and how I am interested in it but I'm not sure because there doesn't seem to be much definitive evidence out there. She said that everything she had seen about it is very positive. I have a friend who does encapsulation, so I might just have her do mine. The midwife said that they will make sure to take care of the placenta if I decide I want to have it encapsulated.

Somehow we got on the subject of cord clamping and I said that both of my prior two babies had their cords clamped earlier than I wanted. She said that they prefer to wait a long time, because even after all the blood has gone to the baby, there are stem cells that transfer from the placenta to the baby. I said that with my prior babies, they were taken away to be given oxygen, deep suctioning, etc. The midwife explained that it is possible to do those things in the mother's arms. She explained that at a recent neonatal resuscitation class she attended, she demonstrated, using the neonatal resuscitation doll, that the way that people instinctively hold newborns actually keeps their airways open.

The fee for my midwives is paid and the birth kit is ordered! My midwife will be giving me the birth pool next week, and I also ordered a liner to go in it along with my birth kit. I have a student doula who will be coming to the birth to help out with whatever we need--filming the birth, helping with the kids (who I plan to have present, as long as they want to be there and are not bothering me), helping with Hypnobabies tools, etc. I really want to capture this birth on film, which is something I didn't do with my others. I am really happy to give this opportunity to this student doula--I know I appreciate those who agreed to be my first few doula births! She is working on a nursing degree and hopes to eventually do a Masters in Midwifery at Bastyr, so I think seeing my birth will be great for her!

Preschool Co-op Lessons: Pumpkins

I taught for my daughter's preschool again. We lost one of the families in the co-op because they moved across town. We found a new family to join, but at the time I taught, we only had 4 kids in the class.

We did two days of pumpkin lessons. I checked out every book I could find on pumpkins from our public library. The children's favorite was Pumpkin Day by Nancy Elizabeth Wallace, a fiction book about a family of bunnies going to a pumkin patch. The other titles we read were The Pumkin Book by Gail Gibbons (non-fiction, hand illustrations), Pumkins by Ken Robbins (non-fiction, photo illustraited), and Pumpkin Jack by Will Hubbell (fiction). Songs we sang were Five Little Pumpkins and a Halloween version of Ring Around The Rosy, called Ring Around the Pumpkin.

Pumpkin Day talks a lot about cooking with pumpkin, and includes some recipes. The day we read that one, we made pumpkin muffins. I used this recipe from all recipies, but left out the raisins and walnuts and substituted some ginger and allspice for the cloves, because I couldn't find the ground cloves I know I have somewhere, and I thought it would be good with a variety of spices. I took all the ingredients to my kitchen table, along with a big bowl, and had the children all help dump flour, sugar, etc into the bowl. I had them all smell all of the spices as we were putting them in. They got to help crack the eggs (messy!) and stir the batter. They had a lot of fun with it. They came out perfect...

When I chose the recipe, I didn't look closely enough to realize that the yeild is 3 dozen muffins! I only have one muffin pan, so we had muffins our oven for much of the day! They made the house smell amazing, though! There were plenty to share some with friends and they all got eaten! After having our muffins for our snack, we decorated some mini pumpkins. The kids drew on them with markers and I helped them glue googly eyes on them. There were 4 orange pumpkins and 4 white ones. Only the youngest child chose a white one. The one with the eyes on the top of the pumpkin is the same child as the one who glued leaves on the trunk of her tree in the tree's and plants craft (she thinks outside of the box). The one in the back that has a mouth is my daughter's :)

On the second day, we made paper plate pumpkins. I adapted this craft by using pre-cut construction paper for the facial features instead of cutting them out of the paper plate itself and gluing crepe paper on the back (it sounded like it would be too much work for me to do in the middle of the craft). Our color of the week was black and our shape for the week was a diamond, so the black diamond eyes seemed appropriate. I didn't get a picture of all of them, but this is my daughters (she is one of the oldest in the class, so she had better paint coverage and more face-like arrangement than some of the others)

Yay for pumpkins! Have a great Halloween, everyone!

Raise Your Hand if You Have Prenatal Depression

I do. Or I think I did, anyway. I think it is gone now. And now I think I can finally talk about it.

Prenatal depression (also known as antenatal or antepartum depression) is the term for depression that occurs during pregnancy. According to ACOG, it occurs in 14-23% of pregnancies. That is common! Shockingly common, considering how little it is talked about. I think we need to be talking about it! I think a lot of women do what I used to do, and ignore anything we come across about prenatal depression, because we think it could never happen to us. Until it does.

Symptoms of prenatal depression include:

• A sense that nothing feels enjoyable or fun anymore
• Feeling blue, sad, or "empty" for most of the day, every day
• It's harder to concentrate
• Extreme irritability or agitation or excessive crying
• Trouble sleeping or sleeping all the time
• Extreme or never-ending fatigue
• A desire to eat all the time or not wanting to eat at all
• Inappropriate guilt or feelings of worthlessness or hopelessness

(source: babycenter.com)

Guilt was a big part of it for me, as were appetite issues and fatigue, and lack of motivation. I experienced more "irritability" than "excessive crying," though at one point I was crying about once a week. I think that because I felt angry and overwhelmed and not always sad is part of why I wasn't sure I had it at first. It was when I read Sheridan's experience of her postpartum depression that I recognized that feeling irritable could be a symptom of depression. I felt like I wasn't myself, like I wasn't enjoying day-to-day life or motherhood, and a whole lot of guilt because of that.

Prenatal depression wreaked havoc on my marriage. My husband didn't understand why I was so unlike myself, and he took it personally as a rejection. When he feels rejected, he withdraws, which was the last thing I needed at the time. Thankfully, our marriage made it through, and is stronger for it.

If you think you might have prenatal depression, what can you do about it? Here are a few ideas:

• Talk to someone. Someone who understands. I will talk to you if you need me! If you can't get what you need with peer support, seek therapy with a qualified provider. And if your depression causes thoughts of hurting yourself or others, get professional help immediately.
  
• Take a vitamin D supplement. Vitamin D deficiency can cause depression, and the majority of the American population is deficient because of how little time we spend in the sun without sunscreen. My midwives routinely check Vitamin D levels as part of prenatal bloodwork, and mine was 28 (optimal levels are 50-80).
• Take an Omega oils supplement. These fats are good for your developing baby and research suggests they can improve mood.
  
• Eat healthy. I know how hard this is to do when you aren't feeling motivated, but obviously your body needs nutrients to feel well and grow a person at the same time.
• Light or Moderate exercise. Find something you can do to get moving that you don't hate--walking with my kids in the stroller and dancing with my prenatal dance DVD have helped me when I've done them.
• Establish routines. This happened because we started the preschool co-op. It helps tremendously to have a rhythm to the day and the week. I also feel a lot better when I am accomplishing things and when I am in an uplifting (read: organized) environment, but it is hard to clean when you a depressed. Having Hypnobabies classes in my home each week has given me a reason I have to keep my house clean. If cleaning routines are new to you, I recommend FlyLady.
• If you are spiritual, pray or seek other spiritual help.
  
• Recognize that it will get better. Feeling this way is a temporary thing. It is not your life from now on. You are not a bad mother and prenatal depression is not your fault.

Support Resources:

• Postpartum Support International also offers support for prenatal depression. Visit their Support Groups & Area Coordinators page to get connected with help in your area.
  
• Prenatal and Postnatal Depression Support Group on Facebook
• Prenatal Depression and Anxiety Support at CafeMom

You are not alone: other women's expereinces:

• Antepartum depression - Birth Faith
• Depression in Pregnancy? - Choose Your Birth
• I Battled Prenatal Depression...For the Whole Nine Months, article at Mail Online
• So why doesn't anyone ever tell you about PREpartum depression? - Home/work
• The Pregnancy Taboo by Jody Santos
• Antepartum Depression: Stopping the Tears - The Deliberate Mom

Comparison of Midwifery Education in Different Developed Countries

A couple of months ago, Amber at Midwife{ology} wrote a post, Educational Standards of American Midwives: A Comparison, which compared the direct-entry midwifery education program she left to the nurse-midwifery education program she is currently pursing. She points out what she sees as a huge discrepancy in the training of these two different types of midwives, and concludes that CPM training is inadequate to prepare a midwife to be a competent birth attendant. Stephanie at Nurturing Hearts Birth Services (who I highly respect as a midwife and appreciate for the wonderful midwife's perspective on Hypnobabies she wrote) responded in her post CNM vs CPM by saying that she feels that the training of CNMs and CPMs are different because they have a different scope of practice: CPMs attend only out-of-hosptial births with low risk women who are not being medically induced or receiving drugs, while CNMs are trained to work with medical interventions in a hospital environment and do pretty much everything an OB can do except vacuum/forceps assisted births and cesareans. Training for CPMs is different because what they need to know is different. Good points on all sides.

I think that maybe comparing different midwife certifications in the U.S. is the wrong comparison, and we should be comparing American midwife training to midwife training in the rest of the developed world.

The United States: In the U.S., the types of midwives practicing fall into three basic categories:

• Certified Nurse Midwives (CNMs): Those seeking this path must train as a Registered Nurse first and obtain a Bachelors of Science in Nursing (BSN) or the equivalent (usually through a "bridge" program), and then complete a midwifery program. CNM clinical training focuses mostly on hospital birth, and most CNMs attend hospital births, though some work in birth centers or have homebirth practices.
• Credentialed Non-nurse Midwives: This path to midwifery is for those who do not have and are not seeking a nursing degree. These include those with the Certified Professional Midwife (CPM) credential obtained through the North American Registry of Midwives (NARM), the Certified Midwife (CM, which is only recognized in 3 states) credential from the American College of Nurse Midwives (ACNM), and various credentials bestowed by state licensing, such as Licensed Midwives (LM), Licensed Direct-Entry Midwives (LDM), or Registered Direct Entry Midwives. Different states have different requirements for their licenses. A midwife can obtain both her state license and a CPM (in some states a CPM is required to get a license, some states have requirements above what the CPM credential gives). There are multiple training paths for a CPM, including MEAC-accredited midwifery schools and apprenticeship options. All must pass the NARM exam. For more information, see the NARM website. These midwives practice almost exclusively out of the hospital and very rarely get training in hospital birth.
• "Traditional" or Non-credentialed midwives: Licensure for non-nurse midwives is available in about half of the U.S. states. In the others, there are midwives who practice without licenses. Some do go through the training process with NARM, but they are still not legally allowed to practice. Some midwives in states that offer licenses choose to remain unlicensed, and do so illegally, except in Oregon and Utah, where it is currently legal to practice midwifery without a license. Training for these individuals varies widely.

United Kingdom: In the UK, there is one type of midwife training, done through a university. Training in nursing is not required, but those who have it have a head start in the program, so there must be overlap between basic nursing and early midwifery training. Midwives in the UK are qualified to attend births in all settings, home, hospital, and birth center. From the Nursing and Midwifery Counsel:

Education and training

In the UK midwifery education and training programmes are only run at NMC-approved educational institutions. Courses usually take a minimum of three years, unless you are already registered with the NMC as a level 1 (adult) nurse, in which case the training can be reduced to 18 months.

Midwifery training takes place at a university, with at least half of the programme based in clinical practice with direct contact with women, their babies and families. This can include the home, community and hospitals, and in other maternity services such as midwife-led units and birth centres.

Canada: Midwifery training in Canada is done through university education that prepares midwives to be able to attend both home and hospital births. From the Canadian Midwifery Registers Consortium

Midwifery education in Canada is offered at a university baccalaureate level. Education programs are “direct entry” (i.e. there is no nursing or other credential required for entry).

One example: The University of British Columbia Midwifery Education Program

The Midwifery Education Program at UBC is a four-year, direct entry, full time undergraduate program leading to a Bachelor of Midwifery degree. The curriculum combines broad-based knowledge and understanding in the humanities and the social and bio-medical sciences. . . .The first two years of study are located on the UBC campus and in the area of the Lower Mainland. The final two years, including the summer between years 3 and 4, consist of clinical courses. . . .Students are prepared for practice in both high tech and low resource settings (home, hospital, rural, international).

Australia: From the Australian College of Midwives - New South Wales

To become a midwife you need to complete either a Bachelor of Midwifery degree (direct entry) or a postgraduate program if you are already a registered nurse.

For an example of an undergraduate midwifery program in Australia, see Bachelor of Midwifery from the University of Technology, Sydney. This program takes 3 years of full time study to complete.

New Zealand: New Zealand also has a 3-year direct-entry program, where registered nurses can get advanced placement. From the New Zealand College of Midwives:

Each midwifery school offers an extended three year bachelor degree programme meaning that each year has a minimum of 45 programmed weeks rather than the more usual 36 programmed weeks. All students whether full time or part time must complete the programme within four years of commencement. This is the framework for all routes to midwifery registration. Each programme has a Recognition of Prior Learning Policy that enables those with appropriate previous qualifications and experience to receive credits or partial exemptions for aspects of the programme. Midwifery students who hold a previous nursing registration or those with other degrees or other relevant experience are likely to gain credit under these policies and complete a shorter programme. Registered nurses will usually complete at least two years of the full programme.

New Zealand midwifery training also includes mandatory hospital-based clinical experience:

Students work in a variety of settings over three years including family planning clinic, independent midwifery practices, neonatal intensive care units, maternity hospitals, laboratories, homebirth, and community. All students have a dedicated ‘block’ in base hospitals to achieve the experience necessary for competency in recognising deviations from the normal and working collaboratively with obstetricians in the provision of secondary care.

I was unable to find websites about midwifery in countries where English is not the first language, but according to reports from midwifery students on the studentmidwife.net forums, midwives in the Netherlands must complete a 4-year direct-entry program which qualifies them to attend both home and hospital births (and to allow women to choose to change her birth location up until the last minute without having to change providers), and midwifery school in Denmark takes 3 1/2 years to complete and midwives can do home or hospital births. Though it was a little difficult to decipher exactly what the French student midwife was saying with the language barrier, it appears that midwifery school in France is 4 years and may be part of medical school.

Okay, so, which one of these things is not like the others? All of these other developed countries train midwives to be qualified to attend births in both hospital and out-of-hospital environments and all of them require a university degree to practice midwifery. A class of midwives that deals exclusively with out-of-hospital births is unique to the United States. This raises some questions to me:

• Would requiring midwives who practice out-of-hospital to receive hospital clinical experience (where they are much more likely to encounter rare complications), make them more qualified to handle rare emergencies when they occur in out-of-hospital births?
• Would it benefit consumers for direct-entry midwives to be qualified to attend both home and hospital births and be able to obtain hospital privileges and attend the same types of hospital births certified nurse midwives currently do? Would this allow for better continuity of care when circumstances require a change in planned birth location?
• Would standardized training and education for midwives similar to what other countries do give midwives who attend out-of-hospital births more respect in the medical community, allowing for better cooperation with obstetricians, nurses, and other hospital providers?
• Would requiring more education for midwives, as some fear, "turn them into obstetricians"? Would training have less emphasis on skills needed to support normal birth with too much focus on pathology?
  

What do you think about how the training and scope of practice of midwives in the U.S. compares to the rest of the developed world?

Preschool Co-op Lessons: Trees and Plants

On Thursday of my first week teaching preschool, our theme was trees and plants. I only had three in my class that day because one was out of town and one was sick. After doing puzzles and block and the calendar/weather/letter/color/shape routine, we sang our songs, In the Leafy Treetops (an LDS Primary Song), and Trees (to the tune of The Farmer in the Dell, which I found online). Then we read several books about threes, The Giving Tree by Shel Siverstein, Up, Down and Around by Katherine Ayres, and A Tree is A Plant by Clyde Robert Bulla. (I think only having three kids in the class probably allowed them to pay attention to reading books longer!)

Then, for a "sensory activity" we went outside, and my husband had these packets of sunflower seeds and little containers left over from something they did at his work, so each child got to fill a container with soil (which I had bought), put some seeds in it, and put more soil on top. Then we watered the seeds and the kids got to take them home. I put my daughter's in the windowsill above our kitchen sink, and five days later, the seeds sprouted!


Then, since we were already outside, we went on a short walk and looked at my neighbor's garden and talked about all of the vegetable plants she has growing there. By this time, it was already almost time for snack, but I let the kids play for a few minutes while I got it ready.

For our craft, I had prepared large pieces of paper each with a drawing of a tree (I just drew them myself) and I had some cut up some pieces of green tissue paper to be "leaves." The kids used glue sticks to glue the "leaves" on the trees. Most of the trees ended up being a bit sparse, and one child took creative license with the placement of the leaves (she put them on the trunk). I think they are very lovely trees!
















We always close each day of preschool with the same set of songs:

Ring around the rosey
Pockets full of posies
Ashes, ashes, we all fall down!

Cows are in the meadow
Eating buttercups
Thunder, lightning, we all stand up!

Teddy bear, teddy bear
Turn Around
Teddy bear, teddy bear
Touch the ground
Teddy bear, teddy bear
Give a jump a try
Teddy bear, teddy bear
Wave bye-bye

Thank you for being our friends today
Come back again and we'll sing and we'll play!

Preschool Co-op Lessons: The Farm

I recently taught for my daughter's co-op preschool for the fist time. We have five kids in the class, and we rotate it to each mom's home each week, so when it was my turn, I taught two lessons. Here is the structure of the day:

9:00-9:15 Structured Play
9:15-9:35 Circle Time
9:35-10:05 Sensory Activity and Free Play
10:05-10:20 Snack
10:20-10:40 Art Time
10:40-11:00 Outdoor/Indoor Play
11:00-11:15 Clean up and close

For both days, I did puzzles and blocks for the structured play. Circle time consists of a welcome song, which includes each of the children's names in the song, followed by updating the calendar and weather chart, and there is a song we sing for the weather, too. Then we go over the letter, color, and shape for the week. Our week we had the letter C, the color yellow, and triangle. We have a color book in the preschool box (which travels to each home, along with the calendar and weather chart) with pictures of things that are all one color on each page, so the kids get to point to one thing that the like on the yellow page that is yellow, and there is also a shape puzzle book where all of the pictures on a page are magnetic puzzle pieces that are the same shape, so the kids get to take a piece, say what thing they have that is a triangle, and then put it back. All of this is basically the same in every circle time, no matter whose house school is at for the day..

On Tuesday, our theme was The Farm. We sang some songs about farms: Old MacDonald Had A Farm (the children really enjoyed getting to choose what animal sound we were going to sing) and The Farmer in the Dell (I had one child be the farmer and let her choose who would be the wife, and she chose who would be the child, and so on, and as they were chosen, they got to stand up). Then we read the book Click, Clack, Moo: Cows That Type by Doreen Cronin, which is about a farm, but it is a bit of a higher level and their attention wasn't staying focused on it. I had some other farm-related books picked out, but I decided to skip them. We sang another song "This is the way we..." with farm chores for the actions, while I got out my laptop. I used this website to play real recordings of animal sounds and had the children listen and try to identify which animal it was. I think they got all of them except for the turkey.

For our craft on Tuesday, I printed pictures of a pig on pink cardstock and mixed some shaving cream with a little brown paint in a cup for each of the kids. I explained about how pigs need mud to protect their skin, and let them use their hands to smear the shaving cream "mud" on their pigs. It was really fun! They took a long time to dry, but I thought they looked kind of neat after they dried.


It was actually really cool for my daughter that we had just learned about farms in pre-school because we ended up going to a farm, Smallwood's Harvest Farm Park near Leavenworth, WA, as a family that weekend. She fed the animals, rode the cow train, and did other fun farm-related activities.

Pregnancy Update: 29 weeks!

I haven't been keeping you posted on my pregnancy! This pregnancy is going by SO fast! It has been a bit tough for me, emotionally. I have been a bit overwhelmed about the idea of three children so close together (my oldest will turn 4 about 2 months after this baby will be born) and have just felt out-of-balance and at times, overwhelmed. I am feeling better lately, though.

I had a midwife appointment today. I am 29 weeks, 5 days. We did a blood draw for my glucose screening and a CBC, mostly to see how my iron levels are doing. The midwife I saw today said she prefers to do the version of the test that uses a meal, rather than the glucoa drink, so that's what we did. I considered choosing not to do the test at all because I have easily passed the screen with my other two pregnancies, I am not overweight, never gain excessive weight in pregnancy (I'm only up about 17 lbs from my pre-pregnancy weight so far), my babies have been average-sized (7 lbs 3 oz and 7 lbs 10 oz), etc. But I decided, considering the risks of GD and the fact that I was diagnosed with PCOS in 2007 before we conceived our first, it was better to just do it, and I wanted my iron checked anyway.

My fundal height was 28 cm (It was 20 cm at my 19 w 5 d appointment and 26 cm at my 24 w 5 d appointment). The baby is positioned oblique right now (I had pretty much determined that by where I've been feeling kicks), and that probably has something to do with the slightly lower fundal height measurement. Heart-tones were in the 130s. I have gained one pound per week since my last appointment, so weight gain is going fine. No sugar or protein in my urine. (I love that I get a copy of all of the numbers so I can refer to them later!) .

My midwife recommended a great website, The World's Healthiest Foods. They have a page with a list of nutrients where you can click on each nutrient and it will take you to a list of the foods that are highest in that nutrient. Pretty cool.

Went to the health foods store after my appointment and picked up a liquid whole food vitamin, some probiotic capsules (been having issues with vaginal yeast), almonds (to eat when I have heartburn), and some nettle and red raspberry leaves for my herbal pregnancy tea that I have just started drinking daily.

The fact that this baby is going to be born hardly feels real. I better start adjusting to the idea, because I don't have much time. I am teaching my first Hypnobabies class starting next Tuesday, and am planning on doing all of the homework along with my first student to prepare for my own birth--maybe that will help it feel real for me!

I haven't been taking belly pictures, maybe sometime soon when my husband is home, I'll get him to take one and I can post it!

Can Hypnosis Increase Your Chances of Having an Uncomplicated Birth?

The Hypnobabies (Official) facebook page recently shared a research study published in April 2004 in the American Journal of Clinical Hypnosis.  I think the findings of the study were very interesting, so I am summarizing them for you here.

The researcher performed psychological evaluations on 540 women and randomized them to two groups:  one group received prenatal hypnosis to prepare for birth and the other recieved supportive pyschotherapy.  It compared these two groups to each other, and also to a third group of women who had no contact with the research.  The study used cesareans, pitocin use (for induction and augmentation), diagnosis of fetal distress, low apgar scores, and postpartum hemorrhage as measures of whether a birth was "complicated" or "uncomplicated."   The results between the no-contact group and the psychotherapy group were similar, with rate of epidural use being the only significant difference between the two.  I think the following findings of the study are significant:

• The hypnosis group had a statistically significantly lower rate of complicated births than the other two groups.
• Women whose psychological assessments showed psychological factors such as high levels of fear, poor maternal self-identity, negative beliefs about birth, depression, high anxiety, and high levels of stress were more likely to experience complicated births.
• When compared with the supportive psychotherapy group, prenatal hypnosis was shown to decrease the negative effects of these psychological factors on rates of complications.

The findings of this research appear to support the theory that psychological factors (sometimes called the "mind-body connection") play a role in childbirth.  It appears that the way that hypnosis works to change subconscious beliefs can contribute to less psychology-related complications in birth.

In Hypnobabies, we use hypnosis to help women decrease anxiety and stress, change negative beliefs about birth, and identify and reduce fear.  I believe this contributes to the great outcomes Hypnobabies students experience.  Of course, not all complications are related to psychological factors, some are physiological.  We teach moms about how a healthy lifestyle in pregnancy can give them the best chance at staying low risk.

For those times when unpreventable complications requiring intervention occur, Hypnobabies has a wonderful Change of Plans script, included in the student materials, that can be read to the mom to help her accept changes and move forward.  I used the Change of Plans script with a doula client who had a lot of changes to her plans come up, and she later told me she thought it was very helpful.  In the end, this mom was satisfied with her unplanned cesarean birth and felt that everything that happened during it was for the best.

This study also looked at social support factors, such how well-supported the women felt by her family, friends, and partner.  It also found lack of support to be associated with more complicated births, which makes sense with what we know about the benefits of doula support.  The study found hypnosis to reduce complications in women with low support from friends and family, but not as much from her partner.

Armchair Quarterbacks

Ok, I'm not talking exactly talking about that kind of "armchair quaterback," but with it being football season, it seems appropriate.

 I recently stayed up late to watch a birth that took place a The Farm midwifery center broadcast live on the internet.  A mom named Talina (@TalinaN on twitter, blog: Harvest of Daily Life) was giving birth to her second baby, and Pamela Hunt was her midwife, along with two midwifery assistants.  I got into the event, and even posted a few tweets with the hashtag #twitterbirth.  The first site I was watching it on stopped working, but I found it on another site.  The second site had a live chat running to the side of the video, and, honestly, it started to really annoy me.  I was really bothered by the "armchair quarterbacking" (or perhaps in this case, "armchair midwifing") of the birth.  Many people were judging the birth and imposing their ideas about the best kind of birthing on it. People complained that the midwives were doing vaginal exams, that one of them was sitting on the birth bed while the mom was in the shower, that they were touching things and not changing gloves, that they were using a Doppler to listen to the baby's heartrate, etc.  They also questioned Talina's birthing position (semi-sitting on the bed with her husband behind her), claiming that the birth would go faster if she squatted.  As the birth was getting closer, I switched the video to full screen, both to see the birth better, and so that I wouldn't see any more comments from the peanut gallery.  I watched a beautiful, healthy baby girl born with her daddy and (adorable) big sister in the room.  The whole family seemed very happy with the birth, and in the end, isn't that all that matters?

A few days later, I followed updates on facebook of the birthing experience of Navelgazing Midwife's daughter, Meghann, giving birth to her first baby and NgM's first grandchild.  Meghann was using Hypnobabies.  I posted comments of support throughout a long and obviously challenging journey to the birth of her baby by cesarean.  I did not see the actual birth announcement because I was at the park with my kids (and that was before I got my new phone, so I didn't get facebook on my phone yet!), and I also apparently missed some comments (deleted by the time I was reading) on the fact that Meghann had a cesarean section that were offensive to the new grandmother.  She wrote about her feelings on this here.  An excerpt:

But, when things shifted and it was obvious a cesarean was necessary, a couple of purists felt it was their place to comment… er, judge… what they thought was happening, without the benefit of actually knowing because I wasn’t expressing everything online.

My recent doula client also gave birth by cesarean because her baby turned breech during active labor.  In my postpartum visit, she told me that she had shared her birth story online and she had people telling her that it was because she had her membranes stripped the day she went into labor (after three days of non-progressing pressure waves, and at the same gestation that her previous child was born) that she ended up with a c-section.  Apparently, according to comments she got, having your membranes stripped is "just asking for a c-section." Come on, people!  Are you kidding me?

I just think the judging of other people's births has got to stop.  We don't have all the information, and even if we did, we are not that woman and we can't know her heart.  What she chooses is her choice, and if she seems happy with it, can we please just leave it at that?  Can we please leave the armchair quaterbacking to the sports fans and focus on supporting other women in whatever is the best birth for them?

To staceyjw: Reply-Turned-Post

staceyjw left a comment on a post I previously had a link to in my list of "favorite posts" in my sidebar, which prior to receiving this comment, I hadn't updated in a very long time.  I have now updated the list, and chose to no longer include that post, because I feel it no longer reflects the direction of this blog, and I have more recent posts that are "more favorite" for me currently.

The post, published October 23, 2010, was called Elective Cesareans as Commentary on a Failed Birth Model.  In it, I explored one woman's writing about her view of the choice of cesarean vs. vaginal birth, and how her assumptions about vaginal birth, which, in my opinion, were largely informed by our culture's negative image of childbirth and common obstetric practices that are often seen as dehumanizing, appeared to color her view.  I contrasted that with the view of birth held by the natural childbirth community, suggesting that perhaps if our system could make vaginal birth a better experience for the majority of women, perhaps less women would request cesareans.

This is the comment:

You don't have to think VB is dehumanizing or rape like to prefer the risks and recovery from a surgery to the risks and recovery from a VB. Sure, VB can go well, but when it doesn't, it can be very damaging (NCB or not, it happens). Personally, I would trade a belly scar and ab pain for vaginal pain and possible damage anyway. This doesn't mean we see "modern" VB as horrible, or anything else, just that when looking at all the ways to birth, we prefer one to the other.

This is because many Moms, including myself, see the actual arrival of our child as the life changing event- the act of becoming a parent, welcoming a new member of the family and enlarging our hearts with another human to love. How the baby gets out/into the family is irrelevant. I dont have to push a baby out my vagina to be a Mom! Focusing on a biological act to make a woman/Mom is also the very antithesis of feminism.

By focusing on VB as a "rite of passage", instead of the actual arrival of the baby (or child, in adoption) you cause a lot of hurt to Moms who didn't VB. This is not necessary, as women have enough to deal with without creating a distinction between Vb and CS, adoption, surrogacy as a way to parent.

Here is my response:

In this post, I was responding to the view of vaginal birth expressed in the Pregnancy Zone article.  I was disturbed by the way the author described vaginal birth, and it did sound very negative and verging on sexual assault to me. I do think that particular writer's negative view of vaginal birth was largely formed by the negative image of vaginal birth in our culture and common medical practices that disrespect women. Obviously, each woman is different, and each woman's reasons for her birth choices are going to be different as well, so your reasons for your choices will be different from hers.

You are right that vaginal birth does sometimes cause serious vaginal damage.  I don't deny that.  With good care, though, it is relatively rare, just like serious complications from c-sections (that some of us NCB people are so afraid of) are also rare.

I understand what you are saying about the arrival of the child being the significant, life-changing event.  I also believe that welcoming a child into your family is always special and sacred, no matter how it happens.  I have problems with saying that the baby getting there is all that matters, because that is hurtful to all the women who are traumatized by the way they are treated while giving birth.  Mistreating a women is never okay, even if you hand her a healthy baby at the end of it.  I do believe that the process by which a woman brings her baby into her family matters a great deal.  I do not, however, believe that there is only one correct way to go about it.  If you read my post Why Natural Childbirth is Not Important, you will see that I feel that  going through the literal biological process of natural birth or vaginal birth is not as important as being an informed participant in the process of a birth (which can also extend into other methods of acquiring a child).  I was referring mostly to medically necessary cesareans in that post, but it also applies to elective cesearans.  Only you know your body, your priorities, and your circumstances, and only you can make the best decision for you. 

The way you have interpreted my use of the term "rite of passage," will lead me to use a lot more care in how I use that term in the future.  There are some who believe women who do not experience natural childbirth will not be as good of mothers for not having gone through that experience.  I may also have believed this in the past, but I was wrong.  Just because one woman feels a certain experience was important or necessary to her development as a mother does not mean all women have to have that same experience to become a mother.  We are all different and all of our "rites of passage" into motherhood will be unique.  I believe that God gives us each individual experiences that best help us learn and grow in our own individual ways.  I feel that whatever you go through to get your child is your rite of passage into motherhood.  For some women, the rite of passage will be adoption or surrogacy--which are often very long and difficult journeys.  For one woman the rite of passage is joyfully pushing her baby out with an epidural, for another it is choosing a cesarean as her preferred method of birth, and for another it may be having an unmedicated birth.

Many women have described their unmedicated birth experiences as significant self-discovery journeys, that made their baby's arrival into their life special in a way that was right for them.  You may feel it wouldn't have be an awesome experience for you to give birth that way, and not all women who give birth unmedicated feel that way about it, but that shouldn't lessen the experience for the women who do.  A woman may feel giving birth on their own terms, without feeling powerless to authority figures or controlled by an obstetric system (that many feel is patriarchal), was an important part of her life, motherhood (and possibly feminist) journey.  Another may feel that having experienced the intensity of unmedicated birth is something she can draw strength from in the future.  Another woman may feel that giving birth naturally brought her closer to God.  To say that there is never value in the experience of natural birth is to discredit these women's experiences.  Not every woman wants or needs that experience for her personal growth, but those who choose it should be free to attach whatever personal significance to it that they see in it.  Seeing significance in the journey of birth doesn't take away from the joy of welcoming a child into your home, not any more than appreciating personal growth one might achieve through a challenging adoption journey would take away from that joy.  It is not a one-or-the-other choice between appreciating the process and the product.

And for some women, the process has nothing to do with it.  Some women will define their transformation into "motherhood" as being completely unrelated to it.  I understand not caring about how the baby gets there.  I used to say I was sure I wanted all the drugs I could get.  My own paradigm shift was more about the belief that it would be safer to avoid drugs and procedures as long as there weren't complications (I do still believe this, and it would take a lot to change my mind) than it was about wanting some great experience.  However, learning that it is possible to have a joyful, empowering experience birthing naturally, and that it wasn't necessarily the horrific ordeal I always assumed it would be was also part of it.  Attempting to birth without pain medication in my first birth turned out to be harder than I expected, and I chose to have an epidural.  For my second birth, I used hypnosis (Hypnobabies, which I now teach), and it helped me increase my endorphins and think of the sensations I was feeling in a positive light.  It allowed me to remain mobile when I wanted to be, and feel connected to what was happening as my baby emerged, which was important to me.  I was overall, really happy with the experience, and felt I learned a lot from it about my strength and the power of my mind, just like I learned a lot about being flexible and accepting change in my first birth.  Both birth experiences were different, both were significant learning experiences for me, neither was superior to the other, and I don't think either gives me any advantage over any other woman--we all have different needs for our growth.

I admit that I have difficulty wrapping my head around the idea of a woman wanting to choose a cesarean without a medical reason.  I know this is because of things in my background that influence my perception of the choice.  It has to do with my faith--my belief that vaginal birth is God's design, as well as my desire to have the option of having a large family for religious reasons (since having cesareans is likely to limit how many children a woman can have), my lack of experience with major surgery, and yes, my history of exposure to natural childbirth literature.  But I recognize that you may have a different background, beliefs, and life priorities than I do.

I take your point and I apologize, for myself and the rest of the natural birth community (though I guess I don't really have the right to speak for anyone else) for hurt feelings caused by the idea that there is any best way for all women to become mothers.  There may be a best way for me to welcome my child (and that "best way" may not be the same for each child--it hasn't been for me so far), but what is best for me and my baby may not be best for another mother and hers.  I will do my best in the future to avoid talking about vaginal birth or unmedicated birth in ways that are hurtful to those who do not have those experiences.

Tempering Extremism in the Natural Birth Community

The online world of natural childbirth is often heavily influenced by extremism. People claiming things like "Birth is safe. Interventions are risky" sometimes leads women to believe that as long as there is minimal intervention in their birth and they listen to their intuition, there will be a good outcome. Worse yet is the belief that a bad outcome occured because the woman didn't "trust birth" enough or the ridiculous logic that anything makes a baby's preventable death okay.

Most people who promote natural childbirth also promote that women educate themselves, but as I have said before, the problem with not knowing is we don't know what we don't know. Many women may think that they are educated about birth when they really aren't. And if you really believe that "birth is safe," then what do you really need to know? The same is true of under-trained women who act as "midwives"--many of them follow this same mentality and are unaware of the information out there that they don't have. To be clear, I do not mean all direct-entry midwives. Some are well educated. Some are not. And having the CPM credential doesn't mean anything. Having a state license may mean something, depending on the individual state's requirements--they range from having a CPM (which, as I understand, at minimum, can be achieved by doing an apprenticeship involving at least 40 births, getting CPR and NRC certified, and passing the NARM exam) and being required to graduate from a three-year program at an accredited midwifery school, attend at least 100 births, and pass the NARM exam (Washington State).

I mentioned the homebirth midwifery laws in Oregon in a previous post. A recent tragedy in Oregon has opened debate about these laws, and many are calling for mandatory licensing. I think that this unfortunate event may be a consequence of extremism--untrained midwives thinking they were qualified enough to attend births and a poor mom who didn't know or believe that looking into their training was important.

There will always be extremists in every movement. The internet, with its power to bring people together, sometimes gives the illusion of normalcy to the extreme. Sometimes it is necessary to push back against the influence of extreme ideas--to nudge the proverbial pendulum back the other way a little. Those who do so will often be accused of being "from the other side" or "causing division." I think voices of reason are essential. I have recently come across a circle of bloggers who fight to temper extremism in natural childbirth and homebirth, and to raise standards for midwifery in the U.S. They promote Certified Nurse Midwives as the optimal caregiver for a homebirth and believe that the Certified Professional Midwife credential should be changed to match the CNM standard of education or be done away with. Amber and Jessie are both former CPM students who have now chosen to pursue CNM education. Deb ("The Sensible Midwife") is a CNM with a homebirth practice. While I may not agree with everything these women have to say, I do believe the natural birth movement needs voices like theirs to help keep it in check.

Temper (verb): to dilute, qualify, or soften by the addition or influence of something else: moderate (merriam-webster.com)

Tomorrow is the first day of our Preschool Co-op!

During the school year, a friend of mine does a "music time" for young children and their moms on Wednesday mornings. She has instruments and cute paper cut outs that go along with the songs. It is great. After the singing, she opens up her playroom and the children play while the moms chat. It is lovely.
One of the moms was saying how she was trying to find a pre-school for her daughter for the fall, but was having difficulty because her child's late birthday meant she would not turn three until after school started. Somehow, we decided to just do our own preschool for 2- and 3-year-olds this fall. There are four moms in the group (and 5 kids--one of the moms has 2 who are close-spaced), and we will be doing preschool two days a week for a two hours and fifteen minutes a day. Each week, we will rotate to another mom's house. So, I get to teach preschool again for 2 days out of each month (Maybe I will write some about the lessons I teach on my days here, as a break from some of the birth stuff.) On weeks I don't teach, my daughter will have opportunities to be with other kids, learn to follow a school rhythm and how to act appropriately in school, and I will have 2 days a week to be with just my son (and probably go grocery shopping!) It will be good for me to have some one-on-one time with my current baby before the new baby comes.

It will also be good to help get a little more structure in our weeks. The mom who does "music time" will be starting it up again as well, so we will have "planned days" 3 days out of the week. The lack of structure has been making life kind of chaotic (and often very lazy) around here lately. I'm excited for it! It will be a school experience for my daughter, at a much lower cost and with more input from me than a more traditional preschool. The first day, which will be an "orientation," will be Tomorrow!

Video from One World Birth

I thought this video related to what I wrote about in my last post.

One World Birth: Is there a conflict in birth?

For those who are not familiar with it, One World Birth is a documentary-in-progress that is uploading new footage from interviews with various experts in birth-related fields as it is ready to be viewed. The project seeks to build an online community to participate in the film-making process. It is an original idea and very interesting. The footage that is up right now is mostly from the U.K., but they plan to come to the U.S. and Canada to do more filming soon, and hope to travel all around the world to get a complete picture of all of the issues in birth all over the world. These short videos are great for sharing on social media--I am posting one video on facebook and twitter each day.  Visit the site to view more videos and leave comments for the film producers.

More Thoughts on Research

The comments on Homebirth Research: Another Side of the Story have been interesting. Thank you to everyone who has shared your thoughts or other information you found about the study. I think the letter to the editor from De Jonge that one anonymous commenter shared was interesting, especially the point about how the methods of data collection in the study may have inflated the perinatal mortality rate in the low risk group. If she is correct in this assessment, I believe it does call the validity of the study into question.

That said, I think that the Evers study raises a lot of questions that require further research.

• is midwifery care, with referral to obstetric care if complications arise, optimal care for low risk women?
• are there specific aspects the midwifery system in the Netherlands that are suboptimal (such as, protocols for intervals to check the fetal heart rate, as mentioned in the paper, or as one response to the study pointed out, the use of midwives assistants to watch over women until close to time of birth)?
• how might midwifery care be improved to result in better outcomes?
• how might collaboration between midwives and physicians be improved to result in better outcomes?

I think that many questions such as "Is homebirth safe?" or "Are midwives or obstetricians better caregivers for low risk women?" are questions that may never be fully answered with research. There will always be people who find a flaw in a study's design or some other way to discredit it, because most people have basic beliefs about birth that are not easily changed. There will always be people who focus (some because it is their job) on the cases where things go wrong and work their hardest to save those lives. There will also always be people who want put their primary trust in either a divine design for the process of birth or its thousands of years of improvement through natural selection (whichever is their belief, mine is these former) and who prefer to use the technology of the past hundred years or so as mostly a back-up. Most people find ways to dismiss "evidence" that does not support their basic view while accepting that which is in line with it. It is human nature.

The answer to safety in maternity care is not to convince one side that the other is "right." The answer is respectful collaboration. This is not the first time I have talked about this. In October 2010, I committed to make my blog a doctor-friendly zone, and I hope that I have held true to that promise. I believe now, as I did then, that peaceful dialogue between doulas/activists/midwives and obstetricians and other hospital providers is essential for improving our maternity care system to protect the lives and and best meet the needs of mothers and babies. I believe that hospital and out-of-hospital providers could learn a lot from each other, which I think could help improve the safety of the practice of homebirth and care in transfers, as well as improve the environment and the options available to women in hospital birth. I have started to see dialogue opening up a little more in the past months, as more physicians are creating online presences and the internet is becoming a larger platform for conversation. I'm curious also, to see where the upcoming Home Birth Summit will lead.

Homebirth Research: Another Side of the Story

Information about this has been showing up everywhere for me lately, though I have not sought it out intentionally, and I feel like I would be irresponsible not to write about it.

For a long time, I stayed away from the topic of homebirth, partly because it is such a controversial topic. I have only started writing about it recently because I am pregnant and currently am under the care of a team of homebirth midwives. My post titled "How Homebirth Benefits Babies" was the first post I wrote that "promoted" homebirth (with caveats!). It is also has been the most widely read, currently at 1,788 pageviews.

I have discovered that the evidence really is not clear on the most important point I make in that post when I talk about homebirth research. My words:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6).

It has come to my attention that the results of one of the studies I cite in that post has been called into question by the results of another study--a study that nobody in the online natural birth community appears to be talking about, even though it was published 9 months ago.

The study I cited in my post was the de Jonge study from the Netherlands, which compared outcomes of home and hospital births attended by Dutch midwives among women classified as "low risk" by the Netherlands maternity care system. De Jonge found no difference in mortality or severe morbidity in the home and hospital groups.

The Evers study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study was published in the British Medical Journal in November 2010. It compared outcomes of term births classified as "low risk" by the Dutch system attended by midwives (primary care) with outcomes of births classified as "high risk" and attended by obstetricians (secondary care). It found higher rates of perinatal mortality in the primary care group, and no difference in rates of level 3 NICU admission (the measure the study used for severe morbidity). Yes, you read that right. More low risk babies died. There were 26 delivery-related perinatal deaths out of 18,686 who began labor in primary care(a rate of 1.39/1000) and there were 10 delivery-related perinatal deaths out of 16,739 who began labor in secondary care (rate: 0.60/1000). The transfer rate from primary care to secondary care during labor was 22.9%, and 12 if the delivery-related deaths occurred in those who were transferred. The number of intrapartum stillbirths was also higher in the group that began labor in primary care. The study excluded all instances of congenial anomalies.

This study calls into question the belief that the best and safest care for low risk births is low-intervention care. From the Discussion section of the paper:

This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels. Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes. Delay can occur at three moments. Firstly, diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours. Secondly, transport can delay treatment in case of an emergency. Finally, a delay can occur because the obstetrician underestimates the problem as the referred woman is a “low risk” patient. In addition, essential information can be lost during the referral. These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted.

And this is in the Netherlands, where there is a universal standard for midwife education and there is supposedly to be a good system of transfer of care. Would having low risk women also be cared for by obstetricians be a better system for the Netherlands? That is basically what we have in the U.S., and we have a 33% cesarean rate. Cesareans increase the risk of maternal morality (see Deneux-Tharaux, 2006), though maternal mortality occurs much less frequently than perinatal morality does. Considering the increased risks associated with pregnancies and births in women with prior cesarean sections (see Kennare, 2007) , some of which impact both the mother and baby, I just don't see how this can be the optimal way to care for mothers and babies either. I'm not even going to try to answer the question of how many mothers (and any future babies they may have) should have to accept the risks of a cesarean section to save the life of one baby. It is something to think about.

The choices we have are between sets of risks. The absolute risk of a baby dying at all is low, especially if there is access to fetal monitoring and some level of emergency care (such as midwives who can perform neonatal resuscitation). When are talking about a rate of 1.39/1000, it means an individual has a 0.139% chance of it happening (and a 99.861% chance of it not happening)--and that's all primary care deaths in the Evers study, including ones who would have died no matter what kind of care they received. The risk of preventable death is presumably lower, though we don't know how much lower because there is no obstetrician-attended low-risk comparison group in the study. I don't want it to seem like I am trying to "explain away" the risk of preventable death. The statistics mean nothing when your baby is the unlucky one who dies. I believe in informed choice, and I believe you need accurate information to make informed choices.

After I wrote this post and was waiting to publish it (I usually space posts out further, but I moved this one up because I felt I needed get it out there), I saw this post from Birth Without Fear in my facebook newsfeed, and felt it applied to what I am trying to say. Like her, I am not here to advocate that you have a homebirth. I advocate that you look at the information, weigh your options, and make whatever is the best decision for you.