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.

The Trap of Idealizing the Intervention-free Birth

Sometimes we get caught in a trap of holding up a spontaneous, drug-free vaginal birth as an ideal, because, well, most women should be able to give birth without interventions, right? Then, we end up comparing an individual birth to this standard. I doubt anyone would actually say this out loud, but I think something like the following happens in some women's minds, though it is probably not this specific.

• Completely intervention-free vaginal birth? A+! Great job!
  
• Vaginal birth with IV and artificial rupture of membranes? B. Good effort!
  
• Induction and epidural? C. Mediocre.
  
• Epidural, episiotomy and vacuum extractor? D. It could have been worse.
  
• Cesarean? F. Better luck next time.
  

But this is not how it works. Your childbirth educator isn't going to give you a grade, because your baby's birth is not an exam! You are not "most women" and every birth is different. It is not your responsibility to prove that birth with minimal interventions is best. As a wise woman once said, "that's a pretty freakin' huge burden to put on one vagina." Interventions are sometimes needed. You can't know in advance that you won't need medical help, so it doesn't do any good to believe that getting it is a negative reflection on you.

After my first birth, I did feel like a C student. I felt like I hadn't done a good enough job at practicing tools for reducing or coping with pain. I thought that if I had prepared better, I possibly could have avoided the epidural. But how in the world can a woman expect to know how to prepare for something she has never done, having no real way of really knowing what it is going to be like for her? Can someone who has never given birth before really prepare for a long, slow, sleep-depriving early labor? An intense, lightening-fast, precipitous labor? Constant pain in her lower back that gives her no break? An emergency cesarean? How can we expect a first time mother to predict what techniques might be helpful for her so that she can practice them? How is she to know how much time she needs to put into practicing so as not to forget everything she practiced immediately when her birthing starts? And how is she supposed to devote any time at all to it when society tells her to "just enjoy the pregnancy" and "don't worry about the birth" until it is less than three months away?

I wish we could irradiate the word "failure" from our vocabulary in conversations about childbirth. I do not call doing something differently from what you wrote on your birth plan failure, I call that a change of plans. Changes of plans can be in response to medical necessity (because intervention sometimes does save lives and improve outcomes), or they can be for psychological reasons. If a woman who wanted a natural childbirth has crossed over from "coping" to "suffering," and nothing is working to bring her back, the decision to use pain medication is not failure. In that kind of situation, medication is probably the best choice to avoid trauma and allow the birth to be a good experience for the mom. As many have pointed out, a traumatized mom is not a "healthy mom."

If a woman had interventions in her birth she wouldn't have chosen with more information or if her options had been presented in a different way, it is not her fault. I hear a lot that a woman has a responsibility to inform herself, but the problem with not knowing is that we don't know what we don't know. Can we really expect a woman to be responsible for understanding all of the situations that may come up in her pregnancy and birth and all of the benefits and risks of available medical procedures? In an ideal world, her care provider (whose job it is to know these things) would present the facts about her choices as objectively as possible, and leave the decision to the woman. In most cases, reality is pretty far from this ideal, but I don't believe in blaming women for not finding out for themselves what their doctors should have told them. (Though getting angry about what doctors should do doesn't do us any good--Felice recently posted about this here.)

As always, the language we use is important. We have to pay attention to the implications of what we say--what a woman may read between the lines of our words. The phrase"sucessful VBAC," implies that a planned-VBAC-turned-repeat-cesarean is a "failed VBAC." Criticizing high rates of medical intervention by saying things like "I find it hard to believe that X percent of women's bodies are broken" implies that the body of a woman who has an honest medical need for that intervention is broken, and "Your body is broken" is not an empowering message. Besides, we don't consider it failure for our bodies to not function optimally all the time in life--I don't usually think my immune system failed me if I get a cold or stomach virus--I usually attribute that to bad luck. I think sometimes birth is the same way. Preparation plays a role in whether or not you get the birth you planned for, but so does chance.

Maybe those of us who have had that idealized birth shouldn't get cocky and maybe need to recognize that it didn't happen all because of what we did, and hopefully those of us who had a birth other than that one can recognize that it didn't happen all because of what we did either. At the same time, I do not wish to invalidate other women's feelings. If "failure" is the word you choose to describe how you feel, then that is your reality. If reading my thoughts on this does not bring you any healing, I wish you healing wherever you find it.

Stay tuned for the next post in the series!

How to get your partner on board with your birth plan

So, you want to change maternity care providers but your husband doesn't understand why you should go through the trouble? You want a natural birth, but your husband says, "why have pain when you don't have to?" You want to write a birth plan, but he thinks it is disrespectful to tell professionals how to do their jobs? You want to hire a doula but your husband doesn't see the benefit? Or maybe you want to give birth at home or in a birth center, but he thinks you should just go to the hospital like "everyone else"?

Here are a few ideas that might help him see why this matters to you:

• Get him to read a book, such as The Thinking Woman's Guide to a Better Birth or maybe a selected article or blog post, such as Dr. Sarah Buckley's Epidurals: risks and concerns for mother and baby or Navelgazing Midwife's Pointless Hospital "Rituals".
  
• If he is the kind of guy who doesn't like to read, have him watch a birth documentary with you. Some possibilities are The Business of Being Born and Pregnant in America.
  
• Set up a meeting for the two of you with the midwife or doula you would like to hire. She may be able to address some of his concerns.
• Get him to take a childbirth class with you. Choose a class that covers the benefits and risks of your various options, rather than one that only teaches what is standard practice at the hospital.
• Sit him down and have a heart-to-heart. Explain how much your baby's birth matters to you and why you want to be involved in the decisions about it.
  

I hope he becomes the supportive partner you want him to be. Or at the very least, he will decide to just leave the choices up to you and go along with it. Good luck!

Doulas and Cesareans

I have written about how a doula can help with different plans for hospital births and for homebirths. A post by Navelgazing Midwife made me realize that I left out yet another group of women. A follow-up guest post Doula-ing for Cesareans on Navelgazing Midwife's blog by Kristen French, of Central Washington's own Three Rivers Birth Services, (small world, huh?) addresses this much better than I ever could. A lot of people assume a doula can't really do anything for a woman having a cesarean, but Kristen's comprehensive post does a great job of explaining otherwise.

Here are a few key things a doula can help with for a cesarean:

• helping the mother understand the procedure and prepare emotionally for a cesarean
  
• helping the mother develop a birth plan that allows her cesarean to be a special birth for her and her baby in whatever ways he woman would like. Kristin's guest post contains a list of options, and some possibilities are shown in this amazing video:
  

• supporting the mother in the moments just before the surgery, where intense emotions are likely to arise
• helping the mother develop strategies for coping with the emotional intensity of the cesarean experience
  
• being present in the OR, if the hospital will allow it
• if the mother and baby must be separated, staying with the mother while the father stays with the baby
• helping with establishment of breastfeeding, which is often more difficult after a cesarean because the incision can make it necessary to use less common breastfeeding positions
  
• helping the mother process emotions from the birth to help her memories of it be as positive as possible
  

Elective Cesareans as Commentary on a Failed Birth Model

A recent article out of Australia, Fear of natural birth driving one in three mothers to cesarean, addresses the issue of maternal request cesareans. I feel that this article misrepresents the issue by placing so much of the burden of rising cesarean rates on maternal request. The author doesn't site a source for the "research" that supposedly supports this, but research can be misleading in what they categorize as "elective cesareans." Sometimes such cesareans are actually "doctor unofficially recommended" cesareans and not "maternal request." Also, elective repeat cesareans are different from elective primary cesareans because of the factor of having a uterine scar. However, there are women out there, while I don't know how few or how many, who do actually request their first cesarean.

While I have strong opinions about what constitutes safe childbirth, I respect the rights of all women to make their own choices about their births. It appears that in reaction to the strong natural childbirth presence on the internet (where many women get support that they do not get from their doctors, families, or local girlfriends), there are now websites with the purpose of promoting elective cesareans as a viable birth choice.

Many birth advocates (perhaps myself not exempt) are guilty of using fear of cesareans as a springboard. I realize that most of the stuff out there is attempting to dissolve some of the fear that surrounds c-sections, and I don't really have a problem with that. I would prefer for women for whom the benefits of having a c-section clearly outweigh the risks to be able to go into their cesarean birth without fear. As I have said before, I am all for lessening fear in all types of birth. However, what good does it do to attempt to make vaginal birth sound scary in order to make c-sections sound less scary?

The September 2009 opinion piece at Pregnancy Zone, The Benefits of A Cesarean Section Delivery, which one of my friends at an online community recently shared, is one such attempt. The article was bombarded by comments from women who disagreed with the point of view of the author and criticized her approach of using generalized claims without evidence to support them. I think the two sides of this argument are starting out with different basic assumptions that prevent them from effectively communicating with each other.

The author of the article is assuming that the alternative to a cesarean section is the typical medical model hospital birth. On the other hand, most of her opponents are likely working from very different construct of "vaginal birth" (such lack of understanding is quite common in internet mommy wars). I'm not going to argue about whether the claims made in the piece are true, but rather to look at her characterization of vaginal birth and what that says about our maternity care model and birth culture.

In the "No Labor Pain" section she brings up three kinds of pain associated with vaginal birth: contractions, perineal stitches, and hemorrhoids. When discussing contractions, she assumes that all women see birth as a necessary evil to get over with in order to get a baby. She compares being in labor to recovering from surgery. She assumes that "most" women receive episiotomies (and don't have a choice in the matter) and seems to feel that stitches in the abdomen are preferable to stitches in the perineum. Even without episiotomy, there are a lot of women who assume tearing is inevitable. The author also assumes that hemorrhoids are common in vaginal birth. So, in this author's view, a woman who has a vaginal birth not only has "labor pain" but also a painful, messy recovery involving a sensitive area.

The "Dignity and Privacy" section assumes that all women giving birth are dehumanized and violated, mentioning the presence of a multitude of medical strangers doing vaginal exams and being in a "less than flattering position for any number of hours." At best, this birth sounds like pseudo-surgery, and at worst like sexual assault and torture. No wonder women want to be disconnected from this.

What does the fact that there are women who view vaginal hospital birth as less desirable than cesarean surgery say about how our system treats vaginal birth? Has our system really made birth so clinical, unknown, and scary that major abdominal surgery sounds preferable to a normal human process?

If birth is just a clinical baby extraction, it does make sense that women would prefer to do it through their bellies instead of their vaginas. But this doesn't make sense to women who see labor as a rite of passage, a challenge to rise to, or even a joyful experience that doesn't have to be painful. Natural birth advocates know that with the right kind of care, vaginal birth with an intact perineum or with very minimal tearing is very possible and that vaginal birth doesn't have to permanently damage the vagina. For women who understand humanized birth, it is sad to realize that women think vaginal birth has to be demeaning and rape-like. With sensitive, respectful care, when women choose their own labor positions and choose when they have vaginal exams (or not to have them at all), vaginal birth can be dignified, private, and even empowering.

Perhaps the question physicians should be asking themselves is not, Should we perform cesareans at a womans's request? but, What have we done to vaginal birth to cause women to request cesareans?

Why Natural Childirth is Not Important

My goal is not for everyone to have a natural birth. Of course I believe that, in cases where everything is going smoothly, mothers and babies will be safest if medical intervention is avoided. However, there are times when things go wrong, making intervention necessary (though it is important to remember that not everyone's definition of "necessary" is the same). Holding an intervention-free birth up as The Ideal Birth sets a woman up for failure if complications occur, which is something she has no control over.

I recently followed an online discussion among student doulas about the use of the term "cesarean birth." Some women wanted cesareans to be recognized as births and some women felt that a cesarean is never a birth because it removes the mother from physically participating in the birth process--since birthing is a verb, and a women having a cesarean is not acting, but being acted upon, it can't be a birth. This lead me to re-examine my definition of what birthing entails.

What does it mean to give birth?

When we use to birth as a verb, we are usually intentionally distinguishing to birth from the more traditional to deliver. In the sentence, "The woman birthed her baby into the midwife's hands," the woman is the subject, actively performing the verb. However, if we were to say "The midwife delivered the woman's baby," the midwife becomes the subject of the sentence, implying that delivery is something the care provider does and not the woman. Yes, words really do have power. Once could say one of the purposes of birth education and advocacy is to help women be empowered to birth their babies instead of having them delivered.

It is true that part of the power of an unplugged birth is that women's bodies are in control and not the machines. A birth without immobilizing pain medication, in which the mother can use positions that are comfortable to her, is truely birth in which the mother is "active." But is natural childbirth the only birthing?

If a woman becomes exhausted and decides she wants an epidural to help her relax and get some rest and goes on to push her baby out, we still call it a birth, even though she needed the help of medical professionals and drugs. Some would say, "Of course it was a birth, it was vaginal." But what if that same mother has her labor slow down and needs pitocin to keep her contractions going and isn't able to push effectively with the epidural and chooses to have the doctor use a vacuum? Is the mother still birthing the baby? Is that really much different from a mother choosing to have the doctor perform a cesarean when the mother feels it is medically necessary?

To birth refers to what a mother does to bring her child from her womb into the outside world. Now, does her body have to do this all by itself in order for her to participate in the process? Not necessarily. I believe birthing can be about more than just he limited definition of pushing your baby out. Being actively involved in your birth can also include deciding that your body needs help from a professional, medications, instruments, or yes, even surgery, to bring your baby into the world. In such cases, the birthing is not in the pushing, the birthing is in the choices. I believe that if it is the woman's choice to have a cesarean--she actively decides that enlisting surgical help is the best way for her baby to come into the world, then she is still giving birth.

Natural childbirth is not important. A woman being involved in the decisions about the medical care of her and her baby--that is what is important. Helping women avoid feeling assaulted because they were not involved in what happened during their births--that is the goal. What I do--this blog, becoming, a doula and childbirth educator--that is what it is all about.

ACOG Issues Less Restrictive VBAC Guidelines

A press release today from the American College of Obstetricians and Gynecologists explained that the organization is tweaking it's previously released guidelines for Vaginal Birth After Cesarean, the release states that the organization now includes women with two prior low transverse incision cesareans (such as Dr. Poppy Daniels, the gynecologist who got a lot of attention for her surprise VBAC story), women carrying twins, and women with an unknown type of uterine scar on their list of appropriate VBAC candidates. The press release also clarifies the organization's prior position that VBAC should only be attempted where emergency surgery is immediately available, explaining that while they feel that this is ideal it is not always possible, and that should not prevent women from being given the choice to have a VBAC.

This guideline change likely comes in response to the conclusions of the VBAC Conference held in March 2010 by the National Institute of Health, whose Final Panel Statement called on ACOG to reevaluate their guidelines. There was also an online petition to ACOG with over 1,200 signatures asking for changes in light of the NIH's findings.

I'm calling this one a Victory for VBAC!

The Fear Problem

Fear of the Unknown

It is normal to fear the unknown. For most first time pregnant women, birth is a huge unknown. Not only have we never done it, we may not even have ever seen it done. In North America today, I think it's highly unlikely that the average woman has ever been at a birth before giving birth. She also won't see uncensored images of vaginal birth in any public media. So, unless her school showed birth films in health class (mine didn't) or she takes a childbirth education class, seeks out birth videos on the internet, or watches a birth documentary such as The Business of Being Born, she may not even have seen a baby birthed before she is expected to do it. As I discussed in a prior post, some women seem to think that viewing a birth would disturb them, so they don't seek out any birth videos.

Add this that the fact that virtually every pregnant woman reaches a point in her pregnancy where, looking at her much-changed body, she realizes her baby is going to have to come out, but to her it just seems impossible that it could. It really is an unbelievable thing, even for those who have seen it and done it. That's kind of the miracle of it. Much of the medical system, however, seems to believe that it really is impossible without their help, and they are also afraid of the rare and very scary things they've seen or heard of going wrong, and they pass that fear on to women to add to their fear of never having done it and thinking there is no way her body can do something that seems impossible. Medicalization of birth also increases the "unknown" factor--it is something for educated doctors and nurses to know about, not average women.

Fear of Pain

It is also normal to fear pain, because pain is usually an indication that something is wrong, and we find it unpleasant. Our young pregnant women has heard others talk about how birth was painful for them and that they would never think about doing it without medication (or they did and it was a bad experience), and this just compounds the fear. She has probably seen birth shows on cable TV, which edit birth footage in ways that focus on the dramatic, because they are in the business of making exciting television, not of educating women about what birth is and can be. She probably has also heard a few stories of births where there were complications--maybe a vacuum delivery or an unplanned cesarean. She may fear something going wrong or having something strange done to her. Many women also feel fearful when they are in an unfamiliar place, surrounded by strangers, as is often the case with birth today.

Effects of Fear on Birth

We know that fear causes the body to release chemicals that can stop the birth process. This makes sense from an evolutionary perspective--a tribal woman wouldn't want to give birth if a tiger was chasing her, but as is explained in the book Birthing From Within (not a hypno-friendly book, by the way), the body doesn't know how to distinguish between real and imaginary tigers, it only knows fear. Fear also increases our perception of pain and prevents us from enjoying birth.

So, what is our average (and now thoroughly terrified) first-time pregnant woman to do?

Most likely, she'll figure that she has a highly-skilled doctor and well-equipped hospital that will keep her and her baby safe because they're the experts, and she'll decide she will get an epidural, so she won't need to worry about pain. It is likely that her preparation won't go much beyond this. She will still have other fears to deal with, though. For example, what if she's afraid of needles?

Fear of Needles

Fear of needles is pretty common. I see nothing unreasonable about having a fear about a sharp object penetrating one's skin to introduce foreign substances into one's body. I realize that needles do a lot of good in medicine, but the idea of them is just disturbing to me. It is sometimes fear of needles that leads women to seek out natural childbirth.

My Answer?

The best answer to the fear problem is childbirth education. And by childbirth education I don't mean most hospital-sponsored classes where the woman learns a little (but usually not enough) about what is going on in her body, what routine medical procedures to expect (without letting her know she has the right to refuse all of them), and that epidurals are usually safe and not anything to worry about. I mean childbirth education that is free to tell you what the hospital doesn't want you to know.

Most natural childbirth classes address fear in two ways. They tell women that they can give birth without medication, just like women did before medication existed, and teach them pain coping techniques which helps increase their confidence and overcome their fears about pain. Some of these techniques rely on freedom of movement, so these classes usually encourage women to consider declining unnecessary routine medical procedures that interfere with movement (such as IV fluids and continuous monitoring). They also address fear of the unknown by teaching about the natural process of birth, as well as explaining how medical interventions might affect the process and giving information about the risks and benefits of these procedures and encouraging women to choose for themselves whether to accept them or not. Feeling like they are involved in decisions about birth helps women feel less afraid.

Fear of Medical Interventions

However, the downside to teaching about medical interventions (both in classes and other places such as books/films/internet groups) is that sometimes this education has the unfortunate side effect of creating fear of medical interventions. So, fear of pain, birth, and the unknown, are replaced by fear of hospitals, pitocin, and iatrogenic complications. Remember, fear interferes with birth, no matter what the source or intention. Going into birthing with any kind of fear is not healthy. And there is always a possibility that a woman will need medical intervention in her birth, and if that happens, we don't want her to be afraid of it. I recognize that fear of pitocin had negative effects in my own first birth.

I want women to be able to make birth decisions without fear. The presence of fear makes it difficult to use the other things we need to make decisions--our logic and our intuition. Sometimes natural childbirth sources are guilty of some of the same fallacies as the medical side of things. Those who believe in liberal use of medical technology in birth will focus on a few rare complications as reason why a woman shouldn't choose a homebirth, a VBAC, minimal monitoring, no IV or heplock, etc, while ignoring the majority of births that go right. Natural birth advocates sometimes focus on the rare scary complications of epidurals and cesareans, without mentioning that the majority of women who choose an epidural or need a cesarean have no major problems. It is important for women to understand the risks of interventions, while at the same time understanding that there are times when the benefits of these interventions clearly outweigh the risks.

Overcoming Fear

I feel that the best type of childbirth education would present information in a way that doesn't scare women, but provides them with unbiased information that allows them to make informed, and not fearful, choices. Good childbirth education also has ways of helping women overcome their fears. Hypnobabies includes a fear-clearing exercise that works very well for this. Some other ideas can be found in this post by Felice at The Gift of Giving Life.

Moving Beyond the Mommy Wars

Whether it's breastfeeding vs. formula feeding, cloth vs. disposable diapers, cosleeping vs. independent sleeping, or stay-at-home mom vs. working mom, it's inevitable that people find ways to judge each other in motherhood. Perhaps it is because we tend to define ourselves by our choices, that we tend to take these things so personally.

The judgmental attitudes begin even before we even officially become mothers, during pregnancy and birth. Pejorative rhetoric abounds in comment threads on internet articles and blog posts regarding birth issues such as midwifery, homebirth, VBAC, and high cesarean rates. One term that is often thrown around is selfish. It's "sefish" to try to avoid medical intervention `because it's putting your experience above the safety of the baby, it's "selfish" want pain relief because *that's* putting your experience above the baby's safety, it's "selfish" to want to avoid a c-section out of fear of surgery, it's "selfish" to opt for a c-section out of fear of damage to the vagina, it's "selfish" to have a homebirth because of the risks, it's "selfish" to schedule an elective induction because of the risks, it's "selfish" to go past 40 weeks, it's "selfish" to want a homebirth, it's "selfish" to want a care provider you know at your birth, it's "selfish" to want a VBAc...the list goes on.

The truth is that having a baby is one of the most unselfish things a woman can do. Women usually make their choices based on what they believe is best for their babies and for themselves. There are differences of opinion on what actually is the best choice, but it is never selfish for a woman to want to be involved in decisions that affect her and her baby. It is also not selfish to enjoy the process by which your baby comes into the world. Many women really enjoy natural childbirth and find it empowering and rewarding (and no one should automatically assume they are not one of these women). Other women choose to enjoy their birth using pain medication. I have given birth both ways, and enjoyed each in its own way. Neither was selfish.

Natural childbirthers are often accused of having elitist attitudes. They say that we think we are better than them because we had a natural birth, and seem to think that the only reason we did it was so that we could rub it in their faces that we are superior. Although I do see some of the elitist attitude, I feel our motives for sharing our stories are being misconstrued. It's not meant to be a "look at me, look at me, I'm so awesome because I had a natural birth and you didn't" thing. It's meant to be a "I did this, it was awesome for me, and it can be for you, too" thing. I think it just doesn't come across that way because of knee-jerk defensive reactions, which are then met by more defensiveness, and a bunch of angry name-calling ensues.

As natural childbirth advocates, we are sometimes guilty of labeling everyone who doesn't make the same choice as "uneducated about her options." This is not always true, and even in cases where it is, it is insulting. People don't often listen to things that people who insult them are trying to say. Women who seek to "advocate" for natural childbirth will not get anywhere with name-calling. The more we respond to insult with insult, the more everyone will be insulted. I would like to hope that we can rise above the petty "mommy wars" and share our experiences and information in ways that don't belittle, accuse, or insult.

Birth Attendant as Lifeguard

Clarification: I use the term "birth attendant" here to describe a maternity care provider such as a physician or midwife, not a doula. I don't often use this term, but I must have subconsciously chosen to use it while writing this post because it is most appropriate for the role I was trying to describe, the midwifery model's idea of a caregiver who "attends births" rather than "delivers babies."

Since writing my last post about lessons from the freebirth movement, I have been thinking more about the roles of birth attendants. A guest post at The Gift of Giving Life (one of my favorite blogs) written by Heatherlady called On Cows and Chickens, got me thinking even more.

I believe that women are created to be able to birth their babies. I have read a lot about how hormones control birth and how negative emotions affect hormones and thus interfere with birth. I think that when a birth attendant interferes with the delicately balanced natural process of birth, they risk doing more harm than good. And interfering can probably happen easier than we sometimes realize.

People who believe strongly in the natural process of birth, including unassisted birthers, often compare birth to other normal activities that have some small level of risk associated with them, such as driving a car, playing a sport, etc. They argue that we don't need immediate access to medical technology while doing these things, so we shouldn't need it for birth.

My husband hates analogies because people sometimes use things that are not similar enough to make a good comparison, and I often agree (for example, unmedicated childbirth is not like getting teeth drilled and has nothing to do with hitting yourself with a hammer). However, occasionally, I find a good anaolgy. One such analogy, which I originally got from the Hypnobabies program, compares the birth attendant to a lifeguard.

Although birthing is instinctual and swimming is a learned behavior for humans, there are still a lot of similarities between the two. Swimming is an everyday activity, and the risk of drowning is quite low. The website for the International Life Saving Foundation(ILS) cites a drowning rate of 1.2 million people per year. Worldwide, swimming is statistically safer than childbirth, as the World Health Organization statistics from 2005 give a stillbirth rate of about 3.3 million, and a neonatal death rate (during the first 28 days of life) of over 4 million (WHO World Health Report). Worldwide maternal mortality for 2005 was 536,000 (WHO maternal mortality)

Most people who know how to swim feel confident and comfortable doing so freely without immediate access to medical technology. We are cautious with our young children, for whom the risk of death is greater ( the ILS website states that children make up more than 50% of drowning victims). But with the proper precautions (such as careful supervision and use of flotation devices), swimming can be safe and enjoyable for young children as well.

Despite the relative safety of swimming, we have people trained to attempt to make it safer. According to the ILS website:

The terms “lifesaver” and “lifeguard” are used around the world to describe individuals with special training who are stationed to prevent accidents and to respond to life-threatening emergencies in the aquatic environment.

My older brother used to work summers as a lifeguard at one of the community pools in the area we lived. His job involved watching swimmers to make sure they were safe and reminding them the rules that would could protect them from danger (things like no running, no diving in the shallow end, and making sure the area below the diving board is clear before diving). He had special training and certifications for the job, and was paid for it. Life guarding is often over-dramatized in movies and television, where they are always jumping in to save people and doing CPR. My brother never had to rescue anyone, he mostly sat on his tower all day and worked on his tan, but he could have saved someone if he needed to.

The ILS website estimates that those trained in their lifesaving skills make over 1 million rescues a year. Considering the drowning rate of 1.2 million per year, that means they cause a significant reduction. Parents who take their children to a pool with a lifeguard might feel some assurance knowing that there is an extra layer of safety there--an extra pair of eyes watching for danger, someone who is trained in rescue swimming and has current CPR certification.

I like to think of a good birth attendant as being like a lifeguard. They are specially trained professionals who have the skills to save lives when things go wrong. Occasionally, they may remind a birthing mom to breathe deeply or help her relax, but mostly they should sit and watch for signs of problems. "Watching" could possibly include a variety of things (checking hearttones, recognizing pathological labors, checking for tears, monitoring blood loss, ect.), but it should not include routine unnecessary medical intervention (e.g. elective induction, IV drips, pitocin augmentation, artificial rupture of membranes, etc), telling the mother how to birth her baby, or making decisions for her. In the event that there are complications, birth attendants can save lives (by helping get shoulders unstuck, giving pitocin for bleeding, resuscitating an oxygen-deprived newborn, ect.) much like a lifeguard, but if lifeguards were to jump in and pull people out of the water who didn't need saving, they would likely interfere with people learning to swim on their own and ruin people's swimming experiences.

Lessons from the Freebirth Movement

I just finished reading the dissertation Born Free: Unassisted Childbirth in North America by Rixa Freeze, PhD, of Stand and Deliver. All 300+ pages of it. It was very interesting. I have understood for quite a while that some women give birth unassisted because they feel forced into it because of a lack of acceptable options (such as for a women who is going for a VBAC but the hospitals in her area have "banned" it, and DEMs are illegal in her state, or other situations like that) I used to not understand why some women choose unassisted birth (also called "freebirth") when a midwife-attended homebirth would be an option for them, though I always respected their right to choose it. I am ione who would, in the face of limited options, find the best attendant for a hospital I could and fight for the kind of birth I wanted over choosing to "go it alone" at home. Rixa's dissertation gave me insight into the way unassisted birthers think. Here are a few things I learned:

1) UCers believe, as do others in the NCB community, that intervention in the birth process increases the risk of complications occurring. Unlike the rest of the NCB community, they include things other than medical procedures as interventions. Instruction, support, or even the mere presence of a caregiver is seen by the UC community as disruptive to the birth process.

2) UCers highly value intuition. They believe that the parents of the child should be responsible to make all decisions about the birth. They trust that as they birth alone and as focused as possible on their bodies, intuition will guide them to seek out medical help if a need arises for it, which prevents anyone but them from deciding that an intervention is necessary.

3) They believe midwifery is misguided--midwives are trained to "do" too much at births. They also take issue with midwifery being a paid profession. They believe that ideally, birth knowledge would be freely shared among women so every woman can be her own midwife. There would be a few trusted experts who would sometimes provide assistance, but as a service and not a job.

There is a lot more in the dissertation, and I recommend reading it to anyone who is curious about it. I'm still not planning on having any of my own babies unassisted, but I do feel like I understand better where women who do it are coming from. Reading it also got me to think about some things I'd never thought about--questions about what role I would want a midwife to fill at a homebirth. Would I want her to coach me or stand back and watch? Be in the other room? Do I want cervical checks, occasional fetal heart monitoring monitoring, suctioning, etc? I always figured, if I had a homebirth, I'd avoid "unnecessary intervention" by being away from the hospital, but Rixa's dissertation helped me see that there is more to it than that.

So, Rixa, if you ever read this, thanks for sharing your dissertation and all of the insights in it.

Views of Birth Reflected in Mirrors

Beauty is eternity gazing at itself in a mirror. -Kahlil Gibran

I watched my first baby being born with a mirror. I felt like it helped me to see that my pushing was making progress, and I think felt a a little more connected with what was going on, despite my body being half-numb. I like watching babies emerge because I think it's amazing to see the divine design of the female body at work. I was not offered a mirror during my son's birth, but it didn't really matter because, being able to really feel it, him descending and crowning was very real--an intensity I couldn't possibly escape, even though I sort of wanted to at the time. But looking back on it, it was actually kind of cool. For me, birthing as connected as possible to the experience helped me appreciate my body and gave me confidence in my strength.

Recently I was telling a group of women about how my doctor had waited for spontaneous rupture of membranes at my son's birth (my water broke when I had only a lip of cervix left) and I mentioned how sometimes babies are born "in the caul" (with membranes intact), and I said I'd seen a video of it and it was really cool. One woman, who chose epidurals for the births of all the children she's had so far, said that she had never seen a birth video showing a baby emerging before and she doesn't want to see what it looks like, at least not until she is done having children herself. She said that declines to use a mirror when it is offered during the second stage. My friend explained that she deliberately distances herself from what is happening to her body--she doesn't want to know. She even said that it is because she has the epidural and can't feel what is happening that she disconnects herself from it, and that if she were to have an unmediated birth, she might not feel the same way about it. She also admitted that she may be making what happens worse in her mind than it actually is.

This woman's words taught me that although epidurals don't usually result in a "drugged" feeling like that reported by some women who take narcotics during birthing, the drugs don't actually have to affect your mind to cause a state of mental numbness. Being numb and disconnected from the experience must drain birth of some of the best parts of it. Numbness is all on one level, while the process of natural birthing has highs and lows.

When reflecting upon this conversation, I remembered another conversation I had with different group of women, about 4 years ago, before my first pregnancy when my husband and I were newlyweds. I had done no personal research into the subject of birth outside of maybe watching TLCs "A Baby Story." I realize that this conversation may actually have shaped a lot of my original perceptions about childbirth, which I discussed in my previous post, My Journey to Natural Childbirth. I remembered a woman in this group also saying she declined to use a mirror during her child's birth, that she did not want to see it happening. She had an epidural and trusted that the episiotomy her doctor performed was necessary. I also remember her saying that she was afraid of giving birth at first, but she explained that by the end of her pregnancy she was so miserable the idea of giving birth "didn't seem so bad."

These two conversations, which both mentioned not using mirrors during pushing, about 4 years apart and with women in 2 different states, reflected very similar views of birth--the view that birth is a "necessary evil"--something no one really wants to experience, but must because the baby has to come out somehow. This idea that the act of giving birth is undesirable would support withdrawing from it as much as possible, physically and emotionally. The view of birth as a medical procedure fits with this idea--it is justified to be squeamish about a medical procedure like surgery--I know I wouldn't want to know what was happening to me during surgery, and I avoid watching surgery on TV. I think our medical establishment has actually influenced us to think of birth, even if it is vaginal, as something like surgery. This may explain where the very small population of women opt for true maternal request cesareans are coming from, whether they give birth vaginally or surgically doesn't matter, because there really isn't much difference between a cesarean and a birth-by-machine. Medicalization of birth makes it scary, removes it from the realm of things women are expected to know about, and makes it something it is okay to be removed from.

If, however, we think of birth as a normal, natural process, then it makes sense that women might want to see it. Midwife Ina May Gaskin has suggested that we need to see images of other women birthing before doing it ourselves in order to know what our bodies are capable of and not be afraid. The woman who shared her experience 4 years ago has no idea what her body is capable of--she neither felt nor saw her baby come out of her and the doctor who performed her episiotmy sent her the message that her body is not capable of naturally stretching to allow a baby to pass through. These numb and mirror-less births, were the baby comes out of the mother's body without her really experiencing it, perpetuate the fear of birth because it remains an "unknown" to women, even those who have done it, and it is normal to fear the unknown.

Perhaps women's attitudes about mirrors in birth reflect back to us the truth about what the birth experience means to them?

My Journey to Natural Childbirth

Before I got pregnant with my first baby, what limited knowledge I had about birth led me to two conclusions: 1) birth is painful, but 2) there are drugs for it. I thought everyone got epidurals. I didn’t understand why anyone wouldn’t. I thought “why would you have pain when you don’t have to?” I certainly try to avoid pain whenever possible. I figured that if epidurals were as common as they seemed to be, they must be pretty safe. I thought an epidural would be the only way to make childbirth not be a completely horrible experience. I believed God must have created epidurals so that women wouldn’t have to suffer.

It's hard to say exactly what opened my mind to the idea of natural childbirth. A lot of it came from my experiences posting on online forums. The internet has a way of exposing people to new ideas. I discovered that people still do natural childbirth. I also went to a seminar at Babies 'R' Us by an instructor of the Mongan Method of HypnoBirthing talking about the theories behind hypnosis for childbirth and recruiting for her class. I decided that I could do natural childbirth.

Then I started reading. And reading and reading. One article that was important in my decision process was The Hidden Risks of Epidurals by Sarah J. Buckley. It showed me that epidurals were not as simple as I once thought. Also on my reading list were The Thinking Woman's Guide to a Better Birth by Henci Goer, Active Birth by Janet Balaskas, and Ina May's Guide to Childbirth by Ina May Gaskin.


All of this reading radically changed my point of view about childbirth. My new conclusions were: 1) God created birth as a beautiful and delicate process, 2) people interfering with that process unnecessarily can easily through it off track, leading to complications and a need for more interventions, and 3) women who plan for and accomplish natural childbirth often have wonderful and empowering experiences.