Being Motivated "Towards"

I just read a really interesting post about motivation by Felice at The Gift of Giving Life. Since I haven't blogged in a while, I would like to respond to her ideas in my own post.

I think it is interesting that motivation towards something is more effective at generating action than motivation away from something. I used to clean my house to get away from messiness, I now clean it to move towards control, order, and a more peaceful atmosphere. Towards motivation does seem to be more effective in this particular instance.

Felice's post focuses on motivation for choices while preparing for childbirth. Fear of pain (an away from motivation) is a common motivation for women in this situation,. Early on in my first pregnancy, when I was planning on getting an epidural, I was motivated by fear of pain. When I discovered the risks of epidurals, I was still motivated by fear--fear of complications resulting from overuse of medical interventions. This is still an away from motivation, even though it was movtivating me in a completely different direction--to have an unmedicated birth. I started to discover other motivations in that pregnancy, but did not have a lot of time to explore them.

In my second pregnancy, I was not so afraid of intervention. I'd had a medically managed birth that turned out fine. I had some fears, but they were more fears of "failing" (in quotes, because I now realize that the word failure has no place in birth) than of complications. I was determined that (of course as long as there were no complications) I was going to do it without drugs. I was motivated to prove that I could do it. I was motivated away from failing. I was also motivated towards an enjoyable birth, a safe birth, an empowered birth--and I worked to keep my choices in line with what these words meant to me at the time, which I'm sure was very different from what they would have meant early in my first pregnancy. They probably mean something slightly different even now.

When we move away from being motivated away from pain and away from "failure" and learn to be motivated towards the most positive safe birth experience we can have, it is then that we discover that gettting a "perfect" birth experience doesn't matter so much and are able to embrace whatever birth gives us and learn and grow from it.

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?

Painless Childbirth, revisited

Lately, my Understanding "Painless" Childbirth post has gotten a lot of attention. I'm so glad, because much of what is in it is so important for women to know. I have gotten a few comments from women who experienced painless childbirth without hypnosis. I think these stories are awesome and they fit right in with the ideology that birth doesn't have to be painful. Here is one of the comments, explaining the various degrees of comfort for her five births.

[. . . ]I experienced almost painless childbirth with and without drugs and never used hypnosis. I think it is different for everyone..[. . . ]In five births, number one and two were painless with drugs. Number three was painful. Number four was not painful until the last ten seconds and number five was painless

I just started focusing on reassuring the baby and the surges never got painful with four and five. The crowning was not painful on number three and number five.

The contractions hurt on number three (possibly because I was panting to keep the baby in on the dash to the hospital.)

Notice her theory that fighting against what her body wanted to do in order to get to the hospital before giving birth may have caused more pain that was necessary. I have been meaning to write about why I feel my second birth became uncomfortable during second stage, after I was almost completely comfortable for first stage, including transition.

My birth plan said "limit vaginal exams to those I request, unless necessary for a medical decision." This request was ignored soon after my OB started to tell I was getting pushy. She had me get into a good position to be checked (big mistake #1 was getting into that position in the first place, big mistake #2 was not getting out of it) and when I was found to have just a lip of cervix left, she continued to check periodically without saying anything. I didn't really mind much at the time since I was really focused on relaxing through the waves, but I do understand why some women feel violated by things like that. I had read about the flaws of the rule of 10 and wanted to be able to push a little if I felt like it even though I was not "10 centimeters." At first, my OB's advice supported this, and she encouraged me to push only as much as I felt I had to. The waves felt different and I began to vocalize through them, because it felt better to, but I was still using my hypnosis and staying comfortable. I don't know how much time passed, but she must have gotten impatient, so she wanted to try holding back the lip of cervix and having me push, which was extremely uncomfortable.

All of you who work with birthing women, this is important, during birthing, our brains sometimes don't clearly interpret what you mean when you say things to us. When trying to hold back the lip of cervix didn't make it go away, my OB told me to try not to push, though I think now she must have meant to only push as much as I had to, but in my confused birth-brain, I read it as "don't push at all" which was very different from what my body was telling me to do, and I think greatly increased the discomfort and, I dare say, pain that I experienced. It is likely that the fighting my body and the confusion caused the pain, not necessarily the pressure waves. When she started telling me I could push, obviously that implied the lip was gone, but again, I had birth-brain. This (and not getting out of that bed) is why I think I ended up needing to be coached to push him out. Once I started really pushing, it wasn't really painful anymore. Crowning didn't really hurt to me either, just felt like really intense stinging.

Here is another comment from a woman who experienced a painless birth:

I had a painless birth with my fifth baby. It was so painless that I didn't realize it was real until he was crowing. (Luckily my husband recognized subtle changes in my mood and called the midwife, who arrived just in time.)

I did not do hypnosis. I just practiced relaxing my perineum with each braxton hicks. When I was lying in bed, in active labor, I thought I was having BH contractions so I just kept relaxing my perineum.

It didn't even hurt when he was crowning. I tore a little and that stung but not bad at all.

For the record: My son was 10lb 6oz and I have a ridiculously low pain threshold

That is pretty amazing. Her comments illustrate beautifully that women do not have to have an unusually strong ability to endure pain to have enjoyable natural birth experiences--it is not an issue of how much pain you can take, but how you choose to think about the sensation you're experiencing.

In both this story and the previous, the moms did not have the painless experience until they had already been through birth before. These women have probably found a solution to the fear problem by experiencing birth. Since they have done it before, they don't need to fear the unknown. Thinking you're not really in labor would probably reduce the fear, too.

Here is another one, from a midwife

[. . .] I had painless childbirth with all my babies. I think it was because I did unassisted births and no one talked to me or touched me while in active labor. I was able to go into the zone and time seemed to stand still. But every time I looked at the clock an hour had gone by. When it was over I felt like I had just had the best sex ever. I was 17 and had a 5 and 1/2 hour labor with my first.

As a midwife, I try to allow my moms to go to that zone, but I also have to listen to the baby, give drinks of water, etc. I tell my apprentices not to talk to her, just support as they see a need and be aware of the mom's response.

I have discussed unassisted birth before. I do think that women are likely to have more comfortable birth experiences if they can be undisturbed. Undisturbed birth does not necessarily have to be unattended. If a doctor or midwife can act as a lifeguard, then a "best of both worlds" birth is possible. The benefits being able to stay focused and follow your instincts while still having a knowledgeable expert available to step in if they are needed. This appears to be how this midwife practices and teaches her apprentices to practice.

"Let them to this and not fear"

I always love reading about traditions of childbirth in various cultures. I have yet to see anything in a natural childbirth book about birth in the traditional South Pacific. My Mother-In-Law is a Tahitian native (now a naturalized American citizen). She had seven natural childbirths before trying the epidural with her last two to see what all the fuss about epidural was about. She was my doula for my daughter's birth. I decided to do some searching on the internet about childbirth in Tahiti, and I found this beautiful passage from the book The Bounty: The True Story of the Mutiny on the Bounty by Caroline Alexander.

When asked about childbirth in his country, Bligh answered as well as he was able, and enquired in turn how this was done in Tahiti. Queen Iddeeah replied by mimicking a woman in labour, squatting comfortably to her heels between the protective arms of a male attendant who stroked her belly. Iddeeah was vastly amused on learning of the difficulties of Pretanee's women. 'Let them to this and not fear,' she told Bligh, who appears to have been persuaded by this tender pantomime.

I love Queen Iddeeah was "vastly amused" learning how difficult Western women had made childbirth. It appears that she demonstrated a "supported upright position with light touch massage," but all she knew was that this is the technique women on the islands found most comfortable and efficient for birthing. They didn't need a randomized controlled trial of upright verses lying positions or a book on anatomy of the uterus to know about this, they just knew it.

I can't completely know what she meant by "Let them to this and not fear," perhaps that the Tahitian method of birthing would help women not fear birth or that if they used this method and were not afraid, their births would go better. Either way, I agree with her.

This is the first mention I've come across of traditional cultures involving men in the birth process. Most other stories feature women birthing with other women or alone. Even in Western culture, birth was the domain of women until doctors came on the scene. Apparently this was not the case in Tahiti.

Perhaps part of why my husband was good at supporting me during my births is that it's in his blood?

More on Overcomming Fears: The OCD Project

Recently, my husband and I were watching VH1's "The OCD Project," which documents a 21 day treatment camp for people with obsessive-compulsive disorder run by Dr. David Tolin. OCD actually has a lot to do with extreme irrational fear. Much of the therapy in the show involves them facing their fears.

The OCD Project Supertrailer

In the tailor, you see a clip where the patients are writing down their fears about what might happen if they don't do their OCD rituals. On the episode, Dr. Tolin has them read what they wrote into a tape recorder. He then uses these recordings as voice-overs for videos he makes called "fear movies"--images depicting their worst fears. He has them watch these films wearing a heartrate monitor, as increases in heartrate indicate anxiety. The films play twice, and during the first run, all of the patients had increases in heart rate in response to seeing their fears. Their rates stabilized when the film ended and then when it played again, their heartrates remained stable because it became less scary after they had seen it--exposure decreased anxiety.

This exercise reminded me of the Fear Release exercise in Hypnobabies, which involves visualizing watching your fears on a screen. I realized that part of how this exercise works is that by seeing our fears, we become less afraid of them.

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.