Saturday, November 26, 2011

Listening to Mothers

Have you read the findings of the 2002 and 2006 national U.S. surveys of women's' childbearing experiences? The Listening to Mothers and Listening to Mothers II surveys are a great look at U.S. maternity care and mothers experiences in birth.

I have read an referenced these findings before, but here is a summary of the findings. I encourage you to download the Pdf's, read through the complete findings, view the graphs and charts, and develop a better sense of what childbirth is like in America.

The 2002 Listening to Mothers study was the first national U.S. survey of women’s childbearing experiences. 136 mothers of singletons were interviewed by telephone, and 1,447 completed an online survey within 24 months of their birth (Declerq et al, 2002). The survey was repeated in 2006 in Listening to Mothers II (Declerq et al, 2006).

In the 2002 survey, mothers were pleased with the care they received during birth. The majority of mothers felt that they understood what was happening, felt comfortable asking questions, that they got the attention they needed, and were as involved as they wanted to be in making decisions. Technology-intensive labor was the norm, with high numbers of women receiving an IV, epidural, pitocin, artificial rupture of membranes, or stitching. Almost half of women reported that their caregivers tried to induce labor. One third reported a non-medical factor as part of the reason for induction. Five percent of women chose labor induction to be able to give birth with the birth attendant of their choice. 

The women surveyed in 2002 reported that obstetricians delivered 80% of babies. This was the same in Listening to Mothers II (2006). Midwives attended 10% of births and family physicians attended 4% of births. 97% of births took place in hospitals. Doulas and midwives were most highly rated providers of labor support, but used only 5% and 11%, respectively. These findings were the same in Listening to Mothers II (2006). Three in ten women had never previously met the person who delivered their baby. Four percent of women had a nurse or assistant deliver their baby (not a doctor).

Nearly two-thirds of women received epidurals and most rated them highly. However, most couldn’t answer questions about side effects of epidurals. Use of the tub, showering, and birth balls was rated high for help with labor pain, but used by only eight percent of women.  71% of mothers did not walk around because they were hooked up to instruments, had pain meds, or were told not to by caregivers. Only twelve percent of women had anything to eat during labor, 31% had something to drink. Most were told by caregivers that it was not permitted. Three quarters of women gave birth on their backs.

Two-thirds of mothers had an unassisted vaginal birth; one fourth of mothers had a cesarean delivery. In LTMII (2006), one-third of mothers had a cesarean delivery. In the 2002 mothers who had a cesarean delivery, 51% were planned (predominantly repeated cesareans). 26% of mothers with previous cesareans had a VBAC (LTMII: 11%). 42%- 58% were denied the option of VBAC. (LMTII: only 1 mother out of all the 1st time c-secs requested her c-section with no medical reason).

By a margin of more than 5 to 1 mothers thought it was unlikely that they would choose a cesarean for non-medical reasons for a future birth. Women who had given birth more than a year prior to the survey were more likely to express willingness of caregivers to permit VBAC, compared to women who had given birth within a year of the survey.
Compared to women with vaginal births, those with c-sections were less likely to ‘room-in’ with the baby and be breastfeeding at one week, more likely to experience several health concerns after birth. Experienced mothers (compared to 1st timers) were less likely to attend CBE, use pain med and other interventions, report negative feelings during labor, have a physician as a birth attendant, give birth by cesarean.
In the 2006 version of the survey, researchers found that first-time mothers identified books as their most important source of information. More mothers were exposed to childbirth through TV than through childbirth education.
The greatest concern with the care received during birth was feeling “rushed.” In 2002 and in 2006, about half of women agreed that giving birth is a natural process that should not be interfered with unless absolutely medically necessary. One-third of women had limited understanding or none about her legal right to full information about any procedure and her right to refuse. More than one-third reported she would have liked to know about this during maternity care.

“What happens to childbearing women, infants and families matters deeply. A vast body of evidence is accumulating about lifelong implications of the medical, physical, and social environment during this crucial period. Growing evidence also supports the long-term impact on maternal well-being of conditions at this time.” (LTMII, 2006, p 8)

“Large segments of this population experiencing clearly inappropriate care that does not reflect the best evidence, as well as other undesirable circumstance and adverse outcomes.” (LTMII, p 8)


Declerq, Eugene, Carol Sakala, Maureen P. Corry, Sandra Applebaum, Risher P. (2002) Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, 2002.

Declerq, Eugene, Carol Sakala, Maureen P. Corry, Sandra Applebaum (2006) Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences. New York: Childbirth Connection.

Monday, November 21, 2011

Facts on Contraceptive Use in the U.S.

These fascinating facts on the use of various forms of birth control in the U.S. were presented in one of my classes, and I thought they were too good not to share.

The best part is the chart of effectiveness in perfect use vs. typical use.

Information from the Guttmacher Institute

Did you know?
  • There are 62 million U.S. women in their childbearing years (15–44).
  • Seven in 10 women of reproductive age (43 million women) are sexually active and do not want to become pregnant, but could become pregnant if they and their partners fail to use a contraceptive method.
  • The typical U.S. woman wants only two children. To achieve this goal, she must use contraceptives for roughly three decades.
  • Overall, 62% of the 62 million women aged 15–44 are currently using a method.
  • Almost one-third (31%) of these 62 million women do not need a method because they are infertile; are pregnant, postpartum or trying to become pregnant; have never had intercourse; or are not sexually active.

  • Thus, only 7% of women aged 15–44 are at risk for unintended pregnancy but are not using contraceptives.

  • Among the 43 million fertile, sexually active women who do not want to become pregnant, 89% are practicing contraception. 

No. of users
(in 000s)

% of users


Tubal sterilization
Male condom
3-month injectable
Periodic abstinence (calendar)
Implant, 1-month injectable, patch
Periodic abstinence(natural family planning)
* Includes emergency contraception, the sponge, cervical cap, female condom and other methods.

OK now check this out - First year contraceptive failure rates (or, the woman becomes pregnant) with perfect use compared to typical use, and all contraceptive methods compared to one another.
This is such an interesting chart! Take a look at how Withdrawal method under typical use has the same effectiveness as Condoms under typical use! Amazing! 


Perfect use*
Typical use
Pill (combined)
Tubal sterilization
Male condom
3-month injectable
IUD Copper-T
IUD Mirena
Periodic abstinence

   Ovulation method
1-month injectable

   Women who have had a child
   Women who have never had a child
Cervical cap

   Women who have had a child
   Women who have never had a child
Female condom
No method

Perfect use: The ability of an intervention to produce the desired beneficial effect in expert hands and under ideal circumstances (i.e., in clinical trials). When contraception is used every time, and used according to the instructions every time. 

Typical use: When contraception is not used every time, or it is not used according to instructions every time. For instance, when you don't take your pill at exactly the same time every day or you forget, or when you forget to replace your patch or get a shot at the right time, or when you don't use the condom exactly right every time.

Did you notice that the vasectomy has a failure rate under typical use?  Were you surprised by some of the "failure" rates? 

What do you find the most interesting, or perhaps shocking? What did you learn that you didn't know?

For more information: The Guttmacher Institute 

Wednesday, November 16, 2011

World Prematurity Awareness Day

November 17th is World Prematurity Awareness Day
  • In the United States, 1 in 8 babies is born prematurely.
  • Worldwide, 13 million babies are born too soon each year. 
  • Prematurity is the leading killer of America's newborns. Those who survive often have lifelong health problems.

    You can find your U.S. state's 2011 Prematurity Report Card here via the March of Dimes:

    As you can see, Vermont is the only state with an A (what are they doing right?).  Louisiana, Mississippi, Alabama and Puerto Rico all have F's. 
    • There are now more babies born at 39 weeks than at full term. 
    • The average time a fetus spends in the womb has fallen seven days since 1992. 
    • In the last two decades, the number of babies born at prior to 37 weeks increased by more than 30 percent, and babies born at 37 and 38 weeks rose more than 40 percent. 
    • In 2007, 9.6 percent of births were early – through scheduled inductions or C-sections – for non-medical reasons. 
    • Deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United Statess.
    • Of the 540,000 babies born before 37 weeks gestational age each year in the United States, approximately 75 percent are born between 34 and 36 weeks.
     Premature birth is a serious health problem. Premature babies are at increased risk for newborn health complications, such as breathing problems, and even death. Most premature babies require care in a newborn intensive care unit (NICU), which has specialized medical staff and equipment that can deal with the multiple problems faced by premature infants.

    Premature babies also face an increased risk of lasting disabilities, such as mental retardation, learning and behavioral problems, cerebral palsy, lung problems and vision and hearing loss. Two recent studies suggest that premature babies may be at increased risk of symptoms associated with autism (social, behavioral and speech problems). Studies also suggest that babies born very prematurely may be at increased risk of certain adult health problems, such as diabetes, high blood pressure and heart disease.

    Preterm birth is a serious health problem that costs the United States more than $26 billon every year, according to the Institute of Medicine. 

    Any woman can give birth prematurely, but some women are at greater risk than others. Researchers have identified some risk factors, but providers still can't predict which women will deliver prematurely.  Three groups of women are at greatest risk for premature birth:
    • Women who have had a previous premature birth
    • Women who are pregnant with twins, triplets, or more
    • Women with certain uterine or cervical abnormalities
    There are other risk factors as well: click here for more information. 

    More and more births are being scheduled early for non-medical reasons, and this is resulting in babies being born prematurely. The March of Dimes “Healthy Babies are Worth the Wait” campaign is an effort to eliminate preventable preterm births.

    Babies born too early may have more health problems at birth and later in life than babies born full term. Here's why your baby needs 39 weeks:
    • Important organs, like his brain, lungs and liver, get all the time they need to develop.
    • He is less likely to have vision and hearing problems after birth.
    • Babies born too soon often are too small. Babies born at a healthy weight have an easier time staying warm than babies born too small.
    • He can suck and swallow and stay awake long enough to eat after he's born. Babies born early sometimes can't do these things.

    All information is via the March of Dimes

    Monday, November 14, 2011

    Childbirth/Breastfeeding Day in Anthropology

    I apologize for the slow down in posting... Grad school and doula work is taking up all of my time this semester! But I will be able to catch up on everything during holiday time, so please stay tuned!

    So that fabulous reproductive health anthropology class that I mentioned? Well we had our unit on childbirth and breastfeeding - my favorite day! Naturally, this is the day I chose to help facilitate the discussion for, so I have a little more information on this topic for you.

    Our readings on Birth were:

    Brunson, J. (2010). "Confronting maternal mortality, controlling birth in Nepal: The gendered politics of receiving biomedical care at birth." Social Science & Medicine 71(10): 1719-1727.
     "Universal hospital deliver also may be inappropriate given the desires and/or economic  limitations of community members"
    "The concept of birth preparedness, like prenatal care, is a part of a biomedical model and risk framework; when birth is considered a natural event, it does not require planning."
    "this study's major contribution is a detailed description of the gendered and household politics that determine whether a woman receives biomedical care at birth."
    "By using the term 'natural' I do not intend to invoke a romanticized vision of low-tech, 'traditional' birth as the ideal form. Nor do I mean to equate a 'natural' view of birth with a purely biological view of it... Rather I am referring to a worldview involving a cosmic order in which many aspects of life are seen as beyond human control (although efforts or propitiations may be made in an attempt to influence outcomes) as opposed to the mechanistic materialism of modern science that rejects an ordered cosmic totality and instead articulates the world in terms of cause and effect..."
    "Women were socialized to keep quiet about their suffering, was usually men who made decisions such as determining at what point situations were dangerous or life-threatening enough to warrant taking them to the hospital."
    "More research needs to be done on possible factors that discourage families from delivering in hospitals, in particular the obstacles for impoverished families such as intimidation or cost."
    • What are the limitations these women face in having a safe and healthy birth? What factors influence a Nepali woman to birth where she does?
    • Would planning for a birth, in any way, mean that birth would no longer be viewed as a natural event? Is a planned-for birth necessarily a biomedical event?
    • In order to reduce maternal mortality, Bruson asks, who ought to control birth? Who should be the advocate?

    Miller, A. C. (2009)  "Midwife to Myself": Birth Narratives among Women Choosing Unassisted Homebirth. Sociological Inquiry  79,1: 51–74.
    "Despite this clear reliance on midwifery, use of a midwife is seen as inappropriate. From the UC perspective, midwives and doctors are 'the same'... professionals who interfere with a woman's natural ability to experience completely unhindered birth. When a birth attendant is present, UC advocates argue that women cease to rely on the inner 'primal' knowledge that exists to guide them through the best, safest, and most empowering birth possible."
    The authority of the biological construction of pregnancy and birth indeed reflects what Foucault described as 'bio-power.'"
    These women already believe that birth isn't medical, dangerous, etc - "A fundamental rejection of the biomedical discourse on birth."
    "The assumption, whether accurate or not, is that when a midwife enters the home she becomes 'in charge'"
    "the natural role of husbands as decision-makers"
    The professional birth attendant has been rejected, but the framework remains, gesturing to the power of the midwifery model as the primary counterdiscourse to the biomedical construction of birth. 
    • In what way is choosing unassisted childbirth a privilege?
    • Where does the authoritative knowledge lie in unassisted childbirth?

    Piperata, B.A. (2008) Forty days and forty nights: A biocultural perspective on postpartum practices in the Amazon. Social Science &Medicine 67: 1094–1103.
    "In the eastern Amazon the immediate postpartum period is referred to as resguardo, lasts for 40-41 days and includes food taboos and work restrictions."
    "Quantitative and qualitative data on dietary intake and energy expenditure were collected on 3 consecutive days in each of three postpartum periods."
    "women responded by saying 'the boy pulls more' meaning the boy places more strain on the mother... a male infant puts more pressure on a woman's body in terms of breastfeeding style and by causing greater pain an hardship during parturition. The implication is that women require more time to recuperate after the birth of a boy."
    "The taboo status of foods was not unanimous... what was taboo for one may not be for another."
    "The seduction of the river dolphin"
    "During resguardo energy expenditure in physical activity was lower, reducing women's energy needs and allowing them to devote more time to infant care. However, energy intakes were also lower. The reduction in dietary intake was impacted more by work restrictions and the loss of women in subsistence tasks during resguardo than by adherence to food taboos."
    • Why is the biocultural framework useful in this study?
    • Thinking about the three articles on birth, what effects to gender roles have on the experiences of parturient women?

    Our readings on Breastfeeding were:

    Gribble, K. D., M. McGrath, et al. (2011). "Supporting breastfeeding in emergencies: protecting women's reproductive rights and maternal and infant health." Disasters 35(3): 
    "Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so..."
    "Mothers and infants are vulnerable groups that are disproportionately affected by emergencies and the negative ramifications of breaching these rights are enhanced in emergency conditions."
    "breastfeeding reduces women's physiological responsiveness to both physical and emotional stress...artificial feeding increases the resources needed and the work associated with caring for an infant."
    The undermining of breastfeeding rights in emergencies
    "Supplying breast-milk substitutes to women as a precautionary measure, in the event that they produce insufficient milk, also undermines their confidence in their ability to breastfeed."
    • Why is breastfeeding a reproductive right?
    • In what ways is this right undermined in both emergency situations and non-emergency situations worldwide? What are the results?

    Kukla, R. (2006) Ethics and Ideology in Breastfeeding Advocacy Campaigns. Hypatia 21(1): 157-180.
    "As a result, many of our public health initiatives specifically target mothers' choices, as though these were morally and causally self-contained units of influence; if only we could talk women into making the right choices, these initiatives presume, then children would turn out healthy"
    "The fact that mothers are not behaving as they are being called upon to behave is here smoothly interpreted as empirical proof that they are no actually hearing the call. Such an interpretation closes down any interrogation of why women might not behave as they are asked to, even if they hear and understand the request."
    "One might have assumed that what makes the United States saliently different from all other developed nations with better breastfeeding rates is not its lackluster advertising campaigns, but rather its abysmal maternity leave policies, privatized daycare system, complete absence of workplace regulations supporting breastfeeding, and so forth."
    "It utterly fails to examine or address the reason for this gap between message and behavior, insistently keeping the focus on changing women's choices... We need to question our assumption that improper education is the cause of low breastfeeding rates."
    There are many American women, especially women from the socially vulnerable groups least likely to breastfeed, for whom breastfeeding is not in fact a livable choice..."
    "Breastfeeding mothers are asked to negotiate an exceptionally complicated set of codes of privacy and publicity."
    " comparison with mobile, privileged white women whose bodies do not challenge normative conceptions of femininity" 
    "As a culture, we expect and demand that breastfeeding be contained within the domestic space..."
    In ads, mothers are portrayed as white women, garbed in bedroom clothing, sitting in a nursery or a nonspace, the women look down at their infants, the children are never older than 1, etc.
    Really interesting section on the sexual texture of breastfeeding... "position the infants as traditional male sexual conquerors" 
    "When we hide the real, deeply culturally embedded barriers to safe, comfortable breastfeeding, we tell mothers who face these barriers that they are unmotherly, shameful, incapable, defective, and morally inadequate/ We then combine this with the message that breastfeeding their child is the only decent choice, the only way of refraining from harming their children, and their responsibility as mothers."
    • The U.S. DHHS breastfeeding advocacy campaign fails to take into account societal and policy level issues related to breastfeeding barriers, focusing only on the assumed rational behavior of individual mothers. What effect does this have on breastfeeding rates?
    • What do the "Breast is Best" and "Babies were Born to Be Breastfed" campaigns mean for the "good/bad mother" debate?
    • Kukla argues that "the reasons women 'fail' to breastfeed go not only well beyond selfishness or lack of education, but even beyond physical and economic barriers such as cracked nipples and long work hours. These reasons lie buried deep within our culture..." How is breastfeeding culturally situated, and how can the cultural context be altered?

    Non-normative bodies and various breastfeeding campaigns (click to enlarge):
    Breastfeeding outdoors, in work clothing, not looking at baby, as a woman of color, breastfeeding twins, in an airport, in front of family, in front of strangers, with tattoos, breastfeeding toddlers, and other kinds of breastfeeding campaigns

    I had been trying to find this image before class and couldn't, but now I have it so I'm sharing it:

    We also touched on laws protecting breastfeeding in the U.S.: 

    Our professor also invited some perinatal loss doulas to come and speak about the support that they provide for women experiencing fetal loss, choosing to terminate a pregnancy, or giving birth to a stillborn baby or baby that is not expected to live past birth. This was very interesting, as I had heard of Full Spectrum Doulas before providing doula support during abortions, but hearing the accounts from these doulas about how they work with mothers and families experiencing various forms of grief was incredible. They are usually called by the hospital health care workers directly when a family finds out about their baby's condition, and they provide information and psychosocial support, as well as physical labor support, in addition to photography, footprint mementos, and so on for families that desire them. These ladies have very big hearts to work with family after family experiencing the loss of a wanted pregnancy.

    Further reading/watching:
    • Canar, Ecuador: Birth and Indigenous Identity in the 21st Century - video preview of an anthropologist's documentary that touches on medical pluralism and birth
    • Breast-Milk for Haiti: Why Donations are being Discouraged, Jan 29, 2010 - an article about the difficulty of sending breast milk donations to Haiti after the earthquake
    • Breastfeeding Legislation and Policy, United States Breastfeeding Committee
    • Best for Babes Foundation - dedicated to beating the Booby Traps, the cultural and institutional barriers that prevent moms from achieving their personal breastfeeding goals 
    • Born Free: Unassisted Childbirth in North America - Dissertation by Dr. Rixa Freeze, department of American studies (2008) - Rixa herself had a planned homebirth, a planned unassisted birth, and an unplanned unassisted birth
    • Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States by Brigitte Jordan (1992) - the mother of anthropology of reproduction, anthro of birth, and the concept of authoritative knowledge
    • Medical Anthropology Quarterly, June 1996 10(2) - a full issue on authoritative knowledge and birth
    • Monique and the Mango Rains: Two Years with a Midwife in Mali by Kris Holloway (2006) - a quick read by a young peace corps worker about her experience with reproductive health issues in Mali

    Monday, November 7, 2011

    It's my Second Blogoversary!


    It's my blog's 2nd birthday! Whoa! I can't believe it has been two years since I started my doula journey! 

    A year ago I was averaging an average of 170 page loads, and now I'm averaging about 200 per day. In the past week I've had 1,580 page loads. I've also added a new popular post:
    I've had visitors from the United States, Canada, the UK, India, Australia, Indonesia, Latvia, Portugal, Greece, South Africa, France, Malaysia, Czech Republic, Switzerland, Norway, Hong Kong, Singapore, Croatia, Netherlands, and Mexico. 

    Also, in the past year, I've met Robbie Davis-Floyd, Penny Simkin, and Jill Arnold from the Unnecessarean! 

    If you are one of my regular readers, thank you for sticking by me! I really appreciate all comments and feedback. I'm still learning as I go!

    I think Ricki Lake and Abby Epstein timed their release of More Business of Being Born DVDs perfectly with my blog's anniversary - Don't forget that MBOBB officially comes out tomorrow! And it is definitely going on my wish list :)

    (And if you weren't around for last year's blogoversary, I encourage you to check out the awesome doula comic I posted a year ago!) 

    Tuesday, November 1, 2011

    Writing Client Birth Stories

    A former client in the state I moved from a year ago, and one of my first doula moms, said: "I have been thinking of you because I know like 6 preggo people! I'd be giving you lots of business if you were here!" Awww :)

    She also said that she showed some people the birth story that I wrote for her, and it made them want to hire me just from that! This is interesting, because I wrote birth stories for all my first clients, and since moving have stopped doing so. You can actually read a couple of the ones I wrote, with names removed, here: Doula Double Header Part 1 and Doula Double Header Part 2. There are many ways to write one - to the parents, to the mom, to the baby. You can say "you" or "I" or "mom."

    There are differing opinions on the forum about whether or not writing a birth story for your client is a good idea. Many doulas do it, but others don't think its a good idea.

    The reasoning is that writing a birth story may alter the mom's perception of the birth, while it is not the doula's story to write. Many doulas say that writing it down from our perspective tells our story, not the mom's, and that's not the point.

    The doula may write that the mom was powerful, or the caretakers were kind, and the mother may see it entirely differently.  And what to do if it was an incredibly difficult labor and delivery? Can you write the story in a positive light, if the mother doesn't see it that way at all? Or what if you felt it was difficult, but the mother thinks everything went well? It would be terrible if we negated a mother's experience of joy or trauma based on our own perspective of it.

    Many get around this by writing only simple timelines of the things that happened - when contractions began, when the doula was called, when they left for the hospital, when vaginal checks occurred, when the baby was born, etc. This removes all emotion and makes it not technically a story at all.

    Since doing my certification births I have stopped writing birth stories for my client. One reason was because I read the forums and was confused about how I felt about it all. Another reason was because I liked writing the stories for my blog, but then realized that I shouldn't be posting another person's birth story with my opinions on my blog, in case the mother found it. A third reason was because I had my first birth where I felt a little bit like a failure in some aspects of my doula work - it was so different from previous births - so how should I write it down for the mom? So I just didn't. And I didn't want to write birth stories only for the births I thought were perfect, because that didn't seem fair. So now I don't write any at all.

    I still talk about the births with my moms afterward, at the postpartum visit. I ask them how they felt about it, what they remember, tell them funny things people said, or what time things occurred. I tell my opinions if asked, which is hard to do sometimes. And I've learned a lot! Things that I'd feel terrible about they didn't think was a big deal, and things I thought were good choices they felt really upset about.

    It's hard to not want to write birth stories for the parents, sometimes, though. Especially when my former client tells me that her husband loves reading the story I wrote for them because it makes him cry, or she shares it with all her pregnant friends. I love to be able to continue to make a happy difference in people's lives for years to come through the story, but I'm still not sure the benefits outweigh the possible risks in other situations.

    Do you write birth stories for your clients? What are your thoughts on all this? Please share!

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