UnBreaking Birth

I recently watched this video "UnBreaking Birth" - a lecture by Ryan McAllister. It is basically a version of the lecture I have given a couple of times as a guest lecturer undergraduate women's/sexual health classes.

"How you're born affects the rest of your life, and can affect the rest of your mother's life, too"

"There are a host of values at play beyond safety"

He says our birth care system is broken for at least 4 reasons:

1. There isn't a sufficient amount of space and time to build an adequate relationship between the mother and the caregivers
2. Our interventions have become routine, instead of based on the mom and baby's best interests
3. Those interventions are often opinion-based
4. There are conflicts of obligation within the hospital that systematically cause behavior that is out of alignment with the mom and baby's best needs

"Even when they know that practicing a different way would be better for their clients, they have some reason to practice differently. That means that there are conflicts of obligation in the hospital. At times, when the hospital's best interest is over here, and the patient's best interest would mean you behave this way, the hospital's best interest wins."

"Obstetrics has been organized around handling high-risk, emergency surgical births. and they may do this well. But treating all births this way actually derails well-birth, which is the vast majority of births. So I think we need to keep the good of this system and pair it with another approach that doesn't break well-birth."

"How could we possibly find or create highly trained experienced professionals who have evidence based practices, who work within a strong relationship wit h the mother, compassion for newborns, and don't experience conflicts of obligation with a large institution?... Those practitioners already exist. They are independent midwives."

The video does not have ALL of the information on the topic, but is a nice overview for consumers. It covers:

• Why birth is broken (evidence that we spend more on maternity care in the U.S. but have worse outcomes; evidence that c-sections are too high and it is not caused by women being in worse health)
• The 4 reasons he believes our maternity care system is broken 
• A system that would work better for well-birth (certified professional midwives, birth centers)
• What YOU can do to help improve the system

This would be a great video to share in a class, because it is only 32 minutes long.

"Being aware of and making available these other options, especially independent midwives, but also including other birth assistants such as doulas, is key to unbreaking birth in the U.S."

I like the way the UnBreaking Birth says about the indicators that we have a serious problem. It is basically a run-down of why I do what I do as a public health professional and a doula/childbirth educator:

there are terrible health disparities by race and socioeconomic status

infant and maternal mortality rates are higher than in 45 other nations

the maternal mortality rate has risen every year since 1995 while in most other countries it has decreased

only 25% of obstetric practice guidelines are based on good scientific evidence, many are overtly contra-indicated

common hospital policies are not in the best interest of moms and babies

and we spend more than any other nation on healthcare

Notes from the Field: Learning with Indigenous Midwives in Chiapas, Mexico

Mounia during the Day of the Dead fiesta
November 2014

Today's post is a guest article from anthropologist Mounia El Kotni. Mounia's "Notes from the Field" appeared in the most recent Council on Anthropology and Reproduction newsletter, and she has kindly allowed its reproduction here. In this post, she describes her participant-observation experience with midwives in Chiapas.


Learning with Indigenous Midwives in Chiapas, Mexico

“Oh, I see, so you want to be a partera (midwife)” is the typical response I hear after explaining the purpose of my visit; that I am doing dissertation research to document how midwives live and work. Although I try to explain my research goal in terms of “helping raise awareness on the difficulties parteras are facing,” I am always met with this same response “so you want to learn how to become a midwife?” And as I have gotten to meet parteras and aspiring midwives, I must admit that there is not always a clear difference between what I do and how I act and what they do and how they act: asking questions about pregnancy care, sitting in on prenatal consults, taking notes on almost everything the partera says... There is a thin line between participant-observation and midwives’ apprenticeship model. And indeed, I have been learning a lot about how parteras work and live, but also a hell of a lot about plants given in pregnancy care and massage techniques.

Since October 2014, I have been in San Cristóbal de Las Casas, Chiapas, conducting dissertation fieldwork and volunteering for the Women and Midwives’ Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). As a volunteer, my work consists mainly of two tasks: administrative tasks (aka looking for funding) and logistical support during events and workshops. Since 1985, OMIECH has been strengthening Mayan medical knowledge and organizing health workshops in indigenous Tseltal and Tsotsil communities of Chiapas. Even though I am in Chiapas, some of my notes echo those of Kara E. Miller (Fall 2014 Newsletter). Here too, the parteras - who are referred to as Traditional Birth Attendants in international documents - are frustrated with the lack of possibilities to transfer their skills to the next generation. This is why the Women and Midwives’ section organizes workshops focused on reproductive health, and care during pregnancy, birth, and postpartum. These workshops are open to all members of the community where they take place, and aim to perpetuate botanical and medical knowledge by transmitting it to younger generations.

Micaela giving a workshop at the meeting of OMIECH parteras
February 2014. credit: OMIECH

The loss of knowledge is accelerated by various factors: young people’s migration, midwifery not being an attractive profession economically, and also the increasing medicalization of birth. The push to send women to birth in hospitals comes with a delegitimation of indigenous parteras’ knowledge as “not-modern”. Through conditional cash-transfer programs (documented by Vania Smith-Oka in the state of Veracruz), women are pushed to have their prenatal visits and give birth in hospitals. Parteras, on their end, have to attend trainings given by the Health Secretary. These trainings emerged in the 1980s, and intensified in Chiapas under the pressure of reducing maternal mortality rate to comply with the Millennium Development Goal (Chiapas has one of the highest maternal mortality rates in Mexico). Indigenous traditional midwives either have to follow the trainings or stop practicing. This can have dramatic consequences in places where they are often the only health care provider in their communities.

Micaela during a community workshop with parteras.
May 2014. credit:Alice Bafoin

As I jot down notes during an interview or observation within these different settings, I feel a thrill of delight when their words echo one another. But then I realize this means that these state policies are really achieving great changes for parteras. And like Sisyphus, tirelessly, my colleagues at OMIECH reweave what is being unwoven: traditional medical knowledge, but also, and as important, pride in it and trust within the community.

While “in the field”, my notes are scribbly at times, crystal clear at others, but rarely absent. I try to type them regularly, as a good apprentice-anthropologist, but have stopped feeling guilty when I could not do so. It took me a few months to be able to “let go” and admit there will always be an event I will miss, a trip I cannot make... At my mid-point in the field (already), I have just started to take drawing classes, which helps me expand the range of my notes, when words fail to describe a hand gesture, or when I do not know the terminology for this exact point on the belly that needs to be massaged. These classes have made the familiar look different, and made me look at people in a new way, which in turns adds more depth to my notes. Life in the field intertwines professional, political and personal spheres. The friendships I have built through this research promise to impact both my career and personal life. As we were searching for plants in the garden of the organization for an upcoming booklet publication, my colleague Micaela corrected me as I got the name of the plant wrong, once again. I could sense, for the first time, an impatient tone in her voice. I pause and I suddenly realized that although I am not studying to become a midwife, every one of the parteras I have met has been a teacher to me, training me a little bit, sharing their story, their tortilla and their endless knowledge. I am looking forward to learning a lot more in the next five months I will be spending with them and I hope my dissertation will bring them knowledge they can use in their struggle.

Mounia El Kotni is a French-Moroccan doctoral candidate at the State University of New York at Albany. Her dissertation documents the impact of Mexican health laws on the practice of indigenous midwives. She is currently conducting fieldwork with the Women and Midwives Section of the Organization of Indigenous Doctors of Chiapas (OMIECH). Since 2012, Mounia is also a member of the French organization Association Mâ, which promotes respected childbirth. She can be reached at melkotni@albany.edu

Weekend Movie: From Womb to Womb

Biological Anthropologist Julienne Rutherford has a fascinating talk available online that is a short but nice overview of the effect of epigenetics from womb to womb. Essentially she discusses the effects on the intrauterine environment, and whether the womb that we develop in affects the womb that our female offspring produce when they reproduce. The purpose is to understand how we pass down, generation to generation, the effects of our socio-ecological environment. Put another way, how our grandmother's life affects our life, and the lives of ensuing generations.

Her talk covers how placentas play a role, how Life Course Theory is part of it, but isn't the whole picture, and how studying primates can help us get an idea of the impact of intrauterine environments on the health and lives of future offspring.

"We are more than our genes. Genes get switched on and off constantly. All the DNA in our bodies in all the cells is essentially identical, but some get turned on, some get turned off...

But even more subtley, gene expression can be affected by our environment in the now, in the lived experience. Molecules attach to the DNA, which sort of locks it down, so its inexpressible - can't get turned on. This phenomenon is called epigenetics. Epi = beyond, above. Something beyond just the molecule themselves. How are the molecules regulated.

We know from a variety of experiments and observations in humans and other animals that the lived experience of an organism can have enormous impacts on how the genes are regulated. We also know that some of these molecular locks can be inherited along with the DNA itself. So, for ex, some genes in the stress pathway of maternal ,fetal, and placental tissues are regulated differently in people who have experienced poor nutrition, poor rearing behavior... high levels of psychosocial stress, institutional racism and discrimination, and the experience of war..."

It's one more argument for improving social and economic environments in order to improve a population's health and future potential. People often think that a poor or unhealthy person can just "do better" to make themselves healthier or more wealthy, but so much depends on our socio-ecological environments, and that of our ancestors.

"The placenta contains the mysteries of the past and predictions for the future..."

You can view Dr. Rutherford's 23 minute presentation on the website for the Cusp Conference 2014.

https://www.cuspconference.com/videos/julienne-rutherford-2014/

Birth by the Numbers Update

Eugene Declerq and the team at Birth by the Numbers have very recently updated their statistics and their video!

Two years ago I posted the video Birth by the Numbers, a fantastic resource for mothers, public health professionals, students, and teachers. If you haven't seen it yet, I highly recommend you check it out.

This brand new updated Birth by the Numbers covers several maternal and infant health indicators, including maternal mortality and neonatal mortality, compared to other countries. This may sound dry, but he makes some jokes to start you off.

Dr. Declerq then covers Cesarean sections, with a great overview of trends in primary cesarean section rates. He even discusses cost savings of reducing these rates.

Are we doing better? Worse? Tune in to find out this answer and more!





I really like this slide:

I also recently saw a graph elsewhere showing the c-section rate rise with the introduction and push of the electronic fetal monitor. And of course, the decrease in the rate during the period in the 90's when Trial of Labor after Cesarean was promoted.


For further information, I highly recommend the Birth by the Numbers website, or any of the sites he references at the end of the video.

Also, if you're into the research on c-sections, here is an article on the variation in cesarean section rates across the country and in each hospital, and some analysis of why:

Cesarean Delivery Rates Vary 10-Fold Among US Hospitals; Reducing Variation May Address Quality, Cost Issues
"We found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteen-fold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals."

Link Round Up to Hold You Over

You would think with graduation behind me I'd have a lot more free time to blog, but the opposite has been true!

I've got 3 part time jobs plus doula work while I apply for full-time jobs. I'm actually quite happy with this situation, as it keeps me on my toes and I can do some of it from home! And it is all related to my future career, so I still feel on-track. Furthermore, I've agreed to some other things, lately, that have been using up my free time - mainly spending time with my fiance, as I promised him I'd use all my free no-homework evenings with him (and wedding planning)! But don't worry, I've got several blog post ideas started in draft form that I plan to get to, eventually.

I missed posting anything for Mother's Day because I was with my mama, but HAPPY MOTHER'S DAY EVERYONE! Also, this past week was National Women's Health Week, and the month of May is International Doula Month.

I've been trying to still keep up with reading, tweeting, and posting on Facebook  though! So if you haven't been able to follow along over there, I'd thought I'd provide you with a link round-up to satisfy your love for all things birthy during my hiatus:

• The big news recently is the Listening to Mothers III survey results! The previous survey reports have been my go-to for so much information on maternity care in the U.S. over the past couple of years, and I am so nerdily excited for these new reports. I sat in on a live teleconference/webcast with Maureen Corry (Childbirth Connections), Eugene Declerq (Epidemiologist), several others who were involved with the survey, and a lot of other maternity care junkies like me :) Childbirth Connection has made the results really accessible - you don't have to read the whole report if you don't want to, they have several briefs and major survey findings documents. I tweeted a lot of the findings during the webcast, so you're welcome to go back to my #LTM3 tweets and skim through those! 
• What does this survey cover, you ask? Things like: maternal satisfaction with care; # who used doulas, midwives, OBs, other providers; # who did childbirth education; breastfeeding care received; disparities by ethnicity or health insurance; what interventions women received; treatment received and attitudes; and more! 

• A recent study in Pediatrics reported that early limited formula supplementation increased exclusive breastfeeding at 3 months. I've spoken about this study with an IBCLC who is a friend of mine and read through a lot of the analyses. This study is a great reminder to always be a critical reader! There are some flaws to this study, and the post from Best for Babes goes through almost all of them, and this post from Breastfeeding Medicine adds some more great points. Mainly, there could have been some errors and bias in the study that need to be understood before everyone jumps to the extreme that many of the news outlets have: How Formula Could Increase Breastfeeding Rates (TIME)

• This story is still going around - Disney made Merida from Brave "sexier" so that she could join the Disney Princess line of merchandise, and everyone flipped out. Several thousands signed a petition that included this great quote: "The redesign of Merida in advance of her official induction to the Disney Princess collection does a tremendous disservice to the millions of children for whom Merida is an empowering role model who speaks to girls' capacity to be change agents in the world rather than just trophies to be admired. Moreover, by making her skinnier, sexier and more mature in appearance, you are sending a message to girls that the original, realistic, teenage-appearing version of Merida is inferior; that for girls and women to have value — to be recognized as true princesses — they must conform to a narrow definition of beauty." 
• Disney said they are pulling back, and everyone rejoiced, and then they indicated that they were still going to sell the merchandise that they already made with sexy Merida on it. Most recent update is here.

• Another big story that went around was an ACOG Study on the adverse effects of Pitocin augmentation on full-term newborns. They found that Pitocin was an independent risk factor for NICU admission and low APGAR scores. 
• (Also, I found out that ACOG has a pretty good source for women's health news - "Today's Headlines)

• If you're into Science and want more Pregnancy and Childbirth news outlets, I read Science Daily's posts on those topics. If you're into social and political updates on Health issues in the U.S., check out Think Progress' health feed. 

• Currently Reading: The Business of Baby: What Doctors Don't Tell You, What Corporations Try to Sell You, and How to Put Your Pregnancy, Childbirth, and Baby Before Their Bottom Line. Stay tuned for a review!

Doula Mom on a Mission to Make Birth Safe in Laos

Recently, Kristyn asked me to spread the word about the project she founded - Clean Birth kits! The kits are aimed at preventing birth-related infections, which kill 1 million moms and babies each year worldwide.  In Laos, where maternal and infant mortality rates are abysmal (MMR worse than Afghanistan!), 80% of women give birth at home without a skilled attendant.  The kits, which cost $5 including the cost of training local community health workers, give mothers the supplies needed to protect themselves and their babies from infection.

Kristyn recently traveled to Laos, and she has shared her story with me!

Doula Mom on a Mission to Make Birth Safe in Laos By Kristyn Zalota
It’s hard to believe than less than two weeks ago, I was bumping through a river in a 4-wheel drive truck en route to a remote ethnic minority village in Laos.  Now, back at home, I am reflecting on this amazing journey, which feels like the culmination of my personal odyssey from mother to doula to safe birth activist.

In 2009-10, while living with my husband and then 1-year-old and 4-year-old on the Thai-Burma border, I witnessed the inadequate pre- and post-natal care available to poor women.  Later, as a doula in Uganda, I discovered Clean Birth Kits (CBKs), basic birthing supplies that prevent birth-related infection in mothers and babies.

These experiences led me to research CBKs and their impact on maternal and infant mortality.  I found that Laos, a country I had visited many times while living in Thailand, has worse-than-Afghanistan rates of maternal and infant mortality rates and could be served by the kits.  So, I emailed several Lao organizations and offered to donate kits and provide training.  One of them took me up on my offer.

Months later, kits and training materials in hand, I headed to southern Laos.  It took me 4 days to get there.  The morning after I arrived, we kicked off the Clean Birth Kits training.  Four nurses journeyed from their posts in remote Tahoy (ethnic minority) villages to attend.   They were eager to learn: they asked questions, challenged ideas, and helped adapt the program to match needs on the ground.  I was impressed with their professionalism and commitment to introducing Clean Birth Kits, which they agreed “the mothers would be happy to use.

In the days after the training, we visited a number of Tahoy villages.   The clinics were spare:  little to offer in terms of medicines, equipment consists of wood slat beds, and refrigeration was not available.  The villages were from another time: too many naked kids to count, bamboo dwellings on stilts, no electricity, not a single store.  The people are still living as they have for centuries: rodents and roots supplement newly-introduced subsistence rice farming.

I learned from the nurses that birthing is steeped in religious tradition, often with fatal consequences.  Due to animist religious beliefs, women and girls give birth alone in the forest.  The nurses suggested starting a “Safe Birth Outreach” program to educate women and families about the dangers of birthing alone, how to make birth safe using the Clean Birth Kits, the need for breastfeeding, etc…

The nurses have also requested that CleanBirth.org develop illustrated posters to be hung in villages that caution against harmful behaviors in pregnancy (e.g. smoking), explain the warning signs of possible problems (e.g. pre-eclampsia) and show hygienic birthing practices using the Clean Birth Kits.

Now, at home, I am committed to giving my Lao partner organization and the Tahoy nurses the funds and supplies they need to improve maternal and infant health.  I feel lucky to support them in their work.  Every mother deserves the chance to survive birth and to give her baby the best start.  For just a few dollars, we can make that happen.

Please consider donating Clean Birth Kits at www.cleanbirth.org/donate.  Looking for a holiday gift that keeps on giving?  Give a donation of $25, which supports 5 mothers, and get a beautiful card to give as a gift: http://cleanbirth.org/holiday-cards/.
Thank you for reading.

Kristyn Zalota is the founder of CleanBirth.org, a non-profit working to improve maternal and infant health in Laos.  She is a doula and childbirth educator who lives with her husband and two kids in New Haven, CT. Read more about her trip to Laos on her blog: http://cleanbirth.org/blog/ 

Once Upon a Birth

Have you heard about Merck's Campaign to improve maternal health and save women from dying for giving life - Merck for Mothers?

Their new effort, "Once Upon a Birth," is a campaign to raise awareness about maternal health and help prevent the deaths of some 800 women around the world who die during pregnancy and childbirth every day. Melissa Joan Hart is the spokeswoman for this campaign, and shared her birth story on the Merck for Mother's Facebook page.

For every person who shares their birth story, a monetary donation will be made to Join My Village, which is a charitable initiative that helps women and girls through education, and supports safe pregnancies and deliveries. These deaths are preventable - family planning, access to health care that can recognize preeclampsia, or timely treatment for postpartum hemorrhage!

All you have to do is share your birth story! Or, if you don't want to go through Merck, there are ways to help Join My Village directly. 



This video is our way of highlighting the urgent issue of maternal mortality and demonstrating how we hope to improve the health of women during pregnancy and childbirth.

I think this is a great video, but I disagree with one aspect... I don't think research into more technologies is what is needed to save the lives of these mothers. I think it's access to quality care, reduction in structural violence, improvement in the lives of the poor and the marginalized. Gender equality, improved transportation, food, etc. Health policies that improve the social and ecological factors that keep people in poor health.

Birth by the Numbers

I just realized that I've never posted this fabulous video on my blog before! It's not a new one, but it is classic. I refer to this all the time, and it was also shown in one of my MCH courses.

Epidemiologist Eugene Declerq examines Birth by the Numbers. First he discusses the neonatal, perinatal, and maternal mortality rates and how the United States continually ranks low compared to other countries. Then he moves onto Cesarean section rates compared to other nations and in what situations it is life-saving, and what situations it is actually harmful. 

Then he focuses on the U.S.'s c-section rate. I love this video because he addresses the falsity that the rising cesarean rate is attributable to upper-middle class white mothers choosing elective cesarean sections. These exist, but it's a very small percentage, and is not driving the increase in c-sections. 

It's also not the case that U.S. mothers are more high risk than other mothers. 

The video is about 22 minutes long, but it's worth a viewing. 

So what is the reason for the increasing cesarean rates? Provider practice changes.

Truth be told, mothers are feeling pressured to have a cesarean by their care provider. They're scheduling more women for inductions, which increase risk for surgery. Providers are lowering their threshold for "medically indicated" c-sections. They fear the tiny percent possibility of something going wrong, and the possibility of a lawsuit. C-sections are more convenient for doctors who want to make it home in time for dinner. 

Don't believe me? Listen to the data, and watch the video above!

 

 

Rally to Improve Birth

Join the National Rally for Change! A full scale birth revolution on Labor Day

Support evidence-based maternity care! 

The National Rally for Change is to encourage and insist that all maternal healthcare providers practice evidence-based care. On average it takes 20 years for proven research to become practice. For the sake of mothers and babies everywhere, we can’t wait 20 years. The long-term effects of unnecessary inductions and cesareans are just starting to be realized. This matters for all people. Despite the dire situation, this is not a protest, but a public outreach event located where the vast majority of the population gives birth.

The Improving Birth rallies are taking place in more than 100 cities across the United States on Monday September 3rd from 10:00 am - 12:00 pm.

Why Rally to Improve Birth?

The results of Childbirth Connection's national "Listening to Mothers" survey show that high c-section rates don't come from maternal request, and that although most women want to make the ultimate decisions in their own care, they don't always have this option.  (If you'd like to read a summary of the findings of these surveys, I wrote one up a while back here.)

Improving Birth was founded with the vision of encouraging hospital administrators to review their birth-specific policies and procedures. We ask that they implement incentive programs for doctors and nurses to get up-to-date information and education about the most current care practices. The U.S. outspends every country in the world for maternity care, and yet we rank #49 for maternal mortality rates.

The U.S. has trailed behind most of the developed or industrialized world for many years and our maternal and infant mortality rates have gotten worse in the last few years. It's more dangerous to give birth in the United States than in 49 other countries. From Amnesty International:

Maternal deaths are only the tip of the iceberg. During 2004 and 2005, more than 68,000 women nearly died in childbirth in the USA. Each year, 1.7 million women suffer a complication that has an adverse effect on their health.

This is not just a public health emergency - it is a human rights crisis. Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.

The facts speak for themselves.  The World Health Organization recommends cesarean rates should be no higher than 10-15% and that anything higher does more harm than good for moms and babies.  Despite this warning, 1 in 3 American women are giving birth surgically.  That equates to a high number of medically unnecessary surgeries.  Additionally, the recommended rate of induction is 10% or less but in an analysis of 19 hospitals across the country, it was found that 44% of women planning a vaginal birth were medically induced.

http://www.improvingbirth.org/the-evidence-shows/

An eye-opening study published in the journal Obstetrics and Gynecology examined the “quality of evidence that underlies the recommendations made by the American College of Obstetricians and Gynecologists.”  It was discovered that only 30% of these guidelines were based on “good and consistent scientific evidence” and that 32% were based simply on “consensus and opinion.”  When obstetric guidelines were looked at individually, a mere 25% was found to be based on quality science and nearly 35% based on opinion.

 Reducing medically unnecessary interventions will not only save lives, but also a huge sum of money.  Childbirth Connection and WHO report that the US could save an estimated $3.4 Billion dollars each year by reducing the cesarean rate to 15%, the rate recommended by WHO.  The Amnesty International report states “an estimated $1 Billion could be saved annually—mostly by reducing neonatal intensive care unit admissions—if early elective deliveries were reduced.”

RALLY TO IMPROVE BIRTH!

Weekend Movie: Midwifery Training in Afghanistan

Women in Afghanistan are being trained to become midwives, so that women in remote areas will have a trained birth assistant with them during childbirth. Trained birth assistants are one of the worldwide efforts that have proven highly effective in reducing maternal mortality (see Millennium Development Goal 5)

This CNN video shows the women being trained. I thought it provided an interesting view of women in another country being "medically" trained - illiterate women are trained with pictograms, demonstrations are done with a pelvis and a baby doll whose face is painted and decorated just like the real newborn the video shows!

Female Bodies and the Issue of Choice: Part Two

Click here for Part One

When it comes to Birth, I am Pro-Choice.

I believe in a woman's right to choose every single aspect of her health care during her pregnancy and during her labor and delivery. She has the right to choose what kind of care provider she wants. She has the right to choose her location of birth (and I don't mean which hospital, I mean home birth or birth center as well). She has the right to refuse glucose rests, HIV tests, amniocentesis, and any other prenatal examination she desires. She has the right to have an unmedicated childbirth or a medicated one. It is HER CHOICE. Despite what biomedicine says, or the authoritative knowledge of care professionals, or a book says, or her mother says, or what a politician says: A woman has the right to CHOOSE what happens to HER body. She has the right to make an informed decision that is right for her.

Erin Rockwell from RH Reality Check writes:

The right to choose how a woman gives birth is not confined to just whether she’ll have a cesarean or a vaginal delivery, or whether she’ll have an epidural or go natural. In many states, the right to choose the very place where a woman gives birth is a contentious subject. While maternal and infant mortality rates in the United States continue to rise, legislatures continue to refuse to grant licenses to Certified Professional Midwives, the most common type of midwife who attends home births. And even in states where home birth is legal, hospital policies can prevent a woman from being accompanied by her midwife should she need to be transferred during or after the birth. Women are ostensibly free to make the choice---in most states it is only midwife-attended home birth that is illegal---but the choice often comes down to going to a hospital and risking losing their autonomy or planning a home birth and losing their advocate (and the person with the medical knowledge) if something goes wrong.

And Miriam Perez writes:

There are many negative effects of the medicalization of birth, but let’s keep it simple. Childbirth is more medicalized now than ever, with more interventions, more drugs, and more surgeries. Our Caesarean section rate is up to around 30 percent, despite World Health Organization recommendations of 15 percent. Are women and babies healthier? Safer? Happier? The answer is no. The United States continues to rank near the bottom of developed countries in relation to infant mortality, coming in second to last in 2006. Experts disagree on why. Some cite sub par health care for low-income pregnant women, while others point to increasingly complicated neonatal surgical interventions for otherwise unviable pregnancies. The simple fact is that Americans have one of the most costly health care systems in the world, but in many respects our health outcomes are nothing to brag about among our developed-world peers. Beyond all of this, what the birthing rights movement addresses is the narrowing scope of women’s choices about how they give birth. Hospitals and doctors have increasingly specific requirements and regulations about childbirth, many times based on standardized ideas of how a “normal” birth progresses. When women fail to meet these standards, interventions are employed, many of which are costly and cause a landslide of further intervention. Let’s not forget the emotional and psychological component. Many women give birth in environments where they feel unsupported, a fact exacerbated by hospital staffers who are overworked and face increasing productivity demands. They instead rely on family to give emotional support, but not all women have the familial support they need or want.

And this is why I am a Birth Activist.

I think it makes sense that this pro-choice sentiment rolls over to generally being pro-choice when it comes to all issues related to an individual's body. Most people would agree that this right belongs to male bodies, but unfortunately do not always extend this right to female bodies. And the issue lies mainly with aspects of reproduction.

And so I define myself also as Pro-Choice when it comes to choosing NOT to be pregnant, give birth, or parent (and yes, I'm talking about Abortion now).
Arwyn at Raising my Boychick is a fellow birth activist and pro-choicer who describes why she is pro-choice in her post "I'm pro-choice because..." and here is part of it:

    I’m pro-choice because I can’t but see a difference between a blastocyst and a baby.
    I’m pro-choice because the personhood of a embryo/fetus is irrelevant: no person has the right to impose themselves on another’s body.
    I’m pro-choice because without the right and ability to say no, we lack the ability to say yes.
    I’m pro-choice because every child should have the right to be a chosen child, whether or not their conception was intended.
    I’m pro-choice because parenthood is way too damned hard for anyone to be forced into it.
    I’m pro-choice because people with uteruses are, y’know, people, and capable of making their own decisions.
    I’m pro-choice because there’s no way to ban abortion without upping the death rate of women.
    I’m pro-choice because intended or not (and I’d argue it mostly is), the outcomes of abortion bans are misogynist and reify patriarchy.
    I’m pro-choice because my opinion on anyone else’s choice is irrelevant — and your opinion is irrelevant to mine.
    I’m pro-choice because it’s about so much more than abortion: not just whether but when and where and with whom to birth.
    I’m pro-choice because it’s about so much more than pregnancy: whether and when and how to transition, whether and when and with whom to have sex.
    I’m pro-choice because birth is far safer than we think it is — and abortion, when legal, is even safer still.
    I’m pro-choice because a forced “choice” — whether to birth or to abort — isn’t a choice at all.
    I’m pro-choice because I refuse to tell you what to do with your body, and I wish the same right extended to me.
    I’m pro-choice because in a pro-choice society, one can be against abortion for themselves, but in an anti-abortion society, one is disallowed choice at all.

Unfortunately, not all Birth Activists are with me. Despite the fact that birth activists agree with a woman's choice in birth, they do not always agree on a woman's choice to not be a mother.

And the Pro-Choice movement tends to ignore the fact that though some women want the choice to not be pregnant and give birth, some women DO want that choice.

As Erin Rockwell writes:

I am a woman “of childbearing age.” I know Planned Parenthood, NOW, Choice USA, et al, will defend my right to choose abortion if I were to get pregnant and needed that option. I know they would provide me with subsidized birth control and pap smears if I didn’t have insurance and couldn’t afford to pay full price, or they would at least direct me where to go. And I know they will fight hard to ensure that legislators cannot stomp out my right to choose, or my access to subsidized birth control and yearly exams. Yet, when it comes to where I choose to give birth, they are silent. It would appear, in their eyes, that ensuring “choices” essentially ends with the decision to have a baby--more specifically of where and with what kind of attendant to give birth. How is that possible? The birth of her child is for many women one of, if not the, most transformative moment in her life. And the circumstances surrounding it can be just as empowering or disempowering as those surrounding a woman accessing her right to an abortion.

 I really like how Miriam Perez puts it here:

When a woman is giving birth in an American hospital, the doctors, nurses, and extended medical team are almost wholly focused on the status of the fetus inside of her—constantly employing technologies to monitor it and drugs to regulate it, allowing fetal well-being to be their dominant concern. When we think of a woman with an unintended pregnancy (and this could be the same woman, in a different phase of her life), a similar logic applies. Anti-choice activists don’t trust women to make responsible decisions about their lives and ability to parent; they instead focus on the potential life inside a woman, and place all emphasis on the future of the fetus rather than on the future of the woman. Anti-choice activism and overly-medicalized birthing practices are both based on a lack of trust in women. Consider the many restrictions imposed on birthing women: rules regulating out-of-hospital midwives, mandatory waiting periods for abortions, forced C-sections, and biased pre-abortion counseling are all examples of how people do not trust women (or their support networks) to make responsible decisions about family well-being.

I realize that not all readers who enjoy my blog will agree with my opinions, and that's OK! But please note that I will not host an abortion debate in the comments of this post.


Additional Reading: Why Birth is a Feminist Issue

Female Bodies and the Issue of Choice: Part One

Part One: On the idea that all women can be mothers, should be mothers, or want to be mothers.


A blog post was recently shared with me in which a woman writes about a surgery she had to have on her reproductive tract that would make her unable to have biological children. She told her male surgeons that she was ready to have the surgery because she didn't want children anyway. But the male surgeons couldn't accept this, and, exerted their patriarchal attitudes and power...

"The director of the surgical team advised tactics to delay the operation as long as possible, so that I could “try to complete my family”. That my family could already be complete was not, apparently, something they considered. 

Because the male surgeons advised that she wait to at least try to become pregnant before having the surgery, her surgery was delayed. She finally had to go to a different surgeon, a female, who "told me, with refreshing frankness: 'A pregnancy would be completely disastrous for your body. It will be a very good thing if we end your fertility.'" It turns out that waiting, which the woman did not want to do, led to the need for a more dangerous surgical procedure.

This gets at an essential point that I, and many birth activists, try to make: that women should be able to make choices about their bodies. 

This argument is made in discussing that women should be able to be fully informed and accept or refuse any procedure during pregnancy, any procedure during birth, and any procedure done to them at all. It is a woman's right (and a patient's right, and any person's right) to be able to choose what happens to her body, whether or not it is the choice that another person might make. While the choice to not be resuscitated when dying is not the choice that everyone might make, many people make the choice to put DNR, or Do Not Resuscitate, on documentation (or tattoo it on their bodies).

Furthermore, it gets to the idea that our society has: that all women should be mothers, or want to be mothers. The assumption is made that women want to have children, even despite any harm to themselves. Research shows that women weigh these odds all the time - their survival vs. the survival of offspring (I encourage you to read Mother Nature by S. B. Hrdy for more on this).

Women are more than their ability to be mothers. And moreover, biological motherhood is not the only way a woman can be a mother.

Society's assumption that all women might one day be mothers is also an important consideration in public health. What I'm thinking about specifically is Preconception Care. You may have heard of preconception care before; It is growing in popularity in the public health arena. You can read more about it on the CDC page here. I hadn't seen the issue here until my public health academic adviser brought it to my attention when she said something along the lines of:

"I have a problem with the assumptions of preconception care... It assumes that all women are going to get pregnant or want to get pregnant."

I have been left thinking about this for months, because she is right. Preconception care assumes that all women should receive the same screenings, nutrition, etc, and that all of these are done with the goal of safe, healthy pregnancies, birth outcomes and infants. But should we treat all women as if they are potential baby makers? My feminist adviser would say definitely not. And this is something I struggle with, because I think that preconception care is a good idea.

Perhaps the solution is that all doctors truly practice patient-centered care - Listen to their patients needs and wants, and don't treat everyone the same. And, of course, never assume!

Please feel free to share your thoughts on this!

More Reproductive Anthropology Readings

So, the semester got away from my and I never did keep up with typing up my Anthropology of Reproduction readings and notes. But hey, half of the syllabus is pretty good. Here is a list of the rest of the readings, in case you're interested personally, academically, or educationally!

Past reading lists and notes are available here: Anthropology of Reproduction Part 1, Anthropology of Reproduction Part 2, and Childbirth/Breastfeeding Day in Anthropology

Abortion

Chi, B. K., T. Gammeltoft, et al. (2010). "Induced abortion among HIV-positive women in Quang Ninh and Hai Phong, Vietnam." Tropical Medicine & International Health 15(10): 1172-1178.

Grossman, D., K. Holt, et al. (2010). "Self-induction of abortion among women in the United States." Reproductive Health Matters 18(36): 136-146.

Joffe, C. and T. Weitz (2003) Normalizing the exceptional: incorporating the “abortion pill” into mainstream medicine. Social Science and Medicine 56:2353-2366.

Roth, R. (2004) Do Prisoners Have Abortion Rights? Feminist Studies 30,2:353-381.

Schuster, S. (2010). "Women's experiences of the abortion law in Cameroon." Reproductive Health Matters 18 (35): 137-144.

Infertility/Assisted Reproduction

Bharadwaj, A. (2003) Why adoption is not an option in India: the visibility of infertility, the secrecy of donor insemination, and other cultural complexities. Social Science and Medicine 56:1867-1880.

Berend, Z. (2010). "Surrogate Losses." Medical Anthropology Quarterly 24(2): 240-262.

Birenbaum-Carmelia, D and M. Dirnfeldb (2008) In Vitro Fertilisation Policy in Israel and Women’s Perspectives: The More the Better? Reproductive Health Matters 16(31):182–191.

Friese, C. G. Becker, and R.D. Nachtigall (2008) Older motherhood and the changing life course in the era of reproductive technologies. Journal of Aging Studies 22 (2008) 65–73.

Hough, C. A. (2010). "Loss in childbearing among Gambia's kanyalengs: Using a stratified reproduction framework to expand the scope of sexual and reproductive health." Social Science & Medicine 71(10): 1757-1763

Sexually Transmitted Infections

Buelna, C., E. Ulloa, and  M. Ulibarri, (2009) Sexual Relationship Power as a Mediator Between Dating Violence and Sexually Transmitted Infections Among College Women

Journal of Interpersonal Violence. 24,8: 1338-1357

Daley, E. et al. (2010) “Influences on Human Papillomavirus Vaccination Status Among Female College Students” Journal of Women's Health.  19(10): 1885-1891.

Dyer, K. E. (2010) “From Cancer to Sexually Transmitted Infection: Explorations of Social Stigma among Cervical Cancer Survivors” Human Organization 69: 321-330.

Gautham, M., R. Singh, H. Weiss, R. Brugha et al. (2008) Socio-cultural, psychosexual and biomedical factors associated with genital symptoms experienced by men in rural India. Tropical Medicine and International Health, 13(3):384–395.

Philpott, A., W. Knerr, and V. Boydell. (2006) Pleasure and prevention: when good sex is safer sex. Reproductive Health Matters 14(28): 23-31.

Special Populations

Ballard, K.D., M.A. Elston, J. Gabe (2009). Private and Public Ageing in the UK. The Transition through the Menopause. Current Sociology 57(2): 269-290.

Lewin, E. (1995) On the Outside Looking In:  the Politics of Lesbian Motherhood. In Ginsburg and Rapp Conceiving the New World Order: The Global Politics of Reproduction. California University Press: 103-121.

Marhefka, S. L., C. R. Valentin, et al. (2011). "I feel like I'm carrying a weapon.”  Information and motivations related to sexual risk among girls with perinatally acquired HIV." AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV.

Smid, M., P. Bourgois, et al. (2010). "The Challenge of Pregnancy among Homeless Youth: Reclaiming a Lost Opportunity." Journal of Health Care for the Poor and Underserved 21(2 Suppl): 140.

Buhi, E. et al. (2010) Quality and Accuracy of Sexual Health Information Web Sites Visited by Young People. Journal of Adolescent Health 47:206-208.

Circumcision

Belisario, O. C. V. (2010). “Muslim Women and Circumcision: A Study of Intergenerational Practice and its Continuity in Southern Philippines." WMSU Research Journal 28(1).

Johansen, R. (2006) Care for infibulated women giving birth in Norway: an anthropological analysis of health workers’ management of a medically and culturally unfamiliar issue. Medical Anthropology Quarterly 20(4): 516-544.

Kurth, E., F. Jaeger, et al. (2010). "Reproductive health care for asylum-seeking women-a challenge for health professionals." BMC Public Health 10(1): 659.

Obure, A. F. X. O., E. O. Nyambedha, et al. (2011). "Interpersonal Influences in the Scale-up of Male Circumcision Services in a Traditionally Non-circumcising Community in Rural Western Kenya." Global Journal of Community Psychology Practice 1(3).

Shell-Duncan, B. (2001) The medicalization of female “circumcision”: harm reduction or promotion of a dangerous practice? Social Science and Medicine 52:1013-1028.

Also, if you are a scholar, MIT Open CourseWare lists tons of anthropology course syllabi and reading lists! 

Transforming Maternity Care

In case you haven't seen this great video, Maternity Care with a Heart, I encourage you to check it out.

Childbirth Connection does great work in their campaign to Transform Maternity Care.


Maternity Care With a Heart from Childbirth Connection on Vimeo.



Why does maternity care need to be transformed? 

We pay more for maternity care than any other country, but have higher rates of maternal death, newborn death, and low birth weight than dozens of other nations. We invest too much in overusing high-tech care with no proven benefit and fail to invest in preventive care, or in strategies to address troubling disparities in access and outcomes. Described in 1989 as "the perinatal paradox: doing more and accomplishing less," the crisis in maternity care has fundamentally worsened in the time since. 

All women and babies deserve maternity care that is woman-centered, safe, effective, timely, efficient, and equitable. Childbirth Connection is working towards this goal.

To donate to this movement in the season of giving, or donate in someone else's name, go here. All donations will be doubled until December 20th!  

Join the Transformation is a campaign for Childbirth Connection. Through the Transforming Maternity Care Partnership, Childbirth Connection works to improve maternity care through consumer engagement and health system transformation. We work with all stakeholders to foster implementation of the landmark "Blueprint for Action," and continue to develop high-quality, evidence-based information for women and maternity care professionals. We're deeply engaged in work to identify and endorse new maternity care quality measures and to develop and test new resources for shared decision making. We're also working at the state and national levels to influence policy, and partnering with employers, payers, and health systems to develop new ways of delivering maternity care that foster quality and value. Finally, we're identifying the people and systems making progress on maternity care quality improvement, and helping to spread the word about these models so others can learn from them.

Baby Blues and Postpartum Depression

What is the difference between "baby blues" and postpartum depression?  Are you at risk for postpartum depression? Is there anything you can do to avoid it? What are the signs to look for, and when?

Baby Blues:

Many women have the baby blues in the days after childbirth. This means that they:

• Have mood swings
• Feel sad, anxious, or overwhelmed
• Have crying spells
• Lose your  appetite
• Have trouble sleeping 
• Feeling withdrawn or unconnected
• Lack of pleasure or interest in most or all activities
• Loss of concentration

The baby blues most often go away within a few days or a week. The symptoms are not severe and do not need treatment. These symptoms are a result of having a huge upsurge of hormones, not having very much sleep during labor/in the hospital, and having a new baby to take care of and worry about. Feelings of inadequacy toward new motherhood, lack of self-esteem, a lack of free time and stressful schedules add into all of this.

Postpartum Depression
The symptoms of postpartum depression last longer and are more severe than those of baby blues. Postpartum depression can begin anytime within the first year after childbirth., an occurs in 15% of mothers. In addition to the symptoms above, postpartum depression may include:

•  Thoughts of hurting the baby
• Thoughts of hurting yourself
• Not having any interest in the baby

There is a range with PPD - you may have anything on the range between a mild case, where baby blues symptoms continue after 2 weeks, and a severe case, called postpartum psychosis (very rare). Be sure to talk to a doctor if your symptoms of depression last beyond 2 weeks postpartum.

Certain factors may increase your risk of depression during and after pregnancy. If you:

• Are under age 20
• Currently abuse alcohol, take illegal substances, or smoke (these also cause serious medical health risks for the baby)
• Did not plan the pregnancy, or had mixed feelings about the pregnancy
• Had depression, bipolar disorder (for example, manic depression), or an anxiety disorder before your pregnancy, or with a previous pregnancy
• Had a stressful event during the pregnancy or delivery, including personal illness, death or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or birth defect in the baby
• Have a close family member who has had depression or anxiety
• Have a poor relationship with your significant other or are single
• Have financial problems (low income, inadequate housing)
• Have little support from family, friends, or your significant other

If you take medicine for depression, stopping your medicine when you become pregnant can cause your depression to come back. Do not stop any prescribed medicines without first talking to your doctor. Not using medicine that you need may be harmful to you or your baby.

Women who are depressed during pregnancy have a greater risk of depression after giving birth.

If you're not sure if you have postpartum depression, you can take this Edinburgh Postnatal Depression Scale quiz online.


Tips to Reduce Risk of Postpartum Depression:

Mood changes are common during huge life events. Making sure you have good social support before, during, and after birth, as well as during the "fourth trimester" can make a huge difference in one's ability to deal with these big changes. Don't feel bad about asking for help, getting some free time to yourself, or joining a support group! And don't be afraid to discuss your feelings with your partner. Getting as much rest as you can and not trying to do too much helps a lot! Also, some moms say they've had success consuming their placenta, generally via encapsulation, in improving mood after childbirth.

MORE GREAT RESOURCES
These are some resources for moms who think they might have postpartum depression and are looking for more information:

Postpartum Progress - one of the most widely read blogs on PPD.
Postpartum Voice - stories, resources, and insights
Beyond Postpartum blog
PPD to Joy blog



HAVE YOU EVER WORKED WITH A MOM WHO HAD PPD, OR HAVE YOU EXPERIENCED IT YOURSELF? What advice would you give a doula on baby blues and PPD?





Info source: Women'sHealth.Gov and PubMed Health

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 1^st 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 1^st 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)

References:

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.