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

Current Research Round-Up

I haven't done a link round-up in a while, mostly due to the fact that I can barely keep up with reading my google reader blogs, let alone blog about them! But I am always reading and always following the latest research. Here is some of what I've come across lately:

• Determining fetal gender at 6 weeks with chorionic villi or The Relationship Between Placental Location and Fetal Gender Ramzi Ismail, Saad

Robin Elise Weiss wrote about really interesting research that found that you can actually determine the gender of the fetus at 6 weeks! It's called the Ramzi's method. In using this data, Dr. Ramzi Ismail concluded that at six weeks gestation, 97.2% of the male fetuses had a placenta or chorionic villi on the right side of the uterus. When it came to female fetuses, there were 97.5% of the chorionic villi or placenta on the left side of the uterus. Robin writes,

"This is amazingly accurate and has nothing to do with actual visualization of the sex organs, which is impossible this early in pregnancy. Parents want to know the sex of their baby for many reasons, including to figure out how to manage a pregnancy when there may be certain sex linked diseases complicating it. Though the author encourages this to be used as a soft marker to be used between the physician and patient when earlier knowledge can help the team with decision making.

The biggest advantage here is that the use of 2D ultrasound does not pose the risks that other methods do to the pregnancy. It can also easily be incorporated into the first trimester screenings and the results are immediately available. This can also prevent the waiting times that can cause much anxiety for families.

Though this is not widely used anywhere currently, parents wishing to know the sex of their baby may be trying to figure this out any way. If you have an early ultrasound and are not trained, you may misinterpret the results, even if you can clearly see the screen. You would be better off asking the person doing the ultrasound which side the placenta is on, than trying to guess yourself."

But she cautions that "it would be wise not to make decisions that are irreparable because of this knowledge. I'm not even sure if I'd paint a nursery with this answer."
 

•  Fetal exposure to synthetic oxytocin and the relationship with prefeeding cues within one hour postbirth. Aleeca F., B., Rosemary, W., &  Kristin, R. (n.d). Early Human Development 

 Can't find the actual article for this, just the abstract.  What it says is that there were fewer prefeeding cues observed in infants who were exposed to Pitocin than those who weren't, especially hand-to-mouth cues. Pitocin-exposed infants also had what the authors called "a low level of prefeeding organization," as evidenced by frequency of 8 prefeeding cues.

• Patient-Initiated Elective Cesarean Section of Nulliparous Women in British Columbia, Canada Hutton, EK; Kornelsen, J BIRTH-ISSUES IN PERINATAL CARE, 39 (3):175-182; SEP 2012

Another article demonstrating that it's not patient-requested C-sections that is driving the increasing cesarean rate. Authors found that those judged to have selected an elective cesarean were significantly older and had babies with a lower gestational age than women with a nonelective cesarean section. No significant differences between the two groups were found with respect to maternal weight, length of stay for the mother or baby, newborn birthweight, or special care nursery days. Overall, the prevalence of nulliparous women judged to have had a patient-initiated elective cesarean was found to be low and is not likely to be substantially contributing to the rising proportion of cesarean births.

• Remote Midwifery in Nunavik, Quebec, Canada: Outcomes of Perinatal Care for the Inuulitsivik Health Centre, 2000-2007 Wagner, V; Osepchook, C; Harney, E; Crosbie, C; Tulugak, M BIRTH-ISSUES IN PERINATAL CARE 39 (3):230-237; SEP 2012

An article on outcomes of Inuit births in Canada. The authors' conclusions are:  The success of the Innulitsivik midwifery service rests on the knowledge and skills of the Inuit midwives, and support of an interprofessional health team. Our study points to the potential for safe, culturally competent local care in remote communities without cesarean section capacity. Our findings support recommendations for integration of midwifery services and Aboriginal midwifery education programs in remote communities.

• Are You Baby-Friendly? Knowledge Deficit among US Maternity Staff Sadacharan, R; Santana, S; Sanchez, E; Matlak, S; Grossman, X; Makrigiorgos, G; Merewood, A. JOURNAL OF HUMAN LACTATION, 28 (3):359-362; AUG 2012

Only 3% of babies were Baby Friendly in 2010. The researchers in this study basically called all maternity hospitals in the US and asked to be connected to the maternity service. Then the person answering the maternity service phone was asked: "Is your hospital a Baby-Friendly hospital?" They found that Although the Baby-Friendly Hospital Initiative was established over 20 years ago, most US maternity staff responding to a telephone survey either incorrectly believed their hospital to be Baby-Friendly certified or were unaware of the meaning of "Baby-Friendly hospital."

This research is begging for follow-up studies. What do the maternity staff thing Baby Friendly means? Why do they think they are or they aren't BF?  Why are IBCLC's only correct 89% of the time in knowing if their hospital is BF?

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!

I Am a Midwife Video Series

I am a Midwife is an innovative public education campaign designed specifically to educate women about midwifery as a high quality maternity care option. I am a Midwife is the most comprehensive and easily accessible tool available online for women seeking information about the midwifery model of care.

I am a Midwife campaign is a free series of eight short videos designed to answer a woman’s questions about how engaging the services of a midwife can achieve the kind of pregnancy and birth experience that most fits her values, culture, preferences, and needs. The video series explores the benefits of midwifery care and the full range of services a midwife provides. One video with a particular theme will be released each Friday for eight consecutive weeks beginning on May 5, 2012, International Day of the Midwife.

I am a Midwife offers a unique look at more than 40 real-life midwives and the work they do across the country providing care to women of all races and socioeconomic levels, in all childbirth settings including hospitals, birth centers and women’s homes. I am a Midwife describes why midwifery care is safe, satisfying, reduces disparities, decreases costs, and increases better outcomes for mothers and their newborns.

Here are the first few!

Midwifery Care: What's in it for Women?

Midwives Know Birth Matters

Midwives Address Health Disparities

Doula for a Home Birth

I think its interesting that most people I encounter who know little to nothing about doulas right away tend to assume that I attend only home births. They'll ask something about if I do mostly home births or if I'll do hospital births, too, or if I only do births in water, or even if I catch babies. "Doula," if its even known, is assumed to be a "hippy" or "alternative" choice, associated with birthing at home. In reality, if I only attended home births, I might not have very many to attend! 99% of women in the U.S. deliver in the hospital. If I want to have any doula clients, in the hospital I must be! And, indeed, the reason many women hire a doula is precisely because they are giving birth in a hospital.

I also think its interesting, then, that many people who do think about planning a home birth do not think that a doula is even necessary at a home birth at all. Many say that they have a midwife, what do they need a doula for? Won't the midwife do everything that a doula does? In reality, this varies. Some midwives may not show up early in labor, and may wait until the time seems close to attend the birth. Or, if they have other clients whose births are imminent, they may have to leave to attend them. Furthermore, if a midwife attends a birth without an assistant, then she isn't likely to be able to check blood pressure, take notes, set up birth equipment, etc AND provide the physical and informational support that a doula provides.

Photo Credit

There are some midwives who work in pairs, where one can take care of the medical side of things and the other can provide doula support. And there are many midwives who want to be there in a doula capacity for a long labor! But this is not true 100% of the time, and many women and partners feel they greatly benefit from having a doula at their home birth.

To read more about perspectives on doulas at home births, check out this post from Citizens for Midwifery: Doulas and Homebirth

What do you think about Doulas at Home Births?



  

Weekend Movie: Waterbirth in a Hospital

Waterbirth in a hospital - It's possible!

Comment Turned Post: Medical Anthropology and Midwife Rituals

Medical anthropologist and midwife Melissa Cheyney published an article in the Medical Anthropology Quartlerly called Reinscribing the Birthing Body: Homebirth as Ritual Performance. Apparently this caught the eye of a writer at Science 2.0, Hank Campbell, who decided to bash anthropology and midwifery in an article called Midwife Rituals: Anti-Science Or Just Symbolism?

Campbell seems to fail to understand certain things about anthropology, like the fact that participant-observation is a dominant method of anthropological research. He also calls her analysis of her research "advocacy" when she says "Just as women and their doctors who deliver in the hospital often feel convinced that their birth was the only safe and 'correct' way, women and midwives who deliver at home feel strongly that they have the solution." This is her analysis statement, not a bashing of obstetricians. Additionally, calling aspects of biomedical care "rituals" is not meant to "create false equivalence for female empowerment rituals," as Cambell states. It is a true anthropological concept and theoretical analysis method which has been studied extensively, not simply made up for Cheyney's convenience.

It is a true concept that the female reproductive body has become medicalized in all aspects - menstruation, pregnancy, birth, breastfeeding, menopause, and so forth. The concept that American medicine has of the birthing body is encompassed in the culture of biomedicine and the beliefs of our society. We like to think that it is objective, evidence-based, and the One Truth, but in fact it is only one reality. Robbie Davis-Floyd explored how medicine, obstetrics, and birth in the U.S. is a ritual; a socially constructed rite of passage. If Campbell had read the article carefully, he would have noted that the reason that Cheyney used ritualization as a lens through which to explore homebirth is because it has been a useful tool for reproductive anthropologists in the past. (Rites of passage and rituals have been studied extensively in other areas of anthropology as well). Davis-Floyd showed that birth is "a reflection of a larger patriarchal and technocratic society." Davis-Floyd examined the rituals associated with hospital birth, and Cheyney examined the rituals associated with home birth midwifery. Both are valid anthropological research and theory.

So while, yes, home birth is partly about a rejection of the dominant biomedical tenants about birth and certain types of authoritative knowledge, it is also about embracing a different point of view regarding the way birth is or should be. Biomedicine is only one example of the way birth is or can be. Differing views are not wrong, they are just different, and exploring them for a deeper understanding is what medical anthropologists do best.

The point of this article is not to add to the "which is better, home birth or hospital" debate. The purpose is to explore the rituals involved in home birth midwifery and what they mean. Cheyney believes that what she calls rituals in home birth are intentionally subverting technocracy, and are meant to "reinscribe pregnant bodies and reterritorialize childbirth spaces and authorities." What this means is that home birth midwives are doing the things they do and saying what they say in order to purposefully go against the hegemony of biomedicine and all it says about bodies and where birth should take place and with whom. She says that midwives are, like obstetricians, taking advantage of this liminality of birth to create a certain meaning of childbirth (in the midwives' case, that nature is sufficient; in the physicians', that technology is supreme).

Many of the rituals (“patterned, repetitive and symbolic enactment of cultural beliefs and values") that Cheyney describes include things like including the woman and her family in prenatal care, repetitive birth mantras and other techniques for a drug-free birth, an inversion of the doctor-up, mother-down hierarchy during pushing, and certain postpartum techniques like delayed cord clamping. Cheyney argues that midwives do all these things in order to intentially be diferent from the biomedical model. Its interesting to read her description of them as their own form of "ritual," and I also would not have thought previously about their being used to intentionally be subversive.
 
Some women do "sidestep obstetric standards of care" and challenge "the hegemony and authoritative knowledge of medicalized birthing care" by choosing birth with a midwive at a center birth or at home. While the idea about which is "better" can be debated until the end of time, the point is that women do make that choice, and have the right to. And though it is not a belief shared by all, it is my belief that women have the right to choose what happens to their bodies and who they hire to provide their health care.

I agree that homebirth is a "medium for the promotion of social change," but I don't think thats the only reason that women choose to birth at home or with a midwife. It has been shown that women who choose home birth are rejecting the technocracy, but this is not always a conscious part of their decision. Furthermore, the reason they do it is not always to be part of political and social change, but simply to make the best choice for themselves and their babies, or because they have no other choice (in the case of the underinsured, for example).

These are my thoughts on the article. Unfortunately, the comments on the Science 2.0 article do not tend to focus on the fact that Campbell's understanding of anthropology is flawed and his analysis of Cheyney's piece is incorrect. Many in the comments section  jump into the home birth vs. hospital and midwife vs. physician debate. So, I am going to weigh-in a bit here:

It is not just mothers, hippies, birth activists, and midwives who are pointing out that the biomedical model of birth is potentially dangerous, it is also physicians and health researchers and scientists. Birth models that include midwives and the midwives' model of care have been shown worldwide to be birth models that work.

So what's the big deal if women are included in all processes, from conception to birth and beyond? Is it such a bad thing if a woman feels empowered, capable, strong and in control? What's the big deal if a woman wants warm water immersion and positive birth statements repeated to her, if it works? Arguments against home birth midwifery tend to call all this "woo woo" or "touchy feely." Women should be able to have this kind of positive care whether or not you're with a physician or a midwife. It has been shown that it matters and that it is a good thing. So why does biomedicine reject it?

I encourage you to put your two cents in over at Campbell's article, even if you're not an anthropologist. The infamous Amy Tuteur has even found it worth her while to do so! Most commenters seem to agree with what he says, and we need to turn the tide.

Weekend Movie: OB/GYN vs. Midwife

A comparison of a prenatal appointment with an OB/GYN to that of a Midwife:

Link Roundup: International Edition

Amnesty International
Science and Sensibility does a focus on some information on maternal mortality from Amnesty International, presenting some truly shocking statistics. Here are a few:

49: The number of countries that have lower maternal mortality ratios than the US.  Women in the US are more likely to die of pregnancy related complications than in 49 other countries, including nearly all European countries, Canada and several countries in Asia and the Middle East.
3 to 4x: African-American women are 3 to 4 times as likely to die from pregnancy-related causes as white women.
2x: Women living in low-income areas across the US were 2 times as likely to suffer a maternal death as women in high income areas
1,000: The number of women around the world who die every day from complications of pregnancy and childbirth. That’s over 350,000 women every year – one woman every 90 seconds.  The vast majority of these deaths are preventable.

Every Mother Counts    
Every Mother Counts is an advocacy and mobilization campaign to increase education and support for maternal and child health. Model Christy Turlington has created a film called No Woman No Cry - powerful stories of at-risk pregnant women in four parts of the world, including a remote Maasai tribe in Tanzania, a slum of Bangladesh, a post-abortion care ward in Guatemala, and a prenatal clinic in the United States.

The organization also takes donations of cell phones to medical clinics in the Democratic Republic of Congo to help save mothers' lives. Donate Your Phones to Hope Phones Today.

  

Birth Around the World: Midwifery in Tanzania
from Rixa at Stand and Deliver

    

Gifts from God: Childbirth and Postpartum Care in Islam 

 

Postpartum Care Considerations in Muslim Communities: Part II of theInterview with Hajara Kutty 

A two-part series from Science and Sensibility on Childbirth and Postpartum Care among Muslim Women

Throughout Time, Throughout the World: Baby Wearing
Bellies and Babies blog posted a great post full of history and photos of women wearing their babies as they went about their lives in cultures and countries all over the world.

"In 1733, William Kent invented a wheeled baby transportation device. In the 1830's, they were brought to America, but it wasn't until the mid 1800's that 'prams' truly became popular."

"But, it wasn't until 1985, when William and Martha Sears began baby wearing their youngest, that baby wearing began to truly gain recognition in the United States. Coincidentally, the Sears' also coined the term “babywearing”.

Happy International Day of the Midwife!

International Day of the Midwife - 5 May 2011

Over 340,000 women die each year, with millions more suffering infection and disability as a result of preventable maternal causes. The International Confederation of Midwives (ICM), alongside UN agencies, World Health Organization (WHO) and a range of other international partners, is committed to addressing maternal mortality and morbidity through greater access to essential midwifery care worldwide, particularly in developing countries where 90% of maternal deaths occur.

The WHO has recognized that the promotion of midwives as the prototype for the skilled birth attendant is crucial for the attainment of the Millennium Development Goals to reduce maternal and child mortality.

Why Choose a Midwife?
Well, most importantly, there's the midwifery model of care:

This model recognizes that birth is a social event and a life-transforming experience for the woman and her family. Birth is seen as a holistic process: professionals recognize the mind-body connection and treat the woman as a whole. Care is family- and relationship-centered and relationship. Midwives are trained to recognize the normalcy of birth and minimize technological interventions, but also to identify women who may require obstetrical attention. This holistic model recognizes that the woman’s mind and body are connected, as are mother and child. The goal is not simply a physically intact woman and baby, but a mentally healthy woman and baby as well.

This model is woman-centered, unlike the biomedical technocratic model, which is physician-centered. The woman delivers her baby, not the physician. Alternate forms of care are respected and used, such as emotional encouragement, touch, and non-pharmacological interventions. Midwives understand that birth is a respected process that cannot be managed or controlled. Unfortunately, only eight percent of pregnant and birthing women receive care from a midwife (see Declerq et al 2006).

Birth Models that Work, a new book edited by Robbie Davis-Floyd (and others), who studies birth models all over the world, has identified the elements of systems that do not work and those that do.
It is an exploration of anthropological, epidemiological, and medical research on various birth models. In areas with birth systems that do not work, mothers and babies are dying because of a lack of access to life-saving health care, or lives are saved but mothers and babies are physically and/or psychosocially damaged.  

Birth models that work “apply the latest scientific evidence to support and facilitate normal physiological birth, deal appropriately with complications, and generate excellent birth outcomes – including psychological satisfaction for the mother." She and her co-editors have discovered that the ideology that underlies all birth models that work is the midwifery model of care, which exemplifies the humanistic model. 


And if you don't take my word for it, get some further opinions in this video:



What are the Types of Midwives?
Midwives come in all kinds of different settings and certifications. Different states have different names and laws regarding midwifery.

A Certified Nurse Midwife (CNM) generally, though not always, provides care in a hospital or birth center setting.

A Certified Professional Midwife (CPM) and a Direct Entry Midwife (DEM) generally practice in out-of-hospital settings, like home birth.

A Licensed Midwife (LM) means the midwife is licensed in her state.

A "Lay Midwife" means that the midwife is trained but is not licensed, either because the state she lives in has no license procedure or because she has chosen not to.



How Can I find a Midwife?
Check out:
Midwives Alliance of North America
American College of Nurse Midwives
The North American Registry of Midwives

Or find a Birth Center near you:
American Association of Birth Centers

Or find one in your health insurance network


How Can I Celebrate Midwives?
Find out if there is a local rally or event celebrating International Day of the Midwife
Join our local Friends of Midwives group or donate to one
Buy your favorite midwife a special thank you gift!

Chimps Give Birth Like Humans, but Don't have Midwives

I can't believe it is almost the end of April! This month totally got away from me. I promise I will make up for the lack of posting soon!

Are humans unique in the way they give birth?

A few months ago I wrote a review of the book Ancient Bodies, Modern Lives by Wenda Trevathan.
This book takes a look at women's reproduction from an evolutionary anthropology perspective

In this review I wrote: 

Trevathan provides a captivating analysis of the medical implications for childbirth of the evolution of bipedalism and large brains and the trade-offs that must be made as a result. Walking upright meant a restructuring of the pelvis, which made it narrower than that of our ancestors and made fitting our larger brains much more difficult during childbirth. Furthermore, the shape of the pelvis changed so that the infant rotates more than once in order for the head and then the shoulders to make their way down into the birth canal. As a result, the baby is born facing the mother’s back, which makes it difficult for the mother to catch her own child without causing damage or death to the infant. Trevathan argues that this accounts for the nearly universal practice of having birth attendants present at birth to assist the mother in catching the baby.

All primates except humans give birth to occiput posterior, or forward-facing, infants, and are able to catch their own newborns. Or so it was thought.

 
It has recently been discovered that this trait of giving birth to occiput anterior infants is not, in fact, unique to humans. An article in Nature Chimps Give Birth Like Humans describes that chimpanzees have been observed giving birth to babies that face the mother's back. This had not been previously known because until now no one had observed chimpanzee parturition, because "they get very nervous" with company around. Probably because the company is some strange human staring at them. I would get nervous, too, if a monkey watched me give birth!

The scientists, who were able to make the chimp comfortable by sleeping in her quarters every night, hadn't even realized that chimpanzees giving birth to occiput anterior newborns was anything special.

 It was only thanks to a discussion with a human-childbirth researcher that the importance of their observations came to light. "She was very surprised to see the orientation of the baby, so we decided to write a paper about it," Hirata says.

The article notes that chimps seek out solitude to give birth to their babies, which the author says "calls into question the argument that backwards-facing babies were an important factor in the evolution of midwifery in humans."

Trevathan says, "I have never said assistance is a necessity in human childbirth, but rather that it's beneficial,"
and she thinks that the pertinent question is not why humans have evolved midwifery, but rather why chimps have not.

From the article:

"It's taken 25 years for people to start reporting some observations that help confirm or refute my hypothesis," she says, "so I'm glad that finally we've got some observational data on chimpanzees — it's advancing science."
 
Trevathan says there are still aspects of human labour that make it "unique, or at least very unusual". "One is the series of rotations that the fetus undergoes as it is born — I'm not sure that's been called into question," she says. "Another is routinely seeking assistance."

She adds that the orientation of the human infant still provides a compelling explanation for the evolution of midwifery in humans because "assistance definitely facilitates delivery when the baby comes out in that position".

If you 'd like to watch the chimpanzees giving birth to their backwards facing babies, which just land on a pile of straw and are then picked up by the mama chimp, there is a link in the article, or you can click this link. Or you can watch it here:



Enjoy!

Biomedical Model of Care vs Midwife Model of Care

I posted this about a year ago, but I thought it was worth sharing once more, as I come back to it again and again myself.

I am a fan of the Midwife Model of Care

Click to Enlarge

If the above strikes a cord with you, I urge you to Consider a Midwife. 

   

Weekend Movie: "Infant Mortality: Causes and Prevention"

Reducing Infant Mortality and Improving the Health of Babies

Listen to Obstetricians, Doulas, Neonatologists, Midwives, Psychologists, Pediatricians, and other Physicians explain how our health care system is failing babies and mothers and what we can do about it. 

http://www.reducinginfantmortality.com/

Reducing Infant Mortality from Debby Takikawa on Vimeo.

"Of the most common procedures in the hospital the top 6 come out of maternity care" 

"We're making it more technologically advanced in our country and we're not doing any better, and we're actually getting worse."

"The rate of prematuriy in the US has increased by 36% since the 1980's"

"Where we get into problems is when we decide that other women then those that are clearly indicated to need them, need to have interventions."

"Most maternity practices that are commonly used in the hospital were never designed to be used at the frequency we're seeing them used now..."

"We have become a little bit cavalier..." 

"It is estimated that for every week that a baby is born before term that they double their risk of having problems..." 

"We know that the use of narcotics at any point interferes with breastfeeding"

"Studies now that show that when women have interventions there are deficits in maternal infant attachment and in breastfeeding as well..."

"Among African American women, breastfeeding numbers are the lowest" 

"Midwives and family doctors primarily are the providers that we've seen in the research have the best outcomes." 

"You do not need someone with the skills of a board certified OB/GYN to do a normal vaginal birth"

"The US is the only industrialized country in the world that uses surgeons to attend normal childbirth."

 "And then we look at those other countries and we see that their healthcare costs are lower..."

"If the system is set up properly where you have a there's a safety net where you work in collaboration and have a nice team effort I think it can be a safe process"

 "A collaborative process...will give patients a better opportunity to have better outcomes."

"There are entire states where midwives are unable to find an OB/GYN who is willing to be available should a woman need to go to the hospital and access those services."

The Status of NYC Midwives

This summer I am living in NYC before I begin graduate school in the fall. I have been keeping an eye open to see if any area doulas with clients in July need back up, or any women with July EDDs want cheap doulas, but I haven't gotten a lot of feedback. So I may be on a summer hiatus from doula-ing :( 

Being in New York does make me even more intrigued by all the news that has been going on with the Midwives vs. Obstetricians battle. I was going to post an article or write up a synopsis, but then I found that Stand and Deliver had already done so! And so I am simply going to refer you to hers:

 

A few days ago, The New York Times published this article about the current status of NY midwives: Doctors’ Group Fights a Bill That Would Ease Restrictions on Midwives. Since the closure of St. Vincent's, half of NYC's home birth midwives have been unable to obtain practice agreements. All midwives, hospital or home-based, currently need a signed practice agreement with either a hospital or physician. So New York state's midwives sought a legal solution to this impasse. Here's what happened:

A week ago, a bill that would repeal that requirement breezed through Assembly and Senate committees, and its champions expected it to pass the full Legislature within days. Then it hit heavy opposition from the American Congress of Obstetricians and Gynecologists.

In a memorandum, backed by a press conference in Albany on Thursday, the congress challenged the safety of midwife-attended births and suggested that the bill was a ploy to allow midwives to expand their turf and directly compete with doctors. “While this legislation does not intend to extend a midwife’s scope of practice, it has the ability to pave the way for midwives to open their own independent birthing centers,” it said.

Heaven forbid that midwives compete directly with physicians.

But wait--it gets even better. ACOG's reason for requiring written practice agreements is that without a practice agreement, giving birth with a midwife, including hospital-based midwives, will become terribly unsafe. The only thing standing between the laboring woman and disaster is this piece of paper. Here's how:

The obstetricians’ group has argued that written agreements are needed to keep women safe. Suppose a woman is giving birth in a hospital, attended by a midwife without a practice agreement, and the woman starts to hemorrhage, Donna Montalto, executive director of the New York division of the congress of obstetricians, said Thursday.

“What obstetrician who has never seen the patient, doesn’t know the midwife, and happens to be at home at their son’s baseball game is going to say, ‘Sure, I’ll come in and take care of your patient,’ ” Ms. Montalto said.

Yes, in the absence of a signed agreement, physicians will be asked to come in from their children's sport games and attend to an unknown woman. Gasp. As if unknown women never go into labor when a physician is on call. As if attending physicians know all of the women they deliver personally--except for those pesky midwife patients.

Emergency Unassisted Labor and Delivery Guide

A great deal of women give birth unassisted by a trained healthcare provider. This includes women in developing countries who give birth on the side of the field and then go right back to plowing, women in developing countries who don't have money or access to a care provider or health facility, women all over the world who plan to birth unassisted at home, and women who find themselves having an unplanned unassisted birth before their care provider can be with them.

This post is about the last group of women: the women who hadn't planned on birthing without help, at home or in the car or wherever, but hopefully have access to emergency supplies. Its also a great crash-course for the women, or dad/partner, about the basics of labor and delivery, and mom and baby postpartum.


Amy Romano on Science and Sensibility wrote a great post on Birth during Times of Disaster: Keeping Women and Babies Safe

In it she included a link to an emergency childbirth guide from the American College of Nurse-Midwives that includes a lot of really great information for women and partners who must deal with an emergency birth in a location where there are no skilled birth attendants present. I include some bits of the text below:


FROM THE AMERICAN COLLEGE OF NURSE-MIDWIVES
Giving Birth “In Place”: A Guide to Emergency Preparedness for Childbirth
Deanne Williams, CNM, MSN

This is not a “do-it-yourself”guide for a planned home birth, nor is it all the information you need for every emergency. It is not meant to replace the knowledge and skills of a doctor or midwife. The information is a basic guide for parents-to-be who want to be ready in case they have to give birth before they can get to a hospital or birth center.

CALL FOR HELP
If you think you are in labor, try to get to a hospital, birth
center, or clinic. If you are alone or travel seems unwise,
call the emergency number in your community and ask for
help. After you have called for help, keep your front door
unlocked so that rescue workers can get in if you are unable
to come to the door. Call a neighbor to come and help the
family. If the phones are working, keep talking to emergency
services or your health care provider who can “talk
you through” a labor and birth.
If your labor is going fast and birth seems near, stay at
home and have your baby in a safe place rather than in the
back seat of the car. Fast labors are usually very normal,
and the mothers and babies can both do well. Slow labors
will give you time to get to a hospital or birth center, or for
a health care provider to get to you. Get out your supply kit
and put the supplies where you can easily reach them.
As the helper, your job is to
Keep mom comfortable. It is good for her to walk, take a
shower, get a massage, and move even if she is in bed.
Be sure she drinks lots of fluids. Water, tea, and juice are
the best.
Be sure she goes to the bathroom every hour.
Say and do things that create a calm feeling, even if you
are very nervous.
Wear gloves if you are going to be touching blood.
Wash your hands or gloves often.
Do not let pets into the labor and birth room.
Talk to mom about the sounds of childbirth. Making
groaning or crying noise during labor is ok and can help
the mom-to-be. It can scare the helpers. So mom has to
try to not scream and lose control, and the helpers have
to let mom make the noise that helps her cope.
Decide how to help other members of the family. Will
they be present for the birth? What do they need to
feel safe?


PREPARE THE BED
To keep the mattress from getting wet, cover it and the
sheets with a shower curtain and then cover the shower
curtain with another clean sheet, plastic-backed under pads
and lots of pillows for comfort. The mother may want to
spend a lot of time in bed, or she may prefer to be on her
feet or in a chair. Whatever feels best is okay.

WHEN THE BABY’S HEAD IS COMING FIRST
If you know your baby has been head down during the last
weeks of pregnancy, chances are good that the baby will be
head first at birth. This is the most common position for a
baby. First labors can last for 12 hours or more, whereas the
next babies can come much faster.

The Urge to Push
The longest part of labor is the time it takes for the cervix
to open wide enough for the baby to pass into the birth
canal or vagina (first stage). You can tell the cervix has
feel with your fingers to find out if the cord is around the
baby’s neck. If you find a cord around the neck, this is not
an emergency! Gently lift the cord over the baby’s head, or
loosen it so there is room for the body to slip through the
loop of cord.
The baby’s head will turn to one side and with the next
contraction the mother should push to deliver the body. If
the body does not come out, push on the side of the baby’s
head to move the head toward the mother’s back. The
shoulder will be born. The rest of the body slips out easily
followed by a lot of blood-colored water.

If the Head Is Born but the Body Does Not Come Out After
Three Pushes
The mom must lie down on her back, put two pillows under
her bottom, bring her knees up to her chest, grab her knees,
and push hard with each contraction. After the baby is born,
place her or him on the mother’s chest and tummy, skin to
skin, and cover both with towels. If the baby is not crying,
rub her back firmly. If she still does not cry, lay her down
so that she is looking up at the ceiling, tilt her head back to
straighten her airway, and keep rubbing. Not every baby
has to cry, but this is the best way to be sure the baby is
getting the air she needs.

If the Baby Is Gagging on Fluids in Her Mouth and Turning
Blue
Use the baby blanket to wipe the fluids out of her mouth
and nose. If this does not help, use the bulb syringe to help
clear things out. Just squeeze the bulb, place the tip in the
nose or mouth, and release the squeeze. This will suck fluid
into the bulb. Move the bulb away from the baby and
squeeze again to empty the bulb. Repeat until the fluid is
removed.
If the baby is still not breathing, follow the CPR
directions.

THE UMBILICAL CORD
There is no rush to cut the cord. All you have to do is keep
the baby close to the mom so the cord is not pulled tight. If
you pick the cord up between your fingers, you can feel the
baby’s pulse. Within about 10 minutes the pulse will stop.
At that time you can tie and cut the cord. Remember the
cord is connected to the placenta (afterbirth) which is still
inside the mother.

THE BABY
At the time of birth, most babies are blue or dusky. Some
cry right away and others do not. Do not spank the baby,
but rub up and down her back until you know she is taking
deep breaths. Once the baby starts to cry, her color will be
more like her mom, but her hands and feet will still be blue.
Now is the time to keep the baby warm. Remove the wet
towel that is over the baby and put another dry towel and
blanket over the mother and baby. Put a hat on the baby.
The mother can help keep the baby warm with her body
heat.
Put the baby to breast. Even if you did not plan to
breastfeed, one of the safest things you can do for mom and
baby is put the baby to breast. A breastfeeding baby helps
keep the mother from bleeding too much and gets the food
it needs right away. If the cord is too short to allow the baby
to reach the breast, it is ok to wait until you cut the cord.

CUTTING THE CORD
There are no nerve endings in the cord so it does not hurt
either the baby or the mother when it is cut. It is very
slippery so take your time because there is no rush. Wash
your hands, put on gloves and then get the container with
the scissors and shoelace. Tie one of the laces around the
cord very tightly with a double knot about 3 inches from the
baby’s tummy. The baby will cry when she is uncovered
because she is cold, not because it hurts. Tie the other
shoelace around the cord about 2 inches from the first knot.
Pick up the scissors by the handle without touching the
blades. Cut between the knots you have tied. It is rubbery
and tough to cut especially if you have dull scissors. After
it is cut, place the end of the cord that is still connected to
the mother’s placenta into the mixing bowl. Cover the baby
again to keep her warm.

THE PLACENTA OR AFTERBIRTH (THIRD STAGE)
The placenta looks like a big piece of raw meat with a shiny
film on one side. On the other side it has membranes that
are attached to the placenta (the membranes look like skin
that has been peeled off). When the placenta is ready to
come, you will see a gush of blood from the vagina and the
cord will get a little longer. Put the bowl close to the
mother’s vagina and put more waterproof pads under her
bottom. Ask the mother to sit up and push out the placenta
into the bowl.
There will be a lot of blood and water coming after the
placenta. Firmly rub the mother’s stomach below her belly
button until most of the bleeding stops. This will hurt but
needs to be done. The heaviest bleeding should stop in a
minute and then the bleeding will be more like a heavy
period. If the bleeding increases again, very firmly rub the
mother’s lower belly until the bleeding slows. When it is
firm, you will be able to feel the uterus (womb), which is
the size of a large grapefruit, in the lower belly. A firm
uterus is a good thing because it will stop the mom from
bleeding too much.
Mom’s bottom and her uterus may be sore. You may see
places where the mother’s skin has torn around her vagina.
Most of these tears will heal without any problems. Mom
will feel better when you put an ice pack on her bottom
where the baby came out and then put the sanitary pad on
top of the ice pack. She may want to take a couple of pain
pills at this time.

Put the placenta in a medium-sized trash bag and wipe
off any blood on the outside of the bag. Put this bag into a
second trash bag. Take the placenta with you to the hospital
or birth center. If you cannot leave the house for more than
4 hours, put the bagged placenta in a container with a lid
and put it in the freezer.

CLEAN UP
After the mother has delivered the placenta and the bleeding
has slowed down, give her a drink of juice, soup, or
milk and something to eat like crackers and cheese or a
peanut butter and jelly sandwich. Put on gloves to clean up
the bed. Roll up the sheet and pads inside the shower
curtain and put in a large plastic bag. Have clean under pads
ready to cover the sheets and a sanitary pad for the mother.
The dirty sheets and towels can be washed in cold water
with bleach or ammonia added. Wear gloves when touching
items that are bloody. Put a diaper on the baby or you will
be sorry!

BREASTFEEDING
It is important for the mother to breastfeed the baby in the
first hour after birth and at least every 2 hours until her milk
comes in.
● Breastfeeding will keep the uterus firm and decrease
bleeding.
● Colostrum, the liquid that is in the breasts right after birth
until the milk comes in, will give the baby all of the food
she needs and it will help prevent infection.
● Even if the emergency situation continues for days,
weeks, or months, there will always be a ready supply of
safe and perfect food for the baby.

Getting Started With Breastfeeding
A newborn will nurse best in the first hour after birth when
she is awake and alert. The mother may be more comfortable
if she lies on her side with pillows under her head. The
mother and baby should be face-to-face and belly-to-belly.

The baby will also nurse better if they are skin-to-skin (see
Figure 2).
The mother should place her nipple and breast against the
baby’s lips. The baby will lick and try to nurse. The mother
needs to help out by placing her nipple into the baby’s open
mouth. It may take a few tries before the baby can start
sucking. If the baby is sleepy, rub her belly and back firmly
to wake her up. If the baby is too sleepy, try uncovering her
for a short time and rubbing the mother’s nipple against the
baby’s lips. If the mother gets tired, take short breaks and
start again. Once the baby nurses for the first time it gets
easier.
If the baby sucks a few times and then lets go and the
mom has large breasts, mom may need to help the baby
breathe by using her finger to hold some breast tissue away
from the baby’s nose.

What to Avoid
● Don’t use a pacifier or a bottle to start the baby sucking.
It confuses some babies because they do not suck the
same on the mother’s breast and a bottle or pacifier.
● Do not separate the mother and baby for very long. The
more they stay together, including when they sleep, the
sooner breastfeeding will be well established.

CARE OF THE MOTHER
If you still cannot get to the hospital or birth center to be
checked, the mother should go to the bathroom within
an hour after the baby is born.
If the room is cold, you can use the hot water bottle to
help keep the baby warm. Just wrap the warm bottle
in a blanket and place it next to the baby’s back.

After birth in a hospital, women are usually offered
Tylenol or Advil for pain every 3 to 4 hours as
needed. This would be a good choice at home if the
mother does not have an allergy to this medication.
When a new mother gets out of bed for the first time, she
may feel dizzy. It is important to have her leave the
baby on the center of the bed and get up slowly:
● Sit up on the side of the bed to see how she feels.
● Have an adult take her to the bathroom and wait to be
sure that she is not feeling faint.
● If she says she is going to faint, believe her and have her
lie down on the floor. Do not attempt to walk her back to
bed. You have about 10 seconds to get her down on the
floor before she passes out and bangs her head on the way
down! Once she is down flat, she will wake up and feel
better. Just wait a few minutes and then carefully help her
back to bed.
In a couple of hours the mom may want to take a shower.
Be sure she has had something to eat and is not dizzy when
she gets up. It is good to have someone close by because
dizziness can return quickly.


To read more of this guide, including a list of emergency supplies to keep on hand, what to do if baby comes bottom first, and baby care in the first couple days, click here.

Weekend Movie: Consider a Midwife

Why Choose a Midwife?
via Doula-ing

Our Bodies Ourselves has posted a video on their blog asking the question "Why Choose a Midwife?" The video is mainly being used to address legislation in Massachusetts governing midwives, but it has the added benefit of detailing the benefits of the midwifery model of care.

Some excellent points from the movie:

"I almost think that midwives do a better job, at the normal deliveries, than we do." - Obstetrician

"A low-risk home birth under well-monitored circumstances can be very safe and ought to be a woman's option" - OB/GYN

"I'd have to say that there's an emotionalism rampant that somehow obstetric emergencies occur with frightening frequency and that people are constantly being subjected to emergency deliveries and life-saving deliveries... and that without these babies will die as a routine gesture and greater amounts will be injured substantially... and that's just not true. Most obstetrical emergencies may be anticipated."

"One of the advantages of home birth is that they avoid... the cascade of interventions." - Professor of Maternal and Child Health at BU

The three Boston hospitals with the most midwife-attended births saved the state nearly $3 million in Medicaid reimbursements in 2006 through lower Cesarean rates.

"Continuous Electronic Fetal Monitoring is everywhere in my universe... We all agree that there's some controversy in how you interpret some of the things that you see on it... In low risk patients it increases the rate of unnecessary C-sections and the data says it does not make a difference in the outcome of the baby." - Doctor

A birth by Cesarean section costs an average of $14,843.
A birth at home with a Certified Professional Midwife costs an average of $2,391.
A birth at a birth center with a Certified Nurse Midwife costs an average of $2,213.