Circus of the Epidurals

My husband and I are long-time fans of the British TV sitcom "Coupling," which ran for four seasons from 2000 to 2004. The fourth and final season followed one of the character's pregnancy and eventual delivery, and one episode, entitled "Circus of the Epidurals" discusses the character's desire for a natural childbirth, and her boyfriend's inability to understand why in the world she would want to forego drugs.

"There's pain, and there's pain relief," he says. "This is not a test anyone should fail!"

The episode is hilarious, and there's no question that it accurately reflects the basic tension between those who desire natural childbirth and those who can't understand why you'd want to "be a martyr" and refuse an epidural when it's right there and available to you. Why would you want to experience pain when you don't have to?

While I enjoy watching this and all of the other episodes of "Coupling," the amount of education I've had on this particular subject does make me want to throw things at the screen. First of all, the female character makes no effort to explain to any interested party why she wants a natural childbirth. (I'm avoiding names to try and limit the spoileriness, in case you decide to investigate the show - available streaming on Netflix!) The closest she comes is, "The pain of childbirth is part of being a woman," to which her boyfriend replies, "Yes! And it's the part we can fix!"

Now, since about the 1970s, there has been a movement toward "natural childbirth," as we well know. It became a trend to eschew any available methods of pain relief, including twilight sleep, Demerol, other narcotics, and epidural, in order to be fully present for the birth of your baby. Medical research has also demonstrated that the use of interventions such as epidurals may attach risks to the birth that otherwise would not exist. While, certainly, "Because I want to experience natural childbirth" is a perfectly valid reason for refusing pain relief, there are also scientifically sound arguments for avoiding or delaying interventions during birth and instead turning to "natural" methods of coping with the pain of labor and delivery.

The prevailing attitude of Western medicine is that our lives are substantially improved by removing pain and treating disease. And I have absolutely no argument with that stance in most cases. However, birth is not a disease, and the pain associated with childbirth is not necessarily an indication that something is wrong. Thus, while normally I'm all about feeling better, experiencing less pain, and reducing discomfort, the process of childbirth, when allowed to progress without intervention, without medication, without probes and monitors, and without interruption, has better outcomes than if we try to "treat" it.

I'm not saying we should never use pain relief, never do surgery, never use the available technology to assist in birth. No one is arguing that infant and maternal morbidity and mortality have not plummeted over the last century, largely due to improvements in medical technology and knowledge surrounding pregnancy and childbirth. However, there is still room for improvement, and mounting evidence suggests that likely over 90% of women will be able to give birth safely and successfully to healthy babies without any medical intervention at all. Allow her the space and time to labor, give her a clean and safe environment in which to birth her baby, have an experienced and well-trained birth attendant by her side, give her a supportive labor coach or two, and she will birth her baby in the most natural and ideal way possible, which will benefit her in her recovery and her baby in his development.

Studies have shown that the use of epidural, especially when in place for a long period of time (more than 10 hours), can interfere with a baby's ability to effectively breastfeed in the first day or two of life. Studies have shown that the use of epidural increases the "need" for Pitocin to augment labor, as the use of the epidural drugs and the fact that the woman is then required to remain on her back may slow labor contractions. Restricting a woman's movement during labor, forcing her to give birth lying on her back, and the use of sensation-dulling medications make it more difficult to push effectively and get the baby into an ideal birthing position. This increases the risk of c-section due to "failure to progress", "long labor", or "large baby." In addition, even if the baby is birthed vaginally, the risks of perineal tearing or episiotomy are increased, which may complicate the mother's recovery. The drugs in the baby's system may dull his sucking reflex and make him more lethargic, contributing to early breastfeeding difficulties. And, finally, the need to push IV fluids to maintain the mother's blood pressure when an epidural is administered may cause edema (swelling) in the mother's breasts within 12 to 24 hours of the birth, making it more difficult for her tiny new baby to latch and suck effectively at the breast, which can delay increased milk production and create a need for formula supplementation where none would otherwise have existed.

The point is, while many women desire a natural childbirth for non-medical reasons, many, many women have solid, evidenced-based reasons to eschew medical intervention and strive for a drug-free birth, for their safety and the health of their babies. Epidurals aren't going away, and many of the risks are manageable or can be mitigated by taking other steps such as allowing immediate skin-to-skin, encouraging rooming-in, and providing in-hospital breastfeeding support, but when women are made aware of these risks, they can make an educated decision as to how much risk they are willing to take on.

My personal desire to avoid the epidural is not a point of pride; it is not a hippier-than-thou exhibition; it is not out of an "I am woman; hear me roar" attitude. It is fear. Plain old fear that getting an epidural might cause a cascade of other interventions that would lead to an undesirable outcome for ME. It's important to note that what I find to be an undesirable outcome, other women may not. This is why women need to be informed, listened to, and included in the decisions made during their births.

So, thanks, "Coupling," for the laughs, but I'll stick to science, and not sitcoms, for birth education!

Choices, Choices, Too Many Choices!

I was listening to the radio today in the car. Just the regular radio. One of the local stations. Actually, six of the local stations - I flipped from preset to preset as commercials came on or songs I didn't like were playing. I enjoyed it immensely. I loved the surprise of what song might come next. I liked hearing songs I've heard often and songs I haven't heard in a long time. I liked cranking up the volume on the ones I especially love, and disliked having to turn it back down when one of my kids had something to say. This is all totally normal and ordinary behavior, of course, but I haven't engaged in this particular activity in a while, because we got 90 days free of Sirius-XM satellite radio when we bought the minivan, and that 90 days just ran out last week. I haven't listened to regular-old live radio in a long time (before that, it tended to be a single CD on repeat to please the little-'uns).

Similarly, we subscribed to some basic cable channels when we moved, after quite a while without having any live TV to watch. There's a certain joy in sitting back on the couch with the TV remote in hand, flipping channels until you find something interesting, browsing during commercials. We've had Netflix for so long, and have relied upon them exclusively, that I'd forgotten how relaxing it can be to simply watch what's on.

It occurred to me today, while flipping back and forth among the six radio stations in my presets, that there's a lesson here for us as parents. Sometimes there can be too much choice. Sure, it's pretty awesome when you can choose from 60,000 TV episodes and movies from all over the world through your various streaming TV options. It's amazing to have hundreds of commercial-free radio stations to browse through on your satellite radio. But I felt so much more relaxed simply letting the radio choose for me, to be totally reliant on whatever the DJ and the radio producers felt should come next.

We are inclined, in this day and age, to offer our kids choices. What do you want to wear? What do you want to eat? Where do you want to go? We feel like we should give them some control over their lives where we can, because we control so much of what they do every day.

But kids can become overwhelmed by the infinite choices of those open-ended questions. What if kids' lives were more like live TV and less like Netflix? What if we could give them the option to watch "Wild Kratts" or "Dora the Explorer" but not include every other PBS and Nickelodeon show ever made? They could then only watch whichever episode of "Wild Kratts" is on, without having to choose from dozens of them. I've found my kids tend to watch the same few over and over again, possibly because choosing from the myriads of options is just too much. It's too hard. It's too complicated.

And, there's the problem when giving open-ended choices backfires on you. "What do you want to eat?" might end in a choice that isn't available. And then you have to deal with disappointment and let-down when they ask for spaghetti with tomato sauce and you don't have any. And then they don't want whatever you do offer, because you asked what they wanted and then denied them that option! (Case in point, when Netflix's contract with Nickelodeon ended a couple months ago and Dora and Diego disappeared from the list of options, my toddler was devastated! And there wasn't anything I could do about it...until we signed up for Amazon Prime. Sigh.)

I'm usually in favor of the "Do you want this or this?" style of offering options. Do you want to wear the giraffe shirt or the cow shirt? Do you want to eat macaroni and cheese or chow mein? This, at least, brings the options down to what's actually available, and it allows you to still direct what they do while giving them the illusion of control.

But this can backfire, too. What if they don't want either of those options and they refuse to choose? What if they expect to be given a choice when you have no intention of giving one? What if they have to wear the blue track pants because everything else is dirty and you haven't done the laundry yet? What if the only thing you have in the house for dinner is hamburgers?

I'm often happy to simply hand over control to someone else. "Where do you want to go for brunch?" "I don't care, you pick" is akin to "Let's just listen to the radio" rather than starting up your iPod playlist. I think kids are that way as well. I don't think "I don't know" as an answer to "What do you want to eat?" is necessarily them being intentionally unhelpful. I think sometimes it's genuinely choice burnout. They really, honestly, don't know, because trying to think of every food they've ever eaten and pick which of those foods they want right now is just too overwhelming. Do I want to watch "West Wing" or "Star Trek" or "30 Rock" or "Frasier" or a movie? Do I want a comedy or a drama or a cartoon? Do I want to start at the beginning or choose from one of the 250 episodes available? I don't care anymore! You pick!

Choice becomes noise after a while. It becomes stressful to have to decide. Let's bring the choices down to a few things that don't matter so much. Let's eliminate some of the clutter in our own minds and streamline the process. And let's enjoy the fact that sometimes there isn't a choice, rather than let that get us down. Hopefully our kids can learn to see the positive in that, too.

Childbirth Choices Series Part I: I've Just Found Out I'm Pregnant; Now What?

This is the first in a series of posts that I plan to enhance into an online course along the same lines. The goal is to educate women before they become pregnant, or when they are newly pregnant, about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

Choosing a Care Provider

Once you've gotten a positive home pregnancy test or a blood test confirming that you are, indeed, pregnant, one of your first steps will be to choose a care provider (CP). By care provider, I mean the person or persons who will handle your prenatal care and help you deliver your baby.

I've described below the three main types of care providers available in most states to provide maternity care. Before you can choose a CP, you'll need to decide what you're looking for when it comes to your prenatal and maternity care. I suggest you talk to friends and family members who have given birth to find out about their experiences with their CPs and the birth(s) of their child(ren). You may find that attitudes vary widely, from those who prefer a medical approach to birth to those who want a more hands-off, back-to-nature style. If you're not sure what you want, it will pay off to do some research and talk to people who have made various choices, and, most importantly, discuss why they made those choices. Your options and decision will also depend on your location. For example, you may have a Baby-Friendly hospital nearby that provides excellent maternity care. Or, your local hospital may have a dismal maternity record, but there is a birthing center not far away that is very highly rated. I'll get into where you might want to give birth right after the discussion about CPs.

Obstetrician (OB)

An OB, or obstetrician, is the type of care provider most of us think about when it comes to pregnancy. An obstetrician is a medical doctor who specializes in maternity care, including prenatal care and delivering babies, either vaginally or via cesarean section, as well as postpartum care. Most OBs also handle general gynecological issues and regular GYN checkups. OBs typically work in an individual or group practice and deliver babies at a local hospital at which they have privileges.

Why Might I Choose an OB?

As mentioned, an OB is the most commonly selected option in the United States when it comes to maternity care. Many women will simply continue to see the same doctor they have been seeing for their regular GYN care. If you are comfortable with your current OB/GYN and feel that your needs and desires for your maternity care are being addressed, then sticking with a provider you already know can be a great option. An OB can oversee your pregnancy and delivery, and it may be comforting to you to have a medical doctor and surgeon with you at delivery and throughout your pregnancy.

Why Might I Not Want an OB?

Depending on what you're looking for in your prenatal and maternity care, you may find that OBs tend to be clinical and traditional when it comes to how they view birth. This is not a blanket statement about OBs, because I know of many OBs who believe strongly in the course of normal birth and are not so quick to offer interventions. However, often OBs think in medical terms and will take a clinical approach to your care, meaning that they will be more likely to recommend interventions, medications, and tests. For some women, this is comforting and familiar and will be attractive. For others, they may want to look for either a non-traditional OB or investigate another care provider, such as a Certified Nurse-Midwife.

Certified Nurse-Midwife (CNM)

Another option for maternity care is a nurse-midwife (CNM). A CNM is a registered nurse who has gone on for special training in prenatal and maternity care, as well as general gynecological care. A CNM is not a surgeon and cannot perform a cesarean section. She (or he) can deliver a baby vaginally as well as order the use of certain medications and tests during pregnancy and delivery, if indicated. CNMs may work privately or in group practices or may be affiliated with a particular hospital or birthing center. Some CNMs work independently or in a group offering home birth services.

Why Might I Choose a CNM?

Midwives tend to take an approach to pregnancy and birth that is less medically oriented. This means they will be more likely to view pregnancy, labor, and delivery as a natural process rather than as a medical issue that needs to be addressed. Women who are interested in having a "natural" (non-medicated) birth, or who are looking for a CP who will take a more holistic approach to their care, may find a CNM an attractive choice. Please note that a competent CNM can and will monitor you and your baby throughout your pregnancy and labor and will know if it is necessary to recommend emergency intervention by an OB.

Why Might I Not Want a CNM?

First of all, CNMs generally cannot take high-risk cases, so if you have a high-risk pregnancy, a CNM may not be able to take you on as a patient. It may also be the case that you cannot find a CNM who can deliver in the venue you've chosen. For example, you may want to deliver in a hospital, but the hospital you go to may not allow CNMs to oversee deliveries. Also, if you have any concerns about the need for medical or surgical interventions during your pregnancy or delivery, you may be more comfortable with an OB.


Licensed Midwife (LM)/Certified Professional Midwife (CPM)

A Licensed Midwife is a practitioner who specializes solely in maternity and women's health services and is licensed by a particular state's medical board. A Certified Professional Midwife (CPM) is a midwife who has been certified by the North American Registry of Midwives. Similar to a CNM, but not a registered nurse, a midwife can provide prenatal and maternity care, deliver babies, and order medications and tests, as needed. She cannot perform surgery. Not all states recognize or license midwives. In some states, out-of-hospital midwifery is illegal. You will need to find out what the options and laws are in your state if you wish to work with a midwife. Most LMs and CPMs work outside of the hospital setting, often offering home birth and home care services.

Why Might I Choose a Midwife?

A midwife will likely be similar to a CNM when it comes to practice and philosophy. Midwives typically work with low-risk women and babies in the normal course of pregnancy and childbirth. Their services are typically low-intervention and focus on pregnancy and birth as a normal process that may require assistance but not necessarily medical or surgical action.

Why Might I Not Choose a Midwife?

If you prefer to deliver in a hospital or a birth center affiliated with a hospital, you may not have the option of a midwife other than a CNM. A competent midwife will have the necessary equipment, medications, and knowledge to assist with birth, and she will also be able to determine if the mother and/or baby need to be transferred to a hospital for medical or surgical intervention if there is a problem. However, if you are more comfortable delivering in a hospital setting, or you feel strongly that an M.D. should attend your birth, for whatever reason, the option of a midwife may not be attractive to you. And, as stated above, midwifery is illegal in some states.


Do I Want a Group or Individual Practice?

You'll also need to decide if you want to see a CP who works privately or one who is part of a group practice. There are advantages and disadvantages to each.

With a CP in an individual practice, you'll be certain to see the same person at every prenatal appointment, and if you deliver your baby during your provider's working or on-call hours, you'll be certain that he or she will attend your birth. However, if your CP is not available at that time, you will be seen by whichever provider is on-call when you're ready to deliver. Some individual practitioners try to make it a point to be available to all of their patients. This is something you'll want to discuss with your provider at an early appointment.

With a group practice, there are several providers who work together. The advantage to this is that there is a good chance that one of the CPs from the practice will be available/on-call when you have your baby. If you choose a group practice, you'll probably want to schedule appointments with each provider in the group so that you can get to know each of them, so that whoever does end up delivering your baby won't be a stranger.

Choosing a Venue

As you can see, the choice of care provider and venue are closely intertwined. If you want a midwife and a hospital, you'll need to find a hospital that allows midwives to attend deliveries, and you'll need to find a midwife who has privileges at that hospital. If you want an OB and an unmedicated birth, you'll probably need to give birth in a hospital, but you'll want to choose an OB and hospital who will be supportive of your wishes. You will also need to check your state's laws concerning midwifery and home birth, and find out the availability of a birth center near you. You'll want to research your local hospitals to find one that fits best with your needs and desires. Some women will find that there doesn't appear to be a "perfect" or even a "good" option that fits with her ideals, and for those women, being armed with knowledge and research will be especially valuable.

Hospital

Over 98% of American women give birth in a hospital. Many women may not even be aware that there are options other than a hospital birth. Hospital birth is seen as the norm in the United States. Most hospitals have a Labor & Delivery unit where women come to labor and give birth, then stay for an average of two to four days (depending on the method of birth and if there were any complications) while they and their babies are cared for by doctors and nurses on the hospital staff.


Why Might I Choose a Hospital to Give Birth?

As mentioned, hospital birth is considered by most to be the "normal" and expected choice for women in the United States. Nearly all women deliver their babies in a hospital setting. In a hospital, you'll be certain to have access to an operating room, if necessary, medications and anesthesia, if you want them, and nurses and doctors for both mother and baby. A hospital will be prepared with personnel and equipment for dealing with most complications of birth and the neonatal period. In a hospital, you will have the reassurance that, should something (G-d forbid) go wrong, you're in a place that can help you.


What Hospital Should I Go To?

The temptation is typically to go to the nearest hospital to your home that has a Labor & Delivery unit. No one relishes the idea of a long car ride or cab ride while in labor just to get to the hospital, and there's always that fear of giving birth on the way if the hospital is far. However, when choosing a hospital, it's important to know a few details.

- Do they have a well-equipped NICU?

Since a major reason for choosing to give birth in a hospital is the comfort of being there "just in case," it's important to know that your baby will be well cared for if there are complications. If the hospital you choose does not have a NICU and you have need of one, then your baby will have to be transported to a different location for care, and you may be separated for several days. If you have the option, giving birth in a hospital with a respected NICU may be important to you.

- What is their rate of cesarean section compared to vaginal births?

If a hospital has a high cesarean rate (and you'll have to decide for yourself what "high" is), there is a higher chance that you may be pressured into a c-section that you didn't necessarily want or need. Over 32% of babies today are delivered via c-section, and most authorities and experts agree that this number is too high. A hospital with a lower c-section rate likely first turns to methods of managing your care during labor that will reduce your risk of c-section, while a hospital with a higher c-section rate likely jumps straight to surgery as an answer to problems or blips that may not actually be emergency situations. You can investigate a hospital's cesarean rate and learn more about c-sections by visiting http://www.cesareanrates.com/.

- What is their policy on rooming-in? Do they have a nursery in the Postpartum ward?

Research shows that rooming-in with your new baby - keeping your baby in the room with you at all times, rather than having him/her cared for in a nursery - facilitates breastfeeding and bonding and is healthier for mom and baby, assuming neither suffered major complications during labor and delivery (which the majority do not). Find out what your hospital's policy is on rooming-in. Some hospitals do not even have a nursery for healthy babies and require that the baby remain with the mother if there are no extenuating circumstances. Others will require that the baby is kept in the nursery at night and brought to the mother only for feedings. Some hospitals will offer each family a choice between using the nursery and rooming-in.

- What kind of breastfeeding support do they offer?

If you plan to start out breastfeeding - as the majority of new moms do - you'll want to know what kind of breastfeeding support your chosen hospital offers. Do they have a high rate of suggesting formula supplementation in otherwise healthy babies? Do they offer the use of a hospital-grade breast pump if needed? Are babies supplemented with bottles or formula without the parents' consent? Are there lactation consultants on staff who are available to new mothers on the postpartum ward? Are the maternity nurses trained in basic breastfeeding support? These are important questions, which you can ask on your hospital tour, ask of friends who have given birth there, and look for more information about online. Research shows that good breastfeeding support in the hospital fosters continued breastfeeding success after mom and baby go home.

- Are they Baby-Friendly?
"Baby-Friendly" is an official designation given by the Baby-Friendly Hospital Initiative (BFHI), an initiative of UNICEF to improve breastfeeding rates and increase exclusive breastfeeding duration. Only 6.7% of births in the United States currently occur in a Baby-Friendly designated hospital. There are 159 Baby-Friendly hospitals in the United States as of January 2013. You can find out if there is a Baby-Friendly hospital near you by visiting this site. A Baby-Friendly hospital will follow all of the 10 Steps to Successful Breastfeeding that evidence has shown to increase the rates and duration of successful exclusive breastfeeding. Some hospitals are working toward the Baby-Friendly designation and may follow some or all of the 10 steps even if they have not received the official title. You can ask if your chosen hospital follows any or all of these steps, as this can greatly affect your birth and postpartum experience at the hospital.

Why Might I Not Want to Give Birth in a Hospital?

There are many reasons why you personally may not want to give birth in a hospital. Reasons some women cite for not wanting to go to a hospital include fear of hospital-borne infection, fear of doctors, fear of hospitals due to previous trauma, or lack of a good hospital close to home. Some women, rather than an issue of a specific reason not to want to be in a hospital, simply want to give birth in another setting. Many women feel that hospitals are for sick people, and pregnancy and birth are not diseases that need to be treated. In a hospital, you are more likely to be offered interventions such as epidurals, Pitocin, and constant monitoring, and your risk of c-section is likely higher.

Home Birth

A home birth is just what it sounds like: giving birth at home (usually your home). Typically, you hire a midwife or team of midwives to attend you prenatally and at delivery. The midwife will advise you how to set up your home for the birth. When you are in labor, she (or they) will come to your home and monitor you as you labor, help you with techniques for pain management and positioning of the baby, and assist with the delivery. A midwife will have equipment to allow her to listen to your heartbeat and that of the baby, to check your blood pressure, to give you an IV of saline or medication if needed, and can make the call that transfer to a hospital is necessary if an emergency situation should arise.

Why Might I Choose a Home Birth?

I'll preface this by saying that home birth is not legal in every state, and many states have regulations about where your home has to be in relation to a hospital if you choose the home birth route. If you're thinking about a home birth, make sure it is an option where you live.
Although fewer than 1% of births in the United States occur at home, the number is rising quickly. Women who choose home birth give a few reasons for their decision. One is that they enjoy being in the comfort of their own home, feeling that being in a familiar environment helps them to relax and give birth in a peaceful state of mind. At home, you may feel you are more in control of your birth, able to make decisions about where in your house (bed, bathtub, special birthing tub, backyard) you feel most comfortable, what position to give birth in, and to avoid medications and interventions. Women who choose home birth also like that they can have their family around them (or not, as desired). Some like the idea of older siblings being present for the birth, for example. Also, if you give birth at home without complications, you don't have to suddenly pick up and go anywhere: you're already home!

Why Might I Not Choose a Home Birth?

There are many reasons you may not want a home birth. Many families are uncomfortable with the idea of not being in a hospital if an emergency should arise. Some are worried about the mess or feel that their home is just too small for comfort. Some desire an epidural or other medication options, which they would not have in a home birth situation. Also, if you have a high-risk pregnancy or birth, you are not a good candidate for home birth, as your risk of requiring emergency interventions is higher, and these cannot be provided at home by a midwife. Some women simply like being in the hospital, recovering on the postpartum floor, and having a couple of days to be waited on by nurses.

Birth Center

A happy medium if you're torn between a hospital birth and a home birth may be a birth center. Birth centers are typically free-standing facilities that strive for a home-like feel, employ midwives for prenatal and delivery care, and promote a non-intervention birth environment. Some birth centers are within hospitals or on hospital grounds, while others are independent.

Why Might I Choose a Birth Center?

If you are striving for a low-intervention or unmedicated birth but you don't want to or cannot give birth in your home, a birth center may be a good option for you. At a birth center, you will typically be attended by midwives who will help you manage the pain of labor, ensure the baby is in a good position, and assist with delivery. You and your baby will be monitored as needed. Many birth centers will offer the option of giving birth in a tub, in a bed, or in whatever position is comfortable for you. You generally will not stay long after your baby is born, just long enough to ensure that you both are healthy, perhaps eight hours or so after the birth, so if you don't want to be away from home for long, this may be another reason to select a birth center.

Why Might I Not Want to Give Birth in a Birth Center?

As with home birth, if you have a high-risk pregnancy, a birth center may not be able to take you on as a patient. Birth centers typically do not have emergency services such as a ready OR or a NICU. If you would like the option of epidurals and other medications, a birth center will generally not offer these, and you may want to consider a hospital instead. Also, if you want to stay longer after giving birth, a birth center will not have the facilities for you to spend several nights there like you would at a hospital.

Making Your Choice

The best way to get most of this information is word-of-mouth from friends and neighbors who have given birth in the last few years. You may also want to join an online community to get more perspectives, or attend a support group meeting such as La Leche League or ICAN where you can learn about options you may not have considered and hear from individual women about their own experiences and why they made the choices they did.

You will also probably have financial considerations when it comes to making your decision. Find out what your health insurance will cover, as you may be limited in your options of hospital and care provider. You'll want to find out what your out-of-pocket share will be. Some insurance companies will cover the services of a midwife and a birth center birth, although most will not cover a home birth - you'll need to find out if this is the case with your insurer. It is important to know that typically the fees for a home birth and the services of a midwife are considerably lower than a hospital birth with an OB, and if your out-of-pocket commitment with your insurance company is high, paying for a home birth in cash may not be much of a difference. You should also consider the importance of a healthy pregnancy and birth for yourself and your child.

Be aware that you may switch care providers and venues far into your pregnancy. If you have made a decision and are not happy with it, even if you're 30 weeks along already, it may be worth investigating other options so that you can be satisfied with your experience.

For the record, I've had three babies, all in a hospital setting. My first was with an OB in a well-respected hospital near my home. I got my referrals from neighbors and friends who had recently given birth at that hospital and were happy with their experience. I didn't know what my other options were, and the most important thing for me at the time was to be in a hospital close to home. Because I had complications and hemorrhaging with my first, and because my first was a c-section birth, my husband and I both felt that it was important that I give birth in a hospital in the future as well. With my second and third babies, I knew about the options of home birth or birthing centers, and I knew about the option of using a midwife rather than an OB. My health insurance HMO did not give me many options of care providers or birth locations, but the hospital where I gave birth to my second and third sons was excellent and had achieved Baby-Friendly status by the time my third was born. My care providers were mostly CNMs, and I appreciated their approach to pregnancy and birth. An OB delivered my second baby, and my third was delivered by a CNM. I was very pleased with both experiences.

***

More articles in this series:
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

What If We Could Have Honest Conversations about Birth with Our Care Providers?

Imagine if, at a regular prenatal appointment, your midwife or OB said to you, "Let's talk about your birth options." Imagine that she or he went on to ask you what you would like to know about giving birth, what you already know, and if you have any particular ideas or plan as for how you'd like to give birth. Imagine if, taking it a step farther, she or he then gave you information such as the following:

"If you would like to avoid a cesarean section, stay home as long as possible once you think you are in labor. The sooner you come into the hospital, the more likely your labor will be augmented with Pitocin, and the more likely you are to end up with a c-section."
"As long as your pregnancy is otherwise healthy and normal, we will not induce you without your express consent. Induction before the body and baby are ready to be born increases the chances of complications, negative outcomes, cesarean section, premature birth, and birth trauma."
"If you would like to discuss the possibility of a scheduled cesarean section, let me first tell you about the risks of doing so, both to you and to your baby. We can then discuss whether the benefits outweigh the risks."
"Unless medically indicated, we do not induce or deliver surgically any baby before, at minimum, 39 weeks' gestation."

And so on.

The point is, women are expected to do research for themselves in order to make informed decisions about childbirth. What's surprising, I suppose, is that more women don't inform themselves. (I didn't, with my first pregnancy.) If I were going in for just about any medical procedure, I would probably be scouring the internet for information about that procedure before agreeing to it. But childbirth? It's natural. The body knows what to do. The nurses and doctors know how it should go. Why do I need to research?

But it's this very problem, that many women (and their partners!) don't know that there's anything to know, that can be rectified by the care providers we trust to deliver our babies. Give us a fact sheet on various birth methods. Discuss risks and benefits. Give us strategies to cope with labor pain, to decide when to come in, to manage our labor process. Help us understand what Pitocin is and what it's for and how to refuse it if we don't think we need it. Talk about induction and scheduled c-section with us, realistically.

When I was pregnant with my second, I had a doctor tell me that babies delivered at 39 weeks via scheduled c-section, 99% of the time, don't have lung issues. She was busy trying to convince me to schedule a c-section, because I was still wavering on whether to attempt a VBAC. What she didn't bother to tell me is about all the risks associated with repeat cesarean sections, such as placenta accreta in future pregnancies, infection, "imposter babies" (those babies who appear to be full term but still aren't quite ready to face the world), etc. (See my post about c-sections for more information.) A second doctor, whom I saw later in the pregnancy, did tell me some of these things, and also told me I was a very good candidate for VBAC and that there wasn't any reason not to try. Obviously, he was right!

Let's move on to the hospital setting. Imagine showing up a little too early, say, at 3cm, and being told, "You should really just go home. It will be a while, and if you stay here, we may end up trying to speed things along, which will increase your chances of complications and possible c-section." Or, perhaps they would say, "Feel free to stick around, but it's still quite early and could be hours or even a day or more before your baby is ready to come. Would you like to speak with a member of our birth support team or a doula on duty to help you cope with these contractions without medication?" (Wouldn't it be amazing if hospitals employed staff doulas to provide labor support?!)

But what if a woman comes in and just wants her pregnancy over with, if she's swollen and in pain and past her due date and horribly uncomfortable and just can't be pregnant another day, and she has called her doctor and requested an induction? Shouldn't her doctor at least discuss the risks of induction? Shouldn't she know that her chances of complications and c-section are dramatically higher than if she waits to go into labor on her own? She shouldn't be "bullied" into waiting any more than she should be bullied into a procedure such as induction or c-section, but she should make the decision fully informed.

A woman isn't "wrong" or "bad" for choosing an elective induction or c-section. A doctor isn't "wrong" or "bad" for suggesting one, especially if a woman is really suffering in her last days of pregnancy. (And, of course, medically-indicated inductions and c-sections save lives.) My concern is that many women show up at the hospital in early labor, sure they'll be holding their baby in their arms in the next few hours, and, 18 hours later, they're under the operating room lights, scared out of their wits, undergoing an emergency c-section because the Pitocin caused fetal distress. Was she fully informed that this was a strong possibility when she decided to come into the hospital?

There's room for change, here. We can work from the bottom up, educating women one at a time about their birth options, which is, in part, what this blog is about. But we can also work from the top down. Hospitals, doctors, midwives, and other care providers throughout pregnancy can help to educate and inform their patients. Indeed, these care providers themselves may need to be more educated and informed about the latest research, evidenced-based care practices, and ways to improve maternal and neonatal mortality and morbidity. Working from all directions to improve birth outcomes - at the hospital administration level, at the care provider level, and with each individual laboring woman - will create a culture of birth that is more powerful, more open, and safer for all involved.

It's Time to Take Back Birth

The first time I was pregnant, I wish I had done more of my own research regarding childbirth.
The first time I was pregnant, I wish we had known more about labor coaching and support.
The first time I was pregnant, I wish I had known that there's more to baby's position besides "head down" or "head up."
The first time I was pregnant, I wish I had known it was okay to labor at home.
The first time I was pregnant, I wish I had known that being mobile during labor can mean the difference between vaginal birth and c-section.
The first time I was pregnant, I wish I had know more about the risks of c-section.
The first time I was pregnant, I wish I had known what I know now.

The second time I was pregnant, I decided to listen to people other than my care provider. I decided to hear what natural birth advocates were saying. I decided to find out for myself everything I could so that I would have a shot at a vaginal birth instead of a repeat c-section.

And what I've learned since then is shocking to me. Many obstetricians and Labor & Delivery nurses have never seen a birth without interventions. Many women have no idea the risks of an epidural. Many women have no idea the risks related to c-section, especially as they pertain to future pregnancies and births. And many women, and even some doctors, have no idea that inducing labor even a week or two before the due date can have lifelong consequences for baby and/or mother.

I want women to be informed. I want them to know the facts. I want doctors and midwives and other care providers to understand the difference evidence-based care can make. Women should be told all of their options at their prenatal appointments. They should be able to make a decision based on facts, statistics, and information. Their care providers should help them make these decisions based on best outcomes, risks and benefits, and the desires and goals of the parents-to-be.

That's why I'm so excited about the National Rally for Change taking place on Labor Day, September 3, 2012. Organized by ImprovingBirth.org, the Rally will bring together women, men, and children in dozens of cities all over the United States to demand evidenced-based maternity care.

Research shows that labor does not need to be rushed along with drugs, that epidurals can interfere with the natural progress of labor, that c-sections are not necessary 32% of the time (the current national c-section rate), that induction of labor is not medically indicated nearly as often as it happens, and that induction of labor leads to c-sections in well over half of cases. Research also shows that c-sections carry much higher risks than vaginal births, to both mother and baby.

C-sections, inductions, and fetal monitoring certainly have their place. Without them, we would see far more mothers and babies suffering injuries or death in childbirth. When we know the baby is in distress and we can quickly retrieve him from danger, we can give thanks for these life-saving interventions. When we know the mother may be in danger of life-threatening blood loss, stroke from toxemia, or damaging complication, the fact that we can identify risks and bring mother and baby through the birth safely is nothing short of miraculous, especially compared to the much higher mortality rates of the past. However, these types of cases are not the norm, and normal childbirth does not need to be treated like an emergency.

When we demand evidenced-based care from our maternity care providers, we are improving birth outcomes across the board. When we inform women of their choices in childbirth, we are creating a new culture of birth that moves away from fear into a place of empowerment.

When I was pregnant for the first time, I wish there had been a National Rally for Change. Thank you, ImprovingBirth.org!

To find a rally site near you, or to organize one for your city, visit ImprovingBirth.org.

Breastfeed Just Once, and Then Decide

I stumbled across a rather polarizing article on why a particular author decided even before giving birth that she wasn't going to breastfeed. I'm not going to link to it, because I found it offensive and simply argumentative, but it can be found on the Mommyish site, if you care to go hunt it down. The problem I had with her article was that all of her reasons for not wanting to breastfeed were uninformed nonsense. She clearly wrote the article just to antagonize and not to convince or even to simply state her position.

Look, I said this in my very first paragraph of my very first post here: "I don't so much care what you choose to do. I just care that you make an informed choice." And I hope that you feel my posts since then have held to that basic philosophy. So if you give birth having already decided that you just don't want to breastfeed, then you don't have to defend yourself. Simply saying, "I just don't want to" is perfectly fine.

But it got me thinking. How can you decide even before giving birth that you just don't want to? I understand if there are underlying issues, such as previous sexual abuse, body image issues, or emotional or health issues that make breastfeeding difficult or insurmountable. Those are reasons far beyond, "I just don't want to." I'm talking about perfectly healthy women who have had healthy pregnancies and healthy birth scenarios who immediately request formula to feed their babies. How do you know you just don't want to? What turns you off so much about it?

For those women, I have a proposal. Breastfeed once. Just once. As soon as the baby's born, the best place for her to be is on your chest, skin-to-skin. Why not give the baby that one dose of colostrum? Nurse for 20 minutes, an hour, just once, while they clean you and the baby up and get you ready to go to the maternity ward. After that, do what you want, but why not give it a try at least? It certainly wouldn't do any harm, and you might be surprised by how it feels. Maybe try it once more when the baby wakes up. And then switch to bottles. After all, those first few breastfeeds help you out almost as much as the baby, by helping your uterus contract, which will help prevent hemorrhage and help you regain your shape.

I'm not going to try to convince you to continue nursing. I'm not even trying to convince you to nurse that one time. I'm just asking, why not? The thing about breastfeeding is, it's almost impossible to change your mind later if you choose not to breastfeed. But you can always change your mind and stop breastfeeding once you've started. Every drop of colostrum and every drop of breastmilk your baby gets makes a difference in her health and in yours. More is better than some, but some is better than none, after all.

Feel free to ignore me. I'm not pushing anything on anyone. I'm just making a suggestion. You might ask my opinion on a car seat or where the baby should sleep or how he should be dressed for this weather. You might ask me whether I swaddled or if I used a pacifier or which pediatrician I like. You might ask me which hospital I delivered at and why. You might ask what stroller I use, whether I let my cats near the baby, and if I took any medications during pregnancy. And, you might ask my opinion on whether you should breastfeed or not. If you're dead-set against breastfeeding, then don't breastfeed. There are plenty of other decisions you have to make about your child, stretching into the long years ahead. If the idea of breastfeeding is just too overwhelming, or you don't want your breasts to belong to someone else for the next year or two, or you just generally find breastfeeding "icky," or you're afraid you'll get sexually aroused by nursing, or you're uncomfortable bearing your breasts, or you have sensitive nipples and you're afraid it'll hurt, or you think breastfeeding will make your boobs saggy, or you want to be able to hand off baby to someone else to feed, or you just don't want to, then don't breastfeed. I'm no one special, that you should listen to me more than anyone else, more than yourself. In the end, you're the mommy, and it's your baby, and you get to choose.

But, just a friendly suggestion, breastfeed once. All of your worries or fears or just not wanting to aside, one feed, one time, the first time will not change anything. If it hurts, then stop. If you get aroused (highly unlikely right after giving birth, I'd think!) and you don't like it, then stop. If you want someone else to feed the baby, then stop (or, you can pump and let someone else give the expressed milk - just a suggestion!). One breastfeed isn't going to make your boobs any saggier than pregnancy already has (although it's a myth that nursing makes your breasts saggy - it's pregnancy, gravity, and age that do that). And having just given birth, your breasts and all the rest of you are going to be bared anyway, so what difference does it make?

Breastfeed just that one time, and then decide. You can always choose not to breastfeed, any time from day one until day 730, but once you've passed the first few days without breastfeeding, it's going to be mighty difficult to choose to breastfeed.

The most important thing, though, is that you love your child, that you make the decisions that you think are best, and that those decisions are informed decisions.

Happy Breastfeeding Awareness Month!

The National Rally for Change - Improving Birth

Labor Day seems a fitting time for us to think critically about birth in this country. This Labor Day, September 3, 2012, women, men, and children will come together all around the country for ImprovingBirth.org's National Rally for Change. "The National Rally for Change is to encourage and insist that all maternal healthcare providers practice evidence-based care," to bring about a shift in the public perception of birth and the way care providers handle pregnancy and birth.

The statistics about birth in the United States show a disturbing number of unnecessary inductions and cesarean sections, unneeded interventions during the labor and delivery process, and a general fear of allowing nature to take its course. While modern medicine certainly has created an environment where it is theoretically safer than ever to give birth, the high rates of inductions and c-sections are disrupting the natural progress of pregnancy and labor and creating a culture of fear surrounding birth.

It's time to "take back birth!" When we demand evidenced-based care during pregnancy, labor, and delivery, we find that c-section and induction rates plummet and maternal and neonatal mortality and morbidity rates improve. Research is showing that our rates of cesarean section, induction, Pitocin augmentation, and other interventions during the birth process are far higher than necessary. Unnecessary or too-early inductions lead to c-section in a staggering percentage (67%) of cases, and c-sections carry a whole host of risks, such as premature birth to lifelong health problems such as asthma for the baby, and infection, infertility, and complications in future pregnancies for the mother.

It's not that c-section, induction, and other interventions don't have their place. Indeed, they are life-saving procedures when used properly. That's where the idea of "evidence-based care" comes in. Use interventions when necessary, based on solid medical research, not just because that's how it's done. 

The National Rally for Change and ImprovingBirth.org want women to be informed about their choices surrounding childbirth. Just as you are entitled to informed consent when it comes to any medical procedure, women have the right to make an informed choice about how they want to handle their births. We have a right not to be bullied by doctors and nurses into unnecessary inductions and c-sections. We have a right to labor in our own time and not on a hospital timetable. We have a right to know when procedures are necessary and when they are for the convenience or protection of the care provider. We have a right to know what a normal birth looks like, and we have a right to choose a normal birth. We have a right to give birth in a birth center or at home or in a hospital, with a midwife or a doctor, in the water or in a bed. We have a right to be mobile during labor, to eat and drink when we are hungry or thirsty, and to give birth in whatever position is most comfortable. We also have a right to choose a scheduled c-section or induction, to have an epidural administered, or to receive other pain relief via IV, as long as we make those choices knowing the risks and benefits. 

What is Evidenced-Based Materinty Care? "'Evidence-based maternity care' means that the care that is provided has been proven by reliable research to be beneficial to mothers and babies, reducing the incidences of complications, injury and death."

We need to raise awareness of the state of maternity care in this country and call for change. Please check out ImprovingBirth.org for information about rally sites in your area, how to become a rally coordinator in your city, and to find out other ways you can help. 

We hope to see you at The National Rally for Change, September 3, 2012!

Like Improving Birth on Facebook.

About Those Formula Freebies and Mayor Bloomberg...

By now, just about every breastfeeding blog I read has made some kind of commentary or another on New York City Mayor Bloomberg's new program for breastfeeding promotion in NYC hospitals. Part of the Latch-On NYC initiative, this voluntary program requires that participating hospitals lock up formula, not routinely give out formula samples and formula-branded paraphernalia to new parents, prohibit the display of formula promotional materials in the hospital, and conform to the New York State hospital regulation that exclusively breastfed babies not be given formula supplementation unless medically indicated. The program is expected to raise breastfeeding rates in participating hospitals because research shows that women who are given formula samples by their doctors or in the hospital are 3.5 times more likely to be supplementing with formula by two weeks of age. If formula is kept under wraps, and new mothers receive education about breastfeeding before their babies are given any formula, the thinking goes, breastfeeding rates will rise and the overall health of the population will improve. Hand-in-hand with this is news of an AAP resolution that pediatricians should not routinely hand out free formula samples to patients, for the same reasons.

I have been reading every blog post I've been linked to, taking in almost every comment on all the major breastfeeding and parenting blogs I frequent, and I still don't quite know how I feel about this initiative. It sounds like they're basically trying to get NYC hospitals to conform to the Baby Friendly Hospital Initiative standards without going through the BFHI certification process. I gave birth to GI in a Baby-Friendly hospital, and I felt that the breastfeeding support there was excellent. Of course, I went in intending to breastfeed. If I had gone in less certain, uneducated, or sure I wanted to use formula, I'm not sure how I would have felt. I didn't need or want to ask for formula, so I don't know what kind of "lecture" or "education" I would have gotten had I made the request. I didn't have any problem nursing or producing milk, so I don't know how I would have been treated had I genuinely felt my baby was starving and needed formula supplementation. Because I've been lucky enough to be able to nurse with relatively few problems, and because I'm extremely pro-breastfeeding, well educated about breastfeeding (I literally wrote a book on it), and because I wasn't going to let anything or anyone stand in my way of breastfeeding, I didn't need to think about "the other side."

I often wonder whether I would have been able to breastfeed NJ had I given birth to him in a hospital like the one where I had SB and GI. Rather than jumping straight to formula when there was the slightest hint of a problem, if they had been more supportive of breastfeeding and, more importantly, had been more supportive specifically of me in my situation, would I have left the hospital breastfeeding instead of with an extra case of formula? It's very hard to say. My husband and I were discussing this last night (in the context of the above-mentioned controversy). His perspective and memories of those early days are different from mine, but we both remember that the lactation consultants who visited me were quite unhelpful. While it may have been true that many women who experience postpartum hemorrhage have difficulty with their milk supply, and while it may have been true that pumping often would help bring in my milk, what I really needed was to spend lots of time skin-to-skin with NJ, nurse him on demand, and be forced to care for him. Yes, I was weak. Yes, I had lost a lot of blood. Yes, I was in pain. But NJ was healthy and strong, had a great latch, and, with a little help, I probably could have initiated breastfeeding while in the hospital and breastfed him several times a day during that four-day stay rather than allowing the nursery nurses, my husband, my mom, and my visitors to feed him for me. It's probable that he would have needed a few bottles (or to be fed via syringe, perhaps?) on the first day when I was fairly down-and-out from blood loss, but on the second day? The third? Through the night? I do remember some good practices, such as telling me to save whatever I did pump and that they could give him that in a bottle instead of formula. They did provide me with a pump and show me how to use it. They did have lactation consultants come every day. But I constantly feel, looking back, that the advice the LCs gave me was, while not necessarily wrong, unhelpful or misleading. If you straight out tell a woman she won't have enough milk, why should she even bother to try? And if you don't tell her or her husband that formula is not, in fact, equal to breastmilk, then why shouldn't she just go straight to formula to begin with?

What's missing in all of this, to me, is that education prenatally is vitally important. The decision to breastfeed can't necessarily be made in the postpartum haze. The desire to stick with it is lowest when in the throes of newborn nursing, and the temptation to use that free formula is highest at the most critical period in the breastfeeding relationship. I know this. I've lived it. You need to walk into that hospital determined to breastfeed. You need a supportive hospital staff, from the OB or midwife to the delivery nurse to the postpartum nurses. You need lactation consultants on hand 24/7 (not just during business hours!). You need good, solid breastfeeding information. And you need to know that you are going to be respected for whatever choices you make.

The loudest complaints against this program seem to be from two basic viewpoints. One is the women who never wanted to breastfeed and don't liked feeling "shamed" or "guilted" by the hospital for their choice. The other is the women who desperately wanted to breastfeed but, for whatever reason, needed to supplement with formula in the early days and struggled long and hard with the decision. Both feel that formula samples are helpful, especially those that only needed a can or two of supplements before being able to go on to exclusively breastfeed. Both feel that being lectured or educated by hospital staff before someone will go get them a bottle for their starving babies is shaming and unfair.

The thing is, I agree with them, too. If my baby is starving because I can't produce enough colostrum or milk to satisfy him (please note that this is rare), then I need to be able to give him something else. If the hospital staff balk at giving me a bottle of formula to feed him, and I have to sign a form or justify my request every time my baby gets hungry, it's going to make me feel even worse and more inadequate. Support doesn't mean just patting a woman on the back and telling her she's doing a good job breastfeeding. Support means sitting down with a woman and figuring out what she wants, what her goals are, and then helping her get there. A good IBCLC knows this, and a good IBCLC will know when formula supplementation is necessary and how best to introduce, use, and wean off of those supplements, if possible. Having a nurse who's had a little bit of lactation training come in and tell you once again that formula isn't as good as breastmilk, and maybe you should have another go at feeding from the breast before you give a bottle, is only going to make a frustrated mother more flustered and upset. We need a balance.

I'm in favor of locking up the formula, but I'm also in favor of giving it to any mother who asks for it. I'm in favor of banning the gift bags and the formula-branded handouts, but I'm also in favor of giving unbranded formula to mothers who need it (in the hospital). I'm in favor of good breastfeeding support and information, but I'm also in favor of education in the proper preparation and use of formula, if a mother chooses to use it. I'm in favor of pediatricians having formula samples on hand to help out mothers who need it, but I'm also in favor of pediatric offices having lactation consultants on staff to help mothers who are struggling. Balance.

We need a more comprehensive solution. While restricting access to free formula will increase breastfeeding rates among those who are on the fence (that's been proven), it will not help those women who truly need it or who adamantly refuse to breastfeed. We need information and education throughout women's lives, and especially during pregnancy, to help them learn about breastfeeding before there's a squalling baby in their arms. We need postpartum support, especially for those women who are going back to work. We need support for pumping in the workplace. We need better, longer maternity leave. We need a cultural shift.

If there is one thing I know, unquestionably, it's that the more babies who are breastfed, the better. Banning formula freebies in hospitals and pediatric offices is a step in the right direction, but it's not the only step.

"Curing" Birth

I'm a huge fan of modern medicine. I'm grateful every day for antibiotics, life-saving surgeries, well-trained emergency room staff, ICU's, NICU's, and PICU's. I find it miraculous that conditions which used to kill us are now easily treated, cured, or managed by medications, surgeries, or simple monitoring and lifestyle changes. Where an illness like strep throat once might have been fatal or cause life-altering disabilities such as deafness and heart disease, now it requires a simple trip to the doctor, a throat culture, and antibiotics to knock it right out and get on with our lives. Appendicitis used to be 100% fatal, and now it can be taken care of with a simple laparoscopic surgery. We can fix or replace teeth so they look better than new. We can repair complicated broken bones with surgically placed pins and help them heal with custom-made splints. We can give people new hearts and lungs and livers and kidneys. We can remove brain tumors with an outpatient procedure using a gamma knife, with no need to even cut through the skull. Modern medicine is a great blessing that has lead to better quality of life, decades-longer life expectancy, and a healthier population.

The problem is that modern medicine is so good at finding and fixing problems that sometimes it seems we're actively looking for things to fix that may not actually need fixing. Or, we go way overboard trying to improve a situation that can be managed with less intervention. For example, often high blood pressure or diabetes can be managed by lifestyle and diet changes, without the need for medications, but we automatically jump to the "quick fix" of medications that may have unknown or unexpected side effects.

Nowhere is this phenomenon more obvious than in pregnancy, labor, and birth. Until about 100 years ago, birth did not take place in hospitals, attended by doctors, hooked up to monitors, using medications. Birth was the territory of women, specially trained midwives, with experienced mothers and grandmothers for support. Indeed, even today, in many other countries, obstetricians only come into the picture if there is a complication or emergency situation where the mother and/or baby need advanced care, made possible by modern medicine.

Statistically, the ability of a woman to safely have a vaginal birth is quite high, possibly over 90%. According to research, the optimal c-section rate (i.e., the total percentage of women who give birth via c-section) should be between 5% and 10% of all births. That is to say that in potentially 90% or more of cases, a woman will not need surgery to help her deliver her baby. Right now, in the United States, the c-section rate is around 32%, meaning that almost one in three women gives birth via c-section. Obviously, there is some disconnect between the optimal and the actual, and the question is, why? It is thought that the high rate of medical interventions during birth, including continuous fetal monitoring, epidurals, and Pitocin, do contribute to the high c-section rate. The bottom line is, in most births, a laboring woman given the proper support will eventually have her baby vaginally using nature's time-tested, age-old methods of contractions to open up the cervix and coax the baby down and pushing to encourage the baby through the birth canal and out into the open. It's primal. It's painful. It's hard work (hey, they don't call it "labor" for nothing!). It involves a lot of bodily fluids and parts of our bodies we don't normally have out in the open. But it's basic. It's biological. And it's a system that has worked to propagate the human race for a very, very long time. I mean, there are, like, seven billion of us. Obviously, we're doing something right.

I'm not saying, by the way, that emergencies don't happen. I'm not saying that interventions, drugs, and surgeries are never necessary. I'm not saying that modern medicine and obstetrical practices haven't saved numerous lives, both mothers' and babies'. I'm not saying that hospitals and doctors don't have a place in the labor and birth process. There's a reason that hospital birth is the norm in the United States and many other Western countries. We feel safe there. We know that if there is, G-d forbid, some kind of emergency, we're right there in a place that can tend to us. I know plenty of stories that end with, "If I hadn't given birth in a hospital, my baby would be dead," or, "If I hadn't been in the hospital already, I would have been infertile after my first birth," or, "Without the c-section, both me and my baby would have died." These stories are true, absolutely. Plenty of mothers and babies died in childbirth in years past from issues that we can now either prevent, treat, or handle because of modern medicine.

The trouble is that because we can make birth "easier" on women, sometimes it seems like we ought to. Obviously, if we have the choice between pain relief and pain in any kind of medical procedure, we typically opt for pain relief. I wouldn't want an appendectomy or tooth extraction without anesthetic! So if we know how to "take away" the pain of childbirth, it makes sense that we would want to. Pain is not typically seen as a good thing, and if we can make it go away, we'd like to do that. I'd rather take an Advil than suffer a headache; I don't know about you.

But birth is different. The pain of childbirth is not a "bad" pain. The pain doesn't mean something is wrong. The process of labor and delivery is part and parcel of bringing a healthy baby into this world. By jumping ahead and providing interventions that may or may not be necessary before finding out if those interventions might be causing problems, we have produced generations of people who were not born "naturally." It's only in the past few years that doctors and researchers are positively identifying real problems that are directly related to interventions during childbirth.

One of the biggest culprits is induction and/or c-section before 39 weeks, which has led to many, many beds in the NICU being taken by "late-term preemies," those born between 37 and 39 weeks, who were not quite ready to be born. Many of these inductions and c-sections were not done for medically indicated reasons but rather for convenience or because the mother was uncomfortable. Hospitals that have started banning non-medically-indicated inductions before 39 weeks are seeing a significant reduction in NICU admits, leaving those beds and resources available for babies who truly did need to come into the world before they were fully developed, in order to save their lives or the lives of their mothers. The use of Pitocin to start and/or "augment" labor is very common, and most women are not told about the risks both to herself and her baby that Pitocin may cause. The use of Pitocin is associated with fetal distress, postpartum hemorrhage, newborn jaundice, and possibly even neonatal brain damage. New studies show that at least half of induced labors lead to delivery by c-section - if the baby is not ready to be born, there is a high chance that induction simply won't work and a c-section will be the only way to get the baby out. Even when labor has started on its own, Pitocin is often used to "speed up" or "augment" the labor, and the risks of the use of Pitocin still apply in these cases.

The fewer interventions and less interference a woman has during labor, the more likely she is to give birth safely and vaginally. And, concurrently, researchers are finding that babies born vaginally tend to suffer fewer neonatal complications and lifelong health problems, such as asthma. Vaginal birth is safer than c-section, and spontaneous labor is more desirable than artificially-induced labor.

The root of the problem is that pregnancy and childbirth are viewed by the modern medical establishment as diseases that need to be treated or injuries that need to be fixed, rather than natural, biological processes that can continue on their own without interference. As more women advocate for their births to be supported rather than treated, the outcome is becoming more positive and healthier for mother and baby.

I'm not advising any woman on how and where she "should" give birth. This post isn't about what choices we as women should be making. Rather, it's about looking at how modern medicine sees birth and to address the changing tides of medical opinion toward better, safer births for all women. We as women need to know our options so that we can have useful, intelligent discussions with our care providers about how, when, and where we want to give birth, and, in return, our care providers need to be sensitive to the changing attitudes toward birth, back to letting nature take its course rather than trying to "improve" upon a system that works better without interference.

Just as we don't try to make our kids grow faster by administering human growth hormone willy nilly, just as we don't try to force our kids to walk before they're ready, or make their teeth start to fall out before the permanent teeth start coming in, just as we only turn to surgery for weight loss as a last resort after trying lifestyle changes, we can look at pregnancy and birth as normal processes that we need to wait out, rather than medical conditions that we need to treat.

Breastfeeding Is Not Always Easy, But Neither Is Raising A Child

Breastfeeding is not always easy.

There, I said it.

Breastfeeding is not always easy.

But it's also not always hard.

And bottle-feeding isn't always easy, either.

See, that's the thing. Caring for a baby is not easy. It's not always hard, but it's not easy, either.

In the beginning, breastfeeding takes effort. For some women, it takes a lot of effort. For others, it comes with only a shallow learning curve.

I don't think most people need to be convinced, nowadays, of breastfeeding's health benefits to both baby and mother, that breastfeeding is more natural, that breast milk contains all sorts of incredible ingredients unmatched by any commercial formula. We know this. And yet, because we have a choice, we still feel there's a choice to be made.

That's fair. We make a lot of choices when it comes to baby care. Start solids at 4 months or 6 months or when the baby shows interest? Commercial baby purees or homemade baby purees or table foods? Cloth diapers or disposable diapers or elimination communication? To swaddle or not to swaddle? Which car seat to buy? Which stroller? Should we baby-wear? What carrier or carriers should we use? To vaccinate on the CDC schedule or delay vaccinations or not to vaccinate at all? To send to daycare or stay home with a parent or hire a nanny or a part-time baby-sitter?

When we have choices, we feel we need to make choices. And the existence of formula means we do have a choice when it comes to how we feed our babies. Thank G-d for that. Thank G-d that babies whose mothers are unable to feed them due to a medical condition, absence, or tragedy have an alternative. Thank G-d that mothers who are suffering from a medical or emotional condition that is incompatible with breastfeeding can still feed their own babies. Thank G-d that working mothers who are unable to pump enough to meet their babies' needs have a backup.

But why is it that so many women want to make the choice about infant feeding based on which one is easier? Because, let's face it, the easiest thing would be to let someone else care for the baby entirely! Come and visit when she's happy and content, and as soon as she starts crying or needs something, hand her off. Wouldn't that be great?!

No.

Of course not.

When we have a baby, we take on the responsibility of caring for her. We expect to have difficult times, but we also expect to cherish the good times. We are filled with love. Every smile melts our hearts. Every cry hurts. Becoming a parent means taking the hard times with the easy, making difficult decisions, caring. And it's not like they're babies forever, when feeding and diapering are our biggest concerns. What about when your 12-year-old tells you that his friend is thinking about suicide, or your eight-year-old expresses concern about her weight? What about when your 16-year-old comes home drunk from a party or your six-year-old asks where babies come from? Things really don't get easier. I heard it put very succinctly, once: "Bigger kids, bigger problems."

We may as well get used to the idea right away that raising kids is not easy. Being a parent is not easy. We will always have difficult decisions to make. Sometimes, we will be confronted with two options, neither of which is easy, and sometimes we will get to choose between two easy actions. Sometimes the right choice is obvious and easy. Sometimes it's obvious and difficult. Sometimes it's neither obvious nor easy. Sometimes there is no "right" choice. Sometimes there is no "easy" choice. And, yes, sometimes there is no choice.


So when it comes to breast milk versus formula, breastfeeding versus bottlefeeding, does it matter which is easier? Is that the only determining factor? It's easier, so that makes it the right choice?

I don't know. Maybe for some parents, that is the major deciding factor. But I hope that when it comes to raising a child, we don't always go with whether something's easier, but rather what's the best thing we can do given our situation.

Your Birth, Your Choice

The birth of a child is a dramatic, life-changing event. I'm not just talking about the impact a new baby has on your life, but how the birth itself affects you. I think often a new mother's feelings about the birth itself are overlooked or minimized. A woman may be reluctant to admit that she was in any way emotionally harmed by the method in which her child came into the world or by the circumstances surrounding the birth. It's as if  coming out and saying that she is dissatisfied, angry, depressed, regretful, or unhappy about any aspect of her baby's birth is tantamount to saying she is not happy to be a mother, or not happy to have a new baby.

This isn't fair, and it isn't true. It does women a great disservice to tell them that their feelings don't matter. If such feelings must be buried, ignored, or hidden then they can't be dealt with. Not only that, but these feelings must be aired so that they can be separated from the feelings about the child. You can absolutely unconditionally love your child but not love the way he was born. You can be over-the-moon happy about motherhood but still be angry about not having the birth you expected or wanted.

Pregnancy and birth change a woman. There are, of course, the obvious physical changes. There are the crazy hormones. And there are actual changes in the brain that prepare a woman to care for, love, nurture, and protect her offspring. Pregnancy and birth change your body and your soul. Those changes may carry emotional consequences, some positive, but some also negative. It's no secret that some women are very uncomfortable in their postpartum bodies, that we spend years after giving birth hoping to return to our "prepregnancy size." For many of us, that simply never happens. Our post-pregnancy bodies have stretched and expanded in ways that cannot be undone through any amount of diet and exercise. This is especially true if there was any surgical involvement in the birth!

While postpartum diets, our "prepregnancy" wardrobe, our flabby tummies and floppy breasts, our widened hips and bigger feet are common topics of discussion among new mothers, the emotions we have attached to giving birth are less often brought to light. The result of this lack is that we are hesitant to bring up issues like "birth options," "alternatives," "unnecessary interventions," and so forth, especially after the fact. We feel we are stuck with what we get, unable to discuss our reactions to the unexpected c-section or the emergency induction we didn't want, because, "at least you have a healthy baby!"

Not everyone is affected by birth in the same way, of course. For some women, birth is a major spiritual event, connecting her back through the generations to all the women who came before, empowering her, grounded in thousands (millions?) of years of evolution and nature, filling her with all the magic of womanhood. For others, birth is simply the vehicle by which the baby goes from inside to outside, without any particular emphasis on spirituality or life-giving. Some don't know how they will feel until they've done it. Others have built up a great deal of expectation about what giving birth will be like.

All of these women have a right to be heard, and all of these women have valid feelings. There is no "right" way to feel about birth.

I have a friend who has two kids. Her older child was born via emergency c-section after a long, hard labor. When she was ready to give birth to her second, she decided on a scheduled repeat c-section. Describing this, she says there's no better way to give birth. You show up, get on the table, and an hour later, you have a baby! No labor, no pushing, no work. She usually punctuates her description by rubbing her hands together like brushing off dirt, as if to say, "All done! Quick and clean."

On the other hand, I have a friend who has one child, born via emergency c-section after a long, hard labor. I still haven't heard her entire birth story, because the experience caused her so much emotional trauma that she has trouble talking about it. She is healing, and she is more open about both what happened the first time and what she'd like the next time around than she was even a few months ago. She most definitely does not want a scheduled repeat c-section!

Then there's me. I had no idea that five years later, I would still be so affected by my first son's birth that I would be writing a blog about it! I, too, had a c-section (although not classified as "emergency") after a long, hard labor. For many months, I assumed future children would be born by c-section as well, not because I wanted it to be that way but because I thought I had no choice. I thought my uterus had been permanently damaged and that labor would put undue stress on my imperfect organ and cause me and my baby harm. It was only when I began to learn about VBAC, and that I might actually be a viable candidate for a vaginal birth in the future, that I began to process my feelings about the c-section and understand why I so badly wanted a vaginal birth.

At first, it was simply that my recovery from the c-section was very hard, and I saw friends who had had vaginal births having much easier and faster recoveries. That seemed to be the way to go. (That's what convinced my husband!) Then I started to learn about the risks of c-section and the benefits to both mother and baby of a vaginal birth. My attitude was still very clinical, but I was starting to acknowledge that there was an emotional aspect to my desire as well. But it wasn't until my second son was born vaginally that I fully recognized the power of getting the birth you want. As that baby slid easily out of my birth canal and was put on my chest, an incredible flood of joy and relief surged through me. This was my birth. I had done it. I was in control.

In a c-section, you have to give up control of the process and place your and your baby's bodies in the hands of others. In a natural birth, you are in control. You do the work. For me, that was very important, because I was able to put my trust in my own body instead of others' hands. I was able to get over the idea that my body was somehow imperfect. I could deliver a healthy baby on my own. I didn't need surgery to get him out. I am a mother. I am meant to be one. The revelation of motherhood didn't come with the first birth. It came with the second. (That's not to say I wasn't a mother to my first child before his brother was born, or that I don't love him and nurture him and care for him and protect him! It's just that I didn't feel like a mother, truly like a mother, until my second was born.)

When the time came to have my third baby, I knew without a doubt that I wanted a VBAC, and I was fairly certain I wanted to have the baby without any interventions, if I could. That is, I wanted no Pitocin and no epidural. I wanted to be in total control. I wanted to be able to ask for what I needed and refuse what I didn't need. And it turned out that the circumstances of his birth allowed me to have total control. I had no complications, and he was a full-term, healthy baby. I went into labor spontaneously and was able to fully dilate and push the baby out with no medication, although an episiotomy was helpful at the end. (This is in contrast to my second son's birth, for which I required an induction two weeks early due to pregnancy-induced hypertension. The intensity of the contractions caused by the Pitocin made it impossible for me not to have an epidural, although I was able to have the baby vaginally.)

Interestingly, despite having all of the power in this third birth, I didn't feel as powerful a sense of accomplishment as I had when my second was born. Partly, I felt I wasn't as strong as I could have been, because though I did end up having him without an epidural or other pain relief, I had broken down and asked for it repeatedly. My husband tells me over and over again that I'm being silly, that I was amazing and strong, but I think maybe I expected to feel more empowered, and instead I felt weaker than I wanted to be. I'm not at all disappointed. In fact, I'm thrilled to have been able to give birth in this manner, and my baby is as much a joy as anyone would expect. But, I think it's important to speak of feelings like these, just as it's necessary to express the anger, frustration, disappointment, or trauma of a birth that didn't go as hoped.

I bring up my third birth experience in order to make my final point. Going into this third pregnancy, labor, and delivery, I felt that I finally was fully informed. I knew what my choices were. I knew the possible consequences of any given option. I knew that sometimes an induction or c-section is unavoidable or absolutely necessary. And I felt that I would be able to make peace with however this birth happened, whether I got the natural birth I was planning or if I (G-d forbid) ended up needing an emergency c-section for whatever reason. I knew how to avoid unnecessary interventions that might lead to what would otherwise have been an unnecessary c-section. I knew what I didn't want (which I think was more important than knowing what I wanted). I'm sure that if the birth hadn't gone as "planned" (although I use that term loosely), I would have had some emotional consequences, especially if it ended up being traumatic as well as undesirable. But at least I would have known that I'd made all the "right" choices, that I'd known going in what my choices were and how various scenarios might pan out.

Thus, in conjunction with giving women the space to discuss birth trauma, to express any "negative" feelings that might be associated with their given birth scenarios, it is also important to discuss birth options. It is important to go into birth knowing what possible outcomes there are, depending on what choices are made. It is vital to understand when something is necessary and when it isn't. That's not to discount those times when we simply don't know what the right thing to do is, and we simply have to make a choice based on incomplete information, of course. But going in knowing that A may cause B, or that C is a direct result of A can help guide our decisions throughout the birthing process, and going in armed with information can at least alleviate the pain of thinking you've done something wrong if events don't play out as expected.

Five years after my own traumatic birth experience, I looked into the bathroom mirror and examined my recent postpartum belly. Under the little "shelf" of belly fat left over from being sewn up from the c-section is my external scar. I noticed, that day, that the scar was quite faded. It was no longer an angry red or purple. It no longer stands out brightly against my pale skin. It's there, but it's become a part of the landscape of my body. It no longer angers me. And I realized that along with the fading of the external scar came the fading of the internal ones, the emotional scars that I'd been left with because I thought I had made a series of bad choices that had led me to end up in a place I didn't want to be. Over the years, I have played out those couple of days of labor and delivery, trying to figure out "what went wrong." I shouldn't have gone to the hospital so soon. I should have walked around more. I shouldn't have gotten the epidural so early. I shouldn't have let them give me Pitocin. I should have been mobile so I could have pushed in a different position. It's easy to go over and over all the "bad" choices I made. For a while, I thought I might write out the "timeline" of the birth and go through and pinpoint each moment where I was led farther down the path to a c-section. But now, as I learn even more about the birth process, I have come to feel that a c-section may ultimately have been necessary no matter what choices I made to begin with. You see, the anger and guilt I felt didn't come from the fact that I had a c-section. It came from the impression that it was my fault I'd had a c-section. That I'd made the wrong choice when presented with an option. I no longer feel that way. I know I didn't have all the information going in. I now know that I couldn't have made good decisions based on what I knew at the time. And beyond that, now that I understand better how a normal birth should progress, I can see that it's entirely possible that my son was simply stuck, that there was no way he would ever have come through the birth canal no matter what I did, or that if I had tried to get him out that way, he or I might have been injured in the process. If that is the case, which I am more and more willing to believe, then thank G-d for the c-section, because I got a healthy baby and a healthy mom out of that decision.

My friend who had the scheduled c-section was describing the difference between the major surgery of a c-section and the major surgery of having her thyroid out. You see, "You get the door prize!" after the c-section. You get to take home your baby. Having your thyroid out isn't nearly as rewarding.

In the end, then, only you know how you feel about birth in general, about your birth experience(s), and about what you want to get out of having a baby. It's not anyone else's job to tell you how you "should" feel, or what choices you "should" make. I do believe, very strongly, that you need to know your options, you need to know the possible outcomes, you need to understand the process before you can make an informed choice. Because when you've made an informed choice, at least you aren't left with the "what ifs." I think it's the "what ifs" that are the most difficult to heal from.