This article makes me sad. Prenatal care can be very inconsistent, especially for unplanned or unrecognized pregnancies, even for women who have insurance. As a childbirth educator, I tell my clients to switch prenatal providers to find a practice with statistics indicating they practice evidence-based medicine (for instance, a total Cesarean rate of less than 10-15%) and that uses expe ctant management during labor. Switching providers, using more than one prenatal provider, or seeing both a midwife/OB and a general practitioner can add to this problem.

If you are pregnant, please talk to your current prenatal provider about ALL the medications you take for any reason. Even over-the-counter medications may have known negative effects on your fetus.

• nutrition, diet and weight gain
• exercise guidelines
• smoking cessation
• testing and screenings during pregnancy
• sexuality during pregnancy
• domestic violence during pregnancy
• relaxation techniques for everyday use
• making lifestyle changes
• bonding with the baby during pregnancy
• normal physical and emotional changes during pregnancy
• changing identity: moving from “I’m pregnant” to “I’m going to give birth” to “I’m going to be a parent”
• consumer options: choosing a birth setting, finding a care provider
• overview of childbirth class and encouragement to take one
• basic breastfeeding preparation
• preparing for baby: car seat, bed safety, basic layette
• resources for new parents

Any other ideas about what it might cover?

I am also thinking about trying to find clients who have health insurance that covers childbirth education classes, but who might not normally take a class – low-income women covered by Medicaid, for instance.  Any thoughts on how to advertise or where to teach?

I’m not great at this computer stuff, so changing the domain names around was a real headache!  Now that it’s all worked out, I am hoping I will feel inspired to blog more often, especially short, “burst” posts to represent what I am thinking about.  I am also going to focus more on tagging my posts rather than categorizing them, which takes less time.

Tonight I am thinking about one of those crazy experiences that only parents get to have: my baby girl threw up her entire afternoon’s stomach contents all over me, her, and the bed.  She managed to drench us both and hit every single piece of the bedclothes, not missing one pillowcase.  It was truly amazing.  Afterward, she was much happier.  Go figure.

The Lamaze certification examination is this coming Friday, and I am taking it.  Wish me luck!

http://icareaboutbirth.com

Please visit my website as well, and feel free to contact me with any questions or comments!

Sara

1. Babies are hardwired to breastfeed
2. Mother’s body is baby’s natural habitat
3. Better feel and flow happen in the comfort zone
4. More breastfeeding at first means more milk later
5. Every breastfeeding couple has its own rhythm
6. More milk out equals more milk made
7. Children wean naturally

It turns out that there was lots for me to learn about each law!  In the first chapter (the first seven chapters correspond with the seven laws), I learned why breastfeeding is a learned skill for mothers.  Women’s bodies respond to our babies, but wanting to breastfeed and being able to do so easily, effectively, and without pain are not the same.  Women have to learn positioning, latch techniques, and what is normal from other women and in some cases from medical professionals.

The second chapter was probably the biggest eye-opener for me.  I have listened to my heart and intuition when parenting my baby, and in my case that means I have held her in my arms for most of her waking hours since birth.  We also sleep in the same bed, and I put her to the breast whenever she gives me feeding cues.  This has been a very demanding lifestyle, and I often felt like my baby was “high-needs” since she would cry unless she was in physical contact with me.  Now I understand that the mother’s body truly is a baby’s natural habitat, helping the baby regulate heartbeat, body temperature, stress hormones, and breathing, and even changing baby’s sleep patterns.

The chapter on good latch-on in the comfort zone had excellent pictures, a cut above what I have found in other resources.  It’s full of great information for first-time nursing mothers or mothers who want to understand latch better.  Similarly, the chapters on the first week of breastfeeding (chapter 4) and on how your baby sets your milk supply (chapter 5) held new information for me: I didn’t know that in order to establish an adequate milk supply, frequent nursing in the first week of birth is a must, and that exclusive breastfeeding for the first 40 days (about 6 weeks) means that a mother is best prepared to meet her long-term nursing goals.  In the section on understanding baby’s feeding cues, the authors point out that early feeding cues include rooting, putting hand to mouth, and fussing, while crying is a late feeding cue and should be avoided.  I heard the old adage that crying is good for a baby’s lungs, but the authors write that research shows crying raises stress hormones in babies and parents.  They go on to say:

“The most important emotional lesson of a baby’s first year is learning to trust that his needs will be met.  And there is no more fundamental need than being fed when hungry.” (p. 73)

The section on creating a feeding rhythm rather than a “scientific” feeding schedule was fascinating.  Looking at the spectrum of mammalian milk composition, maturity of the newborn, and types of care, humans fall all the way on one side of the spectrum – that of a very dependent infant.  Because humans have large brains but small pelvises, humans must be born before they are completely done gestating (for instance, humans have much more brain growth after birth than other mammals).  This leads directly to the concept of the “4th trimester” occurring outside the womb, but still in constant contact with mom, being carried, and still using her body completely for sustenance, feeding often.  The interruption of this basic biological norm increases stress and health problems for the baby and mother, and slows development for the baby.  Parenting styles that allow the mother the time to care for her child as much as possible ease the transition from womb to world for baby and the postpartum period for mom.  The authors emphasize that breastfeeding meets more than one need:

“Whether a baby wants to breastfeed for thirst (taking only the thin, watery foremilk), hunger (breastfeeding long enough to get to the fatty milk), comfort (to ease feelings of fear or loneliness), or closeness (because he loves you!) is immaterial.  Any and all of these needs are legitimately met at the breast and have been for as long as humans have breastfed.” (p. 136)

For the breastfeeding mother, multiple needs are being met as well.  Feeding the baby, comforting him, and experiencing closeness are parental needs satisfied by the breastfeeding relationship as well.

I could list everything I learned about breast storage capacity, weaning, and commercial pressures on breastfeeding, but instead I recommend that you run out and buy a personal copy of this book.  It would also make a great shower gift, even for a woman who does not have plans to breastfeed, and especially for a woman who isn’t sure if she wants to.

The only criticism I have of the book is that the information is not organized in an intuitive way for those who, after reading the whole book, are looking through it to find something specific.  There are both titles and laws for each chapter, somewhat confusingly.  Each chapter also has subheadings, sub-sub-headings, and sub-sub-sub headings, but only the first-and least descriptive-level is listed in the index.  Much of the information could logically go in more than one place.  The book is an excellent resource, but definitely not a pocket handbook.

This book made me feel energized about nursing and more confident in my choice to breastfeed, my breastfeeding goals, the style and rhythm I have found with my baby, and my parenting through the wonderful relationship of trust that breastfeeding engenders.

I couldn’t find any statistics about what percent of births are to women who identify as LGBTQ, who are acting as a surrogate for a gay couple, or who are in a polygamous relationship.  I’m not even sure that birth certificates are designed to record information about FtM transsexual/transgender people who give birth.  My point is, queer pregnancy and birth are out there, challenging traditional ideas of what it means to be childbearing and birthing.

There is a culture of “women-only” that runs rampant in spaces for pregnant women.  You won’t find many men at La Leche League meetings, and much of the talk about midwifery and doulas is about how valuable women find the support of other women.  This is true for some, even most, but it does exclude those who do not identify as female, or who identify as female but not with the idea that women-only spaces are natural or more nurturing.  It also excludes men from the process and experience of pregnancy, as much as they can experience of it.

Women-only spaces for pregnant women assume heterosexuality is normative.  Wikipedia describes heteronormativity as follows:

Heteronormativity is a term describing the marginalization of non-heterosexual lifestyles and the view that heterosexuality is the normal sexual orientation. Instances of this include the idea that people fall into two distinct and complementary categories (male and female), that sexual and marital relations are normal only when between people of different sexes, and that each sex has certain natural roles in life.

The assumption that pregnant women must be in relationship with a man (presumably the man that got her pregant) leads to conversation in women-only spaces about each woman’s male partner.  Women and bio-women who do not conform to this assumed norm may be silenced because the conversation leaves no room for their experience or, if they choose to speak, may face criticism, pity, or be shunned.

We need to create more space for non-heteronormative talking, thinking, and being about pregnancy and birth.  No person should have to go through this experience alone.  No person should have to go through the challenging experience of pregnancy while trying to reinvent the social wheel.  While there certainly are many birth stories about women who identify with “woman power” and feel a connection to all the birthing mothers in their ancestry and around the world, there are also people who need different sources of power and inspiration in order to birth well.

Let us tell the stories that resonate with and give power to each pregnant person, that celebrate and normalize queer pregnancy and birth, and that allow the pressure to be a “real” woman to fall away.

When a healthcare provider tells a laboring woman that she needs labor augmentation to help things along, or offers pain-relieving drugs without offering other non-drug coping methods, or that her baby is in distress and needs a forceps delivery or emergency cesarean section, few women are in a mindset to argue the point.  Relaxation and trust are actually key to advancing the laboring process, so a woman who is concentrating on remaining open to the experience can often find it hard, if not impossible, to turn on her suspicion of the medical establishment at the same time.  Having a trusted partner or doula is a good idea because that person can ask the questions, but even with an advocate present, very few obstetricians will do anything but expect you to trust their professional judgment in the moment.  You won’t be handed a binder of research or a 2-page summary of the evidence in answer to your questions.

This is why Childbirth Connection and other maternity resources promote the idea that two of the most important maternity decisions you can make are:

• Choosing a caregiver
• Choosing a place of birth

Women’s choice of provider and location is crucially important because by the time a woman is in active labor, she is to some extent in her caregiver’s hands.

A woman may have the legal right to fully informed consent, to full and clear information about benefits and risks of procedures, drugs, tests, and treatments, but right in the middle of labor, her decisions and outcomes may well be determined by the attitudes, experience, and model of care of her caregiver and the routines and culture of her place of birth.  Caveat emptor (“Let the buyer beware”).

• Physician training centered on the practice of medicine as curing illness rather than viewing pregnancy and birth as a healthy life event;
• A legal climate where doctors fear being sued for not doing enough rather than doing too much;
• A culture of routine medical intervention in birth and “doctor knows best”;
• Lack of consumer access to information and education about evidence-based maternity care standards and site-specific outcomes; and
• Hospitals without programs in place to meet evidence-based maternity care standards.

The percentages of birth interventions have steadily risen over the last decade or so, and when I compare the real numbers today at my local hospitals against the standards set by Healthy People 2010 or the even more demanding standards of the Mother-Friendly Childbirth Initiative, it is hard to believe that they could be achieved any time soon.

As a pregnant woman in 2008, I found the prospect of giving birth in such a climate very frightening.  I was fortunate enough to avoid most birth interventions by giving birth at a birth center, but here in Rochester, New York there are no birth centers and no hospitals in the county with a total cesarean rate of less than 26.7%.

Yet although the facts seem disheartening, they should not deter consumers and birth advocates from promoting the most stringent, evidence-based standards for care.  It is impossible to know what could be until steps have been taken to reverse the current upward trend.  As the 1988 study cited by the Healthy People 2010 Midcourse Review demonstrates, it is possible to lower cesarean rates through simple measures such as:

• a stringent requirement for a second opinion,
• objective criteria for the four most common indications for cesarean section, and
• a detailed review of all cesarean sections and of individual physicians’ rates of performing them. (Citation)

This study concluded that “an initiative within an obstetrics department can reduce cesarean-section rates substantially without adverse effects on the outcome for mother or infant” (Ibid).  When you consider that the evidence-based standards for maternity care have taken into consideration a risk-benefit analysis, reducing the rate to approach a target objective can only be a good thing.

None of the five reasons I listed above is acceptable when the cost of the status quo is in women’s health and the health of their children.  As a community, a health care system, and a nation, we should not accept reasons as excuses.  There just is no excuse.

A mother-friendly hospital, birth center, or home birth service:

2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.

Without accurate site- or provider-specific information, pregnant women and their partners cannot compare facilities to make informed decisions about their own care.  Easily available, meaningful statistical data represents the “informed” half of “informed consent.”  Informed consent to medical treatment is a basic human right, and is affirmed by both the federal HIPAA Consumer Bill of Rights, which reads in part:

Consumers have the right and responsibility to fully participate in all decisions related to their health care.

and the New York State Patients’ Bill of Rights, which reads in part:

As a patient in a hospital in New York State, you have the right, consistent with law, to:

(8) Receive complete information about your diagnosis, treatment and prognosis.

(9) Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.

(11) Refuse treatment and be told what effect this may have on your health.

This last point is especially important because providers may subtly or overtly discourage a patient’s right to refuse treatment.  Often, a consumer must sign a release of liability form stating that treatment was refused, which can be quite intimidating.  I have also anecdotal descriptions of laboring women being routinely given treatment or interventions without the reason, or even the treatment, being made clear beforehand.  Such is the case, for example, with “surprise” episiotomies.

Not only should site-specific measures of childbirth interventions and outcomes be readily available, but to be really meaningful current statistical measures should be accompanied by targets or guidelines; “what ought to be” as well as “what is.”

How can women find out what the numbers ought to be?

There are two common answers to this question.  The first answer is to conduct and compile scientifically valid research and find out the ideal numbers.  That is the method chosen by CIMS.  The Ten Steps of Mother-Friendly Care specify that interventions are limited as follows:

A mother-friendly hospital, birth center, or home birth service:

• Has an induction rate of 10% or less (this criterion is presently under review);
• Has an episiotomy rate of 20% or less, with a goal of 5% or less;
• Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
• Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.

The evidence to support these numbers can be found in the Journal of Perinatal Education, here.

The second method is based on setting target goals that are realistic based on current numbers or that would demonstrate a trend towards improvement.  This is what the Healthy People 2010 project does when it uses a baseline measurement of an objective and sets a 10-year target that is “better than the best population group.”  For most target outcomes, national averages were used with explicit recognition that all groups should improve.  (Citation)

Let’s look at one indicator of maternal health, Vaginal Birth After Cesarean (VBAC), and see how one local hospital does.  In this example, I will pick on Strong Memorial.

Example: How Strong’s VBAC Rate Compares

In 2007, Strong had a VBAC rate of 13.8% (as a percentage of women with prior cesareans).

Compare this number to CIMS’s estimate that hospitals should have a VBAC rate of 60% or more with a goal of 75% or more.  Compare this to Healthy People 2010′s target that 37% of women with a prior cesarean birth should be having VBACs by 2010.  By either of those measures, Strong’s VBAC rate is pathetic.

Strong’s VBAC rate fares even worse when we compare it to the number from five years previous.  In 2002, Strong had a 24.1% VBAC rate and has been trending steadily downward since 2000, when Strong’s VBAC rate was 34.8%, over twice what it is today.  (Choices in Childbirth)

We could just compare Strong’s VBAC rate to that of current other local birth sites (Rochester General has an even worse 2007 VBAC rate of 10.6%), the state VBAC rate (7.1% in 2007), and national numbers (8% in 2005, the most recent year available), and the trend at Strong to larger trends in maternity care (steady reduction in VBAC since 1998), but the large variance in numbers in just this one statistical measure at one hospital demonstrates that whatever the current state of maternity care, it is possible to at least approach the targeted outcomes, especially those focused on improvement from a baseline.

Let’s not use the current mother-UNfriendly climate as an excuse for these numbers.  It’s a poor excuse to offer in exchange for the health of mothers and babies.

1. The commissioner shall require that every hospital and birth center shall prepare in printed or photocopied form and distribute at the time of pre-booking directly to each prospective maternity patient and, upon request, to the general public an informational leaflet. Such leaflet shall be designed by the commissioner and shall contain brief definitions of maternity related procedures and practices as specified in subdivision two of this section and such other material as deemed appropriate by the commissioner. Hospitals and birth centers may also elect to distribute additional explanatory material along with the maternity patients informational leaflet.

2. Such leaflet shall also include statistics relating to the annual percentage of maternity related procedures performed at such hospital or birth center, as provided by the commissioner, including but not limited to the following:
(a) the annual rate of cesarean sections, primary, repeat and total, performed at such facility;
(b) the annual percentage of women with previous cesarean sections who have had a subsequent successful vaginal birth;
(c) the annual percentage of deliveries by midwives;
(d) the annual percentage of births utilizing electronic fetal monitoring listed on the basis of external and internal;
(e) the annual percentage of births utilizing forceps, listed on the basis of low forceps delivery and mid forceps delivery;
(f) the annual percentage of breech births delivered vaginally;
(g) the annual percentage of births utilizing analgesia;
(h) the annual percentage of births utilizing anesthesia including general, spinal, epidural, and paracervical listed on the basis of vaginal and cesarean births;
(i) the annual percentage of births utilizing induction of labor;
(j) the annual percentage of births utilizing augmentation of labor;
(k) the annual percentage of vaginal births utilizing episiotomies;
(l) whether birthing rooms are available for use in the facility;
(m) whether rooming-in is available in the facility, on the basis of twenty-four hours a day or daytime.

4. Statistical information shall be presented in the most recent one year aggregate.

I know that this information is produced for Monroe County hospitals.  You can see it here.  The maternity information brochure can be found on the same website.  But do local hospitals really have printed copies of this brochure that they distribute to every prospective patient?

Again, I will grind my axe about not having birth-order specific statistics.  I want to know the cesarean rate for first-time mothers, for women who have had a previous cesarean birth, and for women who have had a previous vaginal birth and never a cesarean birth, and I want to know those statistics for low-risk pregnancies and for certain kinds of higher-risk pregnancies (twins, breech, premature/induced labor).

But is even the basic level of information required by the law reaching consumers?  I’m glad the statistics are available online on the NYSDOH website, as well as Choices in Childbirth, but pregnant women should not have to go looking for it.