“Extreme Motherhood” on 20/20 this Friday

At least, it’s supposed to air this Friday (I believe it still airs at 10 Eastern, 9 Central, but check local listings). The last few times it’s been scheduled, it’s been preempted at the last minute, so I’m not holding my breath. But, just in case it does, I’m passing along the info!

Here is what I’ve heard:

Segments include homebirth (both unassisted and midwife assisted), serial surrogates (women that have numerous babies for other women), “fake babies” (life like dolls), long-term breastfeeding, and orgasmic birth.

We’ll see what it ends up like. My expectations are fairly low, so I know they won’t be dashed, but I’ll be curious to see how it finally ends up.

Not just money

A recent article by Jennifer Block, author of the book Pushed which takes a close look at C-sections in America, highlights the disparity between what we as a country spend on maternity health care and what we receive, based on outcomes like maternal and neonatal morbidity and mortality and the premature birth rate. With a price tag of $86,000,000,000 in the year 2006, for an average cost of about $21,000 per birth, we should be getting better results than we are. I understand that a lot of that money goes to help babies who are born too early, and I don’t begrudge the amount it takes to save a life; however, I do wonder why we have so many babies being born too early. Why do we have such dismal results, when we spend so much? — according to the article, we spend twice per capita of what other countries spend, but we are far behind them when it comes to results.

The answer, according to Ms. Block, is to increase the number of midwives, both in and out of hospitals. She notes that 100 midwives saved the state of Washington an estimated $2.7 million over the course of two years; which also reminds me of this midwife I’d previously read about, who works in Washington, D.C., and keeps her funding by noting how much money they have actually saved by going low-cost and low-tech, while getting results that are twice as good as average.

Part of the reason for the midwives’ good results is the much lower use of C-sections, which are expensive, especially when compared to out-of-hospital vaginal birth (mine cost about $3000 apiece for all prenatal care and everything). When a midwife attends a home birth, all the care is included in a single fee, rather than billing for the monitoring of the baby, the after-baby care, the postpartum checkups, etc. One thing that surprises me about getting a bill from the hospital is that often that’s not all there is to it — there’s one from the doctor, the anesthesiologist, and the hospital, and possibly extras for other services rendered, depending on the circumstances.

But hospitals are reluctant to use midwives. Some hospital-based midwives are not allowed to attend out-of-hospital births lest they lose their privileges at the hospital. Despite the fact that you get more for less with midwives, and especially so in an out-of-hospital scenario. But, insurance companies don’t pay for a midwife to “labor-sit” — it’s not “billable” like the use of technology. So it would cost hospitals more to have one-on-one care with laboring women (which they can’t bill, but which shows much better outcomes for mother and baby), than it is to hook the women up to ten kinds of machines (which are billable, despite some questions about their actual efficacy in reducing negative outcomes for mother and/or baby).

Madwives, Medwives, and Midwives

Everybody knows what “midwives” are, even if some think that midwifery is a profession that ended with the Dark Ages (yes, I’ve actually seen at least one person express surprise that there are still midwives). But often on certain birth-related email lists, internet groups, blogs, etc., you’ll see the terms “madwife” and “medwife” in reference to midwives. What is a “madwife”? What is a “medwife?”

These terms are used in a pejorative sense to denote midwives who are — in the opinion of the person speaking or writing — either too quick or not quick enough to intervene medically. But since it’s an opinion, it is subject to a wide scope of interpretation.

Probably most of you are aware that I tend to be politically conservative, although I usually only bring up politics tangentially. I know that quite a large percentage of “birth junkies” tend to be liberal, and many are in my opinion very liberal. That’s fine — I’m not going to fall out with you, but I just won’t attend any political rallies with you. 🙂 In the past Presidential election, I and most everybody I personally know found John McCain to be too liberal, and either voted third-party, abstained from voting altogether, or “held our noses” and voted for McCain. For those of you “left of center”, you may be reading in disbelief that anybody thinks McCain is too liberal, since you found him to be suffocatingly conservative. I know that there are probably some people who felt the same way about Obama — that he was not liberal enough — and that is a little unbelievable to me, too.

Why bring up politics? Because it is an easy analogy to show the spectrum of opinion that exists in both governmental politics and the politics of birth. Just as there can be two widely different opinions about the same man when it comes to his political leanings, so there can be two widely different opinions about the same midwife when it comes to her level of intervention.

The Dr. Amys of this world would probably label any CPM as a “madwife”. I have seen her make the blanket statement that “DEMs [she refuses to call them CPMs] don’t check the fetal heartbeat often enough in home births”. Some people might call a midwife a “medwife” if she requires that fetal heart-tones are checked at least once or twice an hour. Same woman, same level of intervention, two different terms.

Being in various internet groups that promote home-birth and natural birth, I see midwives be labeled as “medwives” more frequently than “madwives”; but I’ve seen a few more medically-minded birth blogs or what-not that attract commenters who more frequently use the term “madwives” than “medwives.” It’s a lot of Monday-morning quarterbacking, to be sure, as well as just someone’s opinion. This means that it’s helpful to know where on the birth spectrum someone is, so that you can get a better idea of how they use the term “madwife” or “medwife.” If you are as conservative as I am, and (hypothetically speaking, and going back in time to before the election) you didn’t know anything about McCain or Obama, and I said something like, “McCain is too liberal!” then you may find that information beneficial and accurate; if you are a liberal, though, and you took my opinion as fact, you would be misled as to McCain’s political stance, because while I think he is too liberal, there are numerous other national political figures who are even more liberal than McCain, Barack Obama being one. If you voted based only on the information that “McCain is too liberal” (which is just my opinion, rather than a statement of comparison between him and Obama), you might choose as your Presidential candidate someone with whom you profoundly disagree — either because you voted for McCain because you thought he was as liberal as you when he was actually far too conservative for you, or because you voted for Obama because you thought if McCain is too liberal then Obama must be more conservative.

If you were to ask me about what kind of birth attendant to choose, you would get a completely different answer from the one you would get if you asked my sister. I prefer low or no interventions and home birth; my sister likes to have access to an epidural as soon as she walks in the door. Before you get my opinion as to how good a particular doctor or midwife is, it would be good to know for you to know where I am on the madwife-midwife-medwife scale, and it would be good for me to know where you are on that same spectrum. As long as our opinions coincide on the preferable level of interventions and desire for medical assistance, my opinion might be very valuable to you. If, however, you want the name of a good doctor who will schedule your C-section right now for a date some months in the future at 37 weeks gestation just because it fits into your schedule, you’ll need to find someone else to make that recommendation, because all of the people I would recommend do not have that practice style. In a similar fashion, if you want the name of a midwife who will just sit in another room while you are in labor and just be close but not enter into your space at all, I might not be able to help you because few midwives would be willing to do that (and many are legally required to have some level of interaction with you, such as listening to the fetal heart-rate at least a few times an hour).

Birth, like so many other areas, is in the eye of the beholder.

“Breastfeeding with Comfort and Joy” — a review

Wonderful!

Beautiful photography!

Excellent advice!

It’s hard to top the words of praise Dr. Christiane Northrup and others — both doctors Laura Keegan has worked with and mothers she has helped — have given:

like having a wise and loving grandmother show you exactly how to nurse your baby… Laura has created a manual of wisdom and celebration… what you need to know to get started in establishing a comfortable breastfeeding relationship and to solve problems should they occur… Before this experience, I never would have believed that learning the correct latch in this book meant that I would spend less time nursing my twins than I did nursing my firstborn and without the pain of sore nipples…

Plus there are many, many more in the opening pages of the book — a variety of mothers who had difficulties nursing for many different stated reasons (one mother was told that her baby had an “abnormal suck”, one baby was slow to gain weight, several mothers had cracked nipples), who resolved all those difficulties with the techniques brought forth and beautifully illustrated in this book.

Once you go past the introductory words of praise and the table of contents (which you can see by going to BreastfeedingwithComfortandJoy.com and clicking on “click here for excerpts”), there are beautiful photographs on every two-page spread — usually one large picture on the left-hand page with explanatory text on the right-hand page, but frequently a series of smaller pictures (for instance, several photos taken just seconds apart showing a baby properly latching onto the breast). These pictures show a variety of babies, from the tiny, still-wrinkly newborns to those oh-so-chubby babies of several months old, with several “milk-drunk” babies who have fallen asleep while nursing, and smile that sweet, satisfied smile. The pictures primarily show good latches and good positioning, with only one “what not to do” picture — this is important, because it is much better to show what to do rather than what not to do. In this way, women get strong and repeated correct images of how to properly breastfeed.

One thing that struck me the strongest while reading this book is the statement she made about how that women in this country often “automatically hold their babies and their breasts in ways that work for bottle-feeding since that is what most of us have imprinted in our minds” — as opposed to women growing up in cultures where breastfeeding is the norm. And it is this “incorrect imprinting” that is the root of so many problems with breastfeeding.

I remember my Daddy kind of poking fun at organizations like La Leche League, or wondering out loud why it was that women should have such problems with nursing their babies when animals don’t have that problem. To be honest, I never had any problems with nursing either. The only times it hurt were when my children got to that stage (about 6 months old?) where they are easily distractable and frequently turn to see what made that noise without letting go of the breast first; and also a couple of times when I was pregnant and nursing, my 10-month-old son would occasionally latch on incorrectly (I don’t know why — we’d obviously been nursing for quite some time), and it would hurt, so I would take him off and start him again (and I couldn’t tell you what was the difference), and it wouldn’t hurt the second time. And sometimes when I hear stories of women who have had just dreadful pain while nursing — like my sister-in-law whose nipples cracked and bled the whole time she nursed her oldest child, and she had terrible pain with every feeding (I give her full kudos for sticking with it for 11 months — I think I’d’ve given up much sooner!) — when I’d hear stories like that, I’d sometimes wonder why it is so hard for some women, when it was so easy for me. Now, I think I know most if not all of the answer.

The next several pages go into detail (in words and in pictures) about the differences between both maternal and baby positioning with breastfeeding vs. bottle-feeding. And it is this that makes all the difference in the world. When the breast and baby are not in proper alignment, the nipple is subjected to abuse which causes pain initially, and if not changed, can lead to cracked and bleeding nipples. I’ve not had that, but I can imagine it to be not fun in the slightest. Yet, often women are told that even when they are in pain that there is nothing wrong — that happened to my sister-in-law I just mentioned. (Just for background, she didn’t tell me about her problem with breastfeeding until well after she had weaned her daughter — she first mentioned it a couple of weeks after I had my first son, when she asked if I was having any problems with pain, cracking, or bleeding. I think she was a little jealous and quite astounded when I said ‘no.’ She may have been a little perturbed at her “bad luck,” but I don’t think “luck” was the problem.) Anyway, when she was in the hospital after having had her baby, the nurse told her that she was doing everything right — despite the pain she was feeling. Because this “authority figure” (I believe she called her a “lactation consultant,” but I’ve heard that sometimes nurses are given that appellation or a similar one when they’ve had little or no training in breastfeeding, but they may be the only L&D nurse with breastfeeding experience, so they are the “go-to person” whenever a mom has a problem) told her that there wasn’t a problem, she persisted with an incorrect latch through months of pain and bleeding. It shouldn’t happen.

There are other sections (see the table of contents in the excerpts of the book) that deal with several other common problems or areas of concern — including many, many pictures of mothers breastfeeding twins, showing different positions for the babies to be in — as well as skin-to-skin contact, kangaroo care, colic, engorgement, etc.

Again, the pictures are just beautiful and both pictures and text are quite informative. It’s a must-have for any woman who has problems with nursing, or anyone who has contact with such women (midwives, doulas, nurses, childbirth educators…). I’m going to loan my copy to a woman at my church who is expecting her first baby any day now. I hope I get it back!

Presto! Change-o!

A recent article in U.S. News and World Report, titled “Rate of Unnecesary C-sections Far Lower than Thought“, discusses an article in January’s Obstetrics and Gynecology which finds that “the real rate of unnecessary C-sections is 4%.” Huh?

First, I don’t have the study, so I can only go by this article, which was brought to my attention by The Unnecessarean Blog. My first thought is, define “necessary.” It appears that the study looked at women who were planning a vaginal birth and ended up with their first Cesarean (whether this was the woman’s first baby or not, I can’t tell). Now, it says, “The CDC researchers sifted through data on 565,767 births from women who were considered at low risk for needing a C-section.” So now, define “low risk.” How was their risk status determined? Would it not be determined by pre-labor factors known to her doctor and presumably herself? The article says that going on birth certificate data alone, 58.3% of these women had no risk factors for a C-section; but that based on hospital discharge data, nearly 90% had a risk factor listed. Ok, define “risk factor.” How is it that over 40% of “women who were considered at low risk for needing a C-section” actually had at least one risk factor for a C-section? Doesn’t having a risk factor move you from “low-risk” to moderate or high risk? Maybe not. Maybe you can have one risk factor for a C-section and still be considered low-risk, but that two or more risk factors bumps you out of “low” risk.

Besides, having a risk factor for a condition and having the condition are two widely different things. A man may “have risk factors” for a heart attack, but that doesn’t mean that he will definitely die from a heart attack if he is not hospitalized from now until he’s 80; nor does it mean that a bypass operation is necessary.

Kahn said there are several possible reasons for this discrepancy. One is that the main purpose of a birth certificate is simply to record the birth. Birth certificates aren’t completed by physicians, but instead rely on worksheets filled out by the mother. And, she said, hospital discharge data is used to bill the insurance companies and doctors must be very detailed on these reports to get paid, which might make them more accurate.

“Doctors don’t touch birth certificates,” said Dr. Miriam Greene, an obstetrician at New York University Langone Medical Center and author of the book Frankly Pregnant. “The person who writes up the birth certificate might not be knowledgeable about all the risk factors for C-section, and they see the baby is fine and may think there was no issue.”

Now here is an interesting factor — doctors rely on discharge data to get paid by the insurance companies. I used to work for a pharmacy, and I know some of the hoops we had to jump through to get a medication approved for a patient. A friend of mine also went through months and months of hassle trying to get her husband’s various treatments approved (or pre-approved) by the insurance company; and some of the rejections were because the pencil-pushers (at either the doctor’s office, hospital, insurance company, or anyone else involved in getting data from one person to another) wrote or typed the wrong code. As an example of a type of false rejection (which also happened to this same friend), her second son (who was named Andrew, obviously a masculine name) was entered as a “female” into the insurance company’s database; and then they refused to pay for his circumcision (this is years ago, when it was still covered by most insurance companies) because their insurance policy didn’t cover pregnancy-related expenses for dependent daughters. In other words, because of the mix-up, the insurance company people and/or computers considered that newborn Andrew had just given birth to her first child.

So, doctors and everyone else in the health-care field have to be careful about how they code things and how they enter data into the various computer systems because their livelihoods depend on it. Doctors who don’t get paid for attending C-sections won’t be very happy campers. It makes me wonder if they are, um, getting creative with women’s risk factors when it comes to hospital discharge data so that they will get paid. Insurance companies — like every other company — don’t like spending money, and especially don’t like spending it unnecessarily. I’ve previously blogged about a hypothetical future scenario in which doctors’ malpractice insurance won’t let them attend VBACs, so they force women to have “elective” C-sections; while women’s health insurance won’t let them have “elective” C-sections — what happens then? Does she have a medically unnecessary repeat C-section or a VBAC? If she has the surgery, and her insurance company won’t cover the surgery because it’s elective, will she have to pay the doctor out-of-pocket for her unnecessary surgery, or will he just “eat” the cost?

Is this scenario actually happening now? Are doctors “discovering” risk factors for women after the surgery so that they can be sure that they’ll be paid for the surgery?

Consider the following story, which actually happened to someone I know. A woman gave birth to her 4th child (planned hospital birth — she loves epidurals), and the doctor came in, ready to discharge her, and asked if she was ready to be home, and she replied quite honestly that she was rather enjoying the respite she had from the demands of being at home with her older children, and enjoyed being able to focus on the new baby. So, the doctor looked at the thermometer he had just taken her temperature with and said, “Hmm, it looks like your fever is a little high [it wasn’t — it was perfectly normal], so I think you should stay in the hospital an extra day, just to be on the safe side — to make sure you aren’t getting an infection.” Presto, change-o, she suddenly “qualified” for an extra day of R&R in the hospital, courtesy of her insurance company. Think this doesn’t happen every day in every hospital in the country?

This study presumes that hospital discharge data is accurate, while birth-certificate data is deficient. It may be. I certainly have read numerous things (studies, mentions in other studies, articles that talked about studies) that have shown that birth-certificate data is not very reliable when making certain judgments. But to go from “nearly 60% of women have no risk factors” to “just less than 4% of women have no risk factors”?? At what point do you start questioning the hospital discharge data’s accuracy? Especially when doctors have a monetary interest in making sure they and the hospitals get paid for everything that was done, so that they don’t lose any money.

I remember a joke Abraham Lincoln was reported as telling: How many legs does a dog have, if you call its tail a leg? Four — calling a tail a leg doesn’t make it one!

In a similar way, suddenly discovering (after the birth) that a woman is obese, or has high blood pressure (you remember — that one time in that prenatal visit when her bp spiked?), or gained too much weight (we know how women lie about their weight), or had protein in her urine, or had edema, or had a headache (we’ll just forget it was because she knocked her head on the car door), or had a small pelvis (let’s just erase the previous “adequate pelvis” notation in her chart), or whatever the “risk factors” were that the doctors charted in order to get paid by the insurance company, doesn’t make them real.

Did the researchers take a cross-section sampling of these women to find out if the discharge data was accurate, or was it just assumed to be so? In the Johnson & Daviss CPM home-birth study published in the British Medical Journal, they said that in addition to the data gathering from the midwives and the birth certificates, that they took a sampling from the mothers and had them verify the details of what they had been told about the births, to make sure that there weren’t any errors. Was something like this done here? It might be interesting what women remember being told before the birth, and what they found out afterwards — like the woman who had a C-section for breech, only to find out that the baby had flipped sometime between the last ultrasound and the surgery, so she could have had a vaginal birth… but then the doctor came in and tried to justify the C-section by saying that “the baby was big [8 lb. something] and your pelvis was small [although it was previously noted to be the best pelvis shape], so you likely would have ended up with a C-section anyway.” That was bull. The parents didn’t buy it (but what could they do?); yet the doctor still got paid for his “necessary” C-section.

$10 off “Breastfeeding with Comfort and Joy”

I had previously mentioned M.I.L.C.’s Facebook awareness effort that breastfeeding is not obscene. In honor of the beautiful pictures of women breastfeeding their babies, Laura Keegan, author of Breastfeeding with Comfort and Joy is offering $10 off the price of her book, bringing the cost down from $35 to just $25. (Clicking on the picture of the book’s front cover will allow you to see excerpts from the book.) The code you’ll need to enter is Joy10 — and it’s only for today! I got a copy of the book a few days ago, and would highly recommend it to anyone who has any contact with a woman who may by any stretch of the imagination ever nurse her babies — pregnant women, just-had-a-baby women, doulas, midwives, lactation consultants — everyone! The pictures are just gorgeous — all those chubby “milk-drunk” babies are just delicious, plus the wonderful close-up pictures of correct positioning and latching, and the simple step-by-step instructions. As Dr. Christiane Northrup said, it *is* “like having a wise and loving grandmother” teach you how to breastfeed your baby, with comfort and joy.

I’ve just finished reading the book, and will be posting my glowing review of it soon, but I had to dash this off quickly to give you time to order the book today, December 27.

Industrial Childbirth

“My experience of childbirth was not an unusually traumatic one. In medical parlance I had an NVD: a Normal Vaginal Delivery. The midwives were pleasant. I was given an epidural. I was admitted to hospital at 2pm and delivered a healthy baby boy ( 8lb 7oz ) eleven hours later. This is the essential information, is it not? This is the only kind of information that we ever really hear about other women’s experiences with childbirth.

“But there is more to it than that. It took me a while to sort out my feelings after the birth – the elation you feel at the presence of a new life combined with your physical exhaustion leave room for little else. And I never really experienced the hopeless grief of the flippantly named “baby blues” in the weeks or months that followed. What I felt – when I was finally able to identify the reasons for my confusion – was anger.

Click here to read the rest of this…