In a previous post, I started talking about intuition in childbirth, particularly in unassisted birth, inspired by Dr. Rixa Freeze’s doctoral dissertation. Continuing on that topic, I want to delve a little more deeply into it. I just can’t stop thinking about it, so I’ll backtrack in the paper.

First a little personal background — I first got pregnant in 2004, and became interested in pregnancy and birth then. That’s the way I am — when faced with a new situation, I try to learn as much as possible about it, and become as familiar as I can, so that when I go through the situation, it feels most comfortable to me. (Unfortunately, my husband is about the opposite, which means we drive each other nuts — like when we’re both playing a computer game, he prefers to just jump in and figure it out as he goes along, while I prefer to read the manual and the user guide and go through all the tutorials before I even start. When I ask him before I begin playing how something works or what to expect, he says, “Oh, just start playing — you’ll figure it out!” And I just can’t do that. It frustrates and annoys me!) So, I read and studied extensively while pregnant. Afterwards, I went into hyperdrive, going deeper and further into natural birth — not just drug-free births in hospitals, but pro-midwife, pro-CPM, pro-homebirth, and pro-unassisted birth.

When I read this section on intuition in Rixa’s paper, I was extremely glad to read her say that it seemed to her that the UC forums she read, moved away from learning medical and clinical knowledge as preparation methods for UC to relying solely on intuition as not only the best but the only way of preparing for a UC. Not having studied UC like she has, and only having limited exposure to it, I have noticed recent things on emails promoting just intuition, and even some people at times saying that women should not read negative things or stories about emergencies or bad outcomes (UC or otherwise), because then they’ll set themselves up for fulfilling those same things in their birth. It seemed that at first when I was introduced to UC that there was a lot more talk about complications and how to deal with them — sharing knowledge and real “what if” scenarios. I’m glad to know that what I picked up on was actually true.

This bothers me — the trend away from some sort of practical knowledge about birth to “oh, just listen to your intuition and everything will be fine.”

I’ve read numerous stories where just this thing happened — mothers who were planning a UC and then changed their minds because of something in their minds they just couldn’t let go of, and it was a good thing because either they or their babies needed help and/or medical attention during labor or after birth; other mothers who were planning a hospital or midwife-attended home birth and changed to a UC, and were glad they did because they had a successful and even glorious birth which would have become a medical problem had they done it differently; one woman who had a placenta previa (didn’t know it until labor) and began bleeding during labor, and got a tremendous urge to push, as if her body just screamed it at her, and she pushed the placenta and baby out in one huge long push, and the baby was perfectly fine (because of the speed of the birth — no time for the oxygen to be cut off); mothers whose babies had meconium and they automatically “suctioned” it out by the mom putting her mouth on the baby’s mouth and sucking it that way; etc.

Intuition can be very powerful, and I don’t discount it; but I don’t want to promote that as the best, and certainly not the only thing that should be considered. For every story of “intuition” telling them that something was going to happen, someone could probably dredge up 10 or 100 or 1000 stories of intuition failing to warn them of advance circumstances. If intuition were so good, then no one would ever die accidentally — there would be no skiing accidents, no falls from roofs, no car wrecks — because “intuition” should warn you of these things. If it were perfect. For me, intuition is one of those things where you should “err on the side of caution” — that is, if intuition is telling you that something bad is going to happen, you’d better freakin’ listen to it! On the other hand, if your intuition is “silent” while there are obvious or clinical signs of something bad about to happen, forget “intuition” and listen to the signs!

I’ve read sometime in the past a discussion about intuition — including why it seems that females are much more intuitive than males — and this article basically said that “intuition” is the brain picking up on subtle signals that the conscious mind does not fully recognize, but the subconscious mind does. And this is why “female intuition” is so much more common than “male intuition” (is that even a term?) — because women’s brains are wired differently, we have a lot more social skills, we’re more talkative and more communicative, and the two sides of our brains share a lot more communication than men’s brains do (it’s no joke that “men have a one-track mind” while women can mentally multitask) — so we women pick up on these subtle “something’s wrong” signals more than men do. But it’s not perfect.

And sometimes, even when you intuitively know something is going to happen, it doesn’t mean you can prevent that thing from happening, just because you knew it ahead of time. One woman I know had a strong feeling throughout her entire pregnancy that something was wrong with the baby; and sure enough, about a week after he was born, he was diagnosed with a fatal heart condition. Her prenatal intuition was correct, but her baby still died — not because of listening or not listening to intuition, but just because the particular defect was not curable, even by the excellent heart doctors at Le Bonheur, one of the best children’s hospitals in the South, and possibly in the nation.

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Define “Safe”

In chapter 5 of Dr. Rixa‘s Born Free dissertation, she discusses risk and safety in birth.

How do you define “safe”?

Is “safe” defined solely as a birth in which both mother and baby survive? In that case, birth is universally defined as safe, since most mothers and babies survive birth even in Sierra Leone, which has the highest maternal and infant mortality in the world. And even among the unassisted births that most obstetricians and even many midwives warn against are safe.

Is safety defined as only births that happen in a high-tech hospital with the high-risk obstetrician in the room and the neonatal doctor just down the hall?

Rixa goes even further — does the woman feel safe?

I daresay that in many births, the mothers do not feel safe — they feel on edge, fearful that something will go wrong because all the technology is in use which must mean that all the technology is necessary to keep them and their babies safe. Some women choose unnecessary C-sections because they do not feel safe in attempting a vaginal birth — afraid that either they or their babies will be damaged or killed. Or maybe their doctors have told them that they must have this intervention or that intervention, so they think that either they or their babies are or will be at risk if they decline. They may be physically safe — that is, these women may not be in danger of their lives or a serious injury, but do they feel safe?

A lot of women do feel safest and best in the hospital, so for them, a home birth would make them feel unsafe (regardless of how safe it actually is or would be). But I remember a doula on an email list I’m on saying several months ago that she couldn’t remember the last hospital birth she’d attended in which the staff (nurses and doctor) were relaxed during labor. Instead, she said that the labors were always very tense, as if the nurses and doctor were on edge, just waiting for something to go wrong, and only seeming surprised when it didn’t.

If “safe” is defined as only those births that take place within the hospital, then any birth outside those parameters that ultimately ends in the safe birth of the child and without serious maternal injury or death is viewed as “lucky.” Hospital-birth advocates may even try to say that every safe out-of-hospital birth is anomalous, or an exception — or even if it is admitted that they are the rule and not the exception, it will still be intoned that such births are risky.

But it depends on how you define “safe.” And until everyone involved in birth can agree on a definition of “safety in birth,” there will never be agreement on which births are safe and which are risky.

Authoritative vs. Authoritarian

This is another post inspired by Dr. Rixa Freeze’s “Born Free” doctoral dissertation; this time from the section starting on p 169 of the pdf, on “Intuition as Authoritative Knowledge.”

Often when the discussion is on unassisted childbirth (UC), the question becomes, “How do you know what to do when?” This type of question can come from women contemplating a UC, in which case they are asking a legitimate question; or it can come from skeptics or people completely opposed to UC, in which case they are asking the question rhetorically, implying that women can’t or won’t know what is happening to them in labor and birth, either at all, or until it is too late to prevent the “it” from happening [shoulder dystocia, cord prolapse, placenta previa, fetal distress, etc.], or the “it” from having serious or even deadly consequences.

The typical response from UCers is that women will “just know” via intuition what is going on — that when women are completely in charge of their own bodies and labors and births (as can only happen in a UC, since even a very hands-off midwife will intrude at least somewhat simply by her presence) — that they will “tune in” to their bodies in such a way as to know or be aware of what is going on that no external machine or person can even approach to knowing. I’ve read several stories along these lines — one that sticks out was not a UC, but rather a woman who “just knew” that something was going wrong, although the EFM didn’t show any problems, and the nurse didn’t think anything was wrong. She actually had a hidden partial placental abruption, which was ignored because the nurse believed the machines instead of the woman. Often, the reverse case is told in UC circles — women who are showing clinical signs of something being not quite right, but intuition saying that everything is fine and no steps need to be taken.

This section of the dissertation made me think of the difference between “authoritative” and “authoritarian.”

First, the quick definitions (taken from OneLook dictionary):

Authoritative — ▸ adjective:  sanctioned by established authority; having authority or ascendancy or influence; of recognized authority or excellence
Authoritarian –▸ noun:  a person behaves in an tyrannical manner▸ adjective:  likened to a dictator in severity; characteristic of an absolute ruler or absolute rule; having absolute sovereignty; expecting unquestioning obedience.

A person can be both authoritative and authoritarian, but these are not the same in meaning. As an example, Rixa may be an authority on the subject of UC, having not only had one herself, but having studied the topic extensively and written this extremely long thesis on it; yet she would only become authoritarian if she insisted that everyone have unassisted births as she did.

Quoting from the dissertation:

Anthropologist Brigitte Jordan, best known for 1978 book Birth in Four Cultures, explained that authoritative knowledge is “the knowledge that within a community is considered legitimate, consequential, official, worthy of discussion, and appropriate.” It is not simply the knowledge of those in authority positions, as the term might suggest, but rather a “state that is collaboratively achieved within a community of practice.” Whether or not the knowledge system is “right” or “truthful” is irrelevant; “the power of authoritative knowledge is not that it is correct but that it counts.”

So, in OB circles, only such information as may be presented in journals and textbooks is considered authoritative; whereas in UC circles, this information is considered less important (or even unimportant altogether) compared to intuition, or a woman’s innate knowledge. This is larger than just birth — “authority” exists in every circle — religion, education, politics, etc. Dr. Amy may be authoritative — she’s got a whole bunch of school and book-learning, and practiced as an obstetrician for years; but she’s also authoritarian in her insistence of no home births. But what she needs to learn is that her “authoritative knowledge” means nothing to women who disagree with her, because she comes across as authoritarian, and nobody likes to be told what they can and cannot do — especially by someone they disagree with, and who insists on “my way or the highway.”

Further on in the dissertation comes this quote:

Dr. D. Ashley Hill wrote: “Women who choose to have an unassisted birth are at best uneducated about the potential complications of giving birth. At worst, they allow negative feelings towards hospitals, physicians, or midwives to place their babies in danger.”

This makes me wonder — why should/do these women have negative feelings in the first place? What can these people and institutions do to reduce or eliminate said negative feelings so that women will want to give birth there or with the people? Rather than legislating away a woman’s choice to give birth in the manner and place of her choosing, they can make the choice become a positive one — she can still choose a home birth alone or with a midwife, but why when the hospital is so much better? The problem for those who promote hospital birth is that we home-birthers don’t think that a hospital is better, after considering all the pros and cons. If these people want us to think the pros outweigh the cons, they need to see what we consider to be things against hospital birth and change those things — much as they did in the late 70s and early 80s when they made birth rooms more home-like and began allowing fathers in to see the birth of the baby, in response to pressure from mothers — rather than just insist in an authoritarian manner (which typically only serves to increase our stubbornness and resolve to continue in our path and ignore and flout them) that birth at home is dangerous and shouldn’t be attempted and should be outlawed.

Midwives, fear, and unassisted childbirth

I’m reading through Dr. Rixa Freeze‘s doctoral thesis on “Free Birth” or “unassisted childbirth” (UC), which is extremely interesting, and well worth reading, regardless of whether you are an extreme supporter of UC, or think it’s the worst thing to happen in the world since the A-bomb. You will certainly learn something, regardless of where on the spectrum you find yourself.

On the 81st page of the pdf (p. 66 of the numbered pages) is this statement: “Morgan argued that midwives’ training in how to handle complications would inevitably instill fear in the birth process.”

I understand this; but whether this fear is unfounded or not is another question entirely. The problem is, on one hand there are a whole host of L&D nurses, midwives, OBs and other doctors who have a view of childbirth as a medical problem, attendant with innumerable potential complications (including death or severe disability for mother and/or child), and it is their job to prevent these negative outcomes from happening, or reduce their severity, and to accomplish this through the use of technology. While I and a great many others would argue that their use of technology is not “judicious”, and they should practice evidence-based medicine, and conserve their interventions when they will be beneficial as opposed to introducing unnecessary risk (such as elective inductions), the truth is that sometimes even in the best, “freest” or “purest” circumstances, bad things can and do happen.

Different people have different ideas when it comes to risk and responsibility in childbirth; and that is one thing that I greatly admire about the UC movement, and that is that the parents assume full responsibility for their child in labor and birth, and don’t put any of that responsibility on anyone else, be it doctors, nurses, or midwives. But this weight of total responsibility is too much for many people to bear, so they put (some would probably use the word “shirk”) part of their parental responsibility onto the shoulders of one or many care providers. In this way, when something goes wrong, the parents can always blame the doctors; in a UC, that’s impossible — all blame must rest with the parents, since no one else had anything to do with the birth. Some would argue that the parents still should shoulder all responsibility, since they choose the care provider who may end up being overly interventive. I agree that in this situation, the parents do share some part of the burden of risk and responsibility in what happens in birth due to their choice of care provider; but that the care-provider, in that s/he holds a position of trust, takes on more.

While most births — even among the very high-risk, such as births which occur in countries like Sierra Leone with little or no access to anything like decent medical care, much less clean water, plenty of food, good nutrition, availability of medications and C-sections when needed, etc. — do not end in the death or serious disability of mother and/or child, there is always a possibility that something might go wrong. Because that’s the way the world works; and anyone who says, “Just think happy thoughts, and happiness is guaranteed to follow,” is either trying to deceive you or is seriously deluded himself. I do think we should “think positively,” but that doesn’t mean that it is only “positive thoughts” or “positive energy” that is keeping us from disaster. That’s superstition. There’s no point in being overly negative, of course; but I think there needs to be some sort of middle ground between the “head in the clouds” idea that everything will be just peachy if we just keep negativity away from us, and the “birth is only normal in retrospect” idea of many obstetricians who spend hours attending women in labor and birth all the while sweating and fearing that something somehow somewhere is going to jump out of the middle of nowhere and cause disaster.

Back to the quote: “Morgan argued that midwives’ training in how to handle complications would inevitably instill fear in the birth process.”

I agree with this statement, but tend to think it is a “healthy fear” or rather “respect” of the birth process which usually works well, but is not guaranteed to do so.

Some months ago, I read of a woman who died from an amniotic fluid embolism when her placenta suddenly detached at 34 weeks gestation; both she and her baby went from (seemingly) perfectly healthy to dead within hours. Those who are of the hospital bent cannot blame “crazy UCers” or “crazy home-birthers,” because she was under the care of an obstetrician; and those of us who are of the home-birth bent cannot blame any medical intervention at all, because she wasn’t induced or anything. It just happened, with little or no warning.

Friends of mine lost their baby a little over 3 years ago, due to cord strangulation, right around the due date. Up until that point, everything had seemed to be perfectly fine and normal, although I think the mom felt less movement leading up to the death but thought it was normal. It wasn’t. She was under the care of an obstetrician, planning a hospital birth — you can’t blame it on home birth. She noticed the last movements either right before, or in the early stages of, her labor, before going to the hospital — you can’t blame it on hospital birth.

One problem I have with the UC movement is the talk I hear in various quarters that pretty much reaches the level of superstition — that if you plan a UC, and don’t have a midwife, and have an unassisted birth, and don’t worry, then everything will work out just fine; but that if you ask to plan a midwife-attended birth or you can’t quite squelch your fears, then you’re asking for trouble, and something negative will happen.

Sometimes complications happen in unassisted births — refusing to have a midwife there is not a talisman against that evil; although I do understand and accept that sometimes midwives (even very relaxed and hands-off midwives) can interfere in the normal birth process, and may even introduce some types of risk or “intervention” that wouldn’t have been there before. Some people think that even the midwife’s presence in the room is an intervention; others do not want to have the midwife intrude into their birth space to check the fetal heartrate. But if a complication arises, and there isn’t a midwife there — then what? In the Discovery Health Channel show “Freebirthing”, the American woman they showed having a UC ended up with a retained placenta, so she went to the hospital (where it ended up coming out on its own, without any intervention). Had she had a midwife, she might have avoided the hospital entirely — either because the midwife would have helped, or just let her know that what she was experiencing was “a variation of normal” or whatever.

So, yes, midwives have to know a lot of the potential negatives of birth, including what to do — how to intervene, when to transfer to a hospital and/or doctor. And I’m sure it does make them not trust in the usually perfectly normal process of birth quite as much as someone who has never seen nor heard of a bad outcome. And they may intervene a little too quickly at some points. But the alternative may well be a dead baby, and who wants that? If there is no trained person, and complications arise and the mother does not have intuitive knowledge that something is wrong (which is, after all, a possibility!), then someone could be very badly hurt or even die. That’s life. That’s death. Most births will turn out just fine — unassisted, midwife-attended, obstetrician-attended, low-risk, high-risk, VBAC, elective repeat C-section.

If I were to plan a UC, I think that my not knowing all of the complications that can arise (which midwives do know) would bother me more than having a midwife there who might possibly step into my birth space, because I like to know and understand all facets of a process or event before stepping into it. So, were I to plan a UC, I would take a lot of time to research the common complications… and then rather than it being, “midwives’ training in how to handle complications would inevitably instill fear in the birth process,” it would become that my training (or lack thereof) in how to handle complications would inevitably instill fear in my birth process. For my part, I’d rather turn the training and fear and study of complications over to someone else, so that I can get out of my head and into la-la-labor land.

“Constellation of Values”

I’m blogging as I’m reading Dr. Rixa Freeze’s “Born Free” doctoral thesis — breaking up the different thoughts into workable posts. I know I have a tendency to talk/write a lot, so if I put all of my thoughts on the dissertation into one post, it would be very long indeed!

On the 158th page of the pdf (144 of the document), she uses the term “constellation of values” to describe the group of values or beliefs or parenting choices that often accompany unassisted birth; and I might add, often accompany home birth or natural (that is, drug-free) birth. From her paper:

Philip D. Holley and Dennis Brewster studied the value and belief systems of people who chose unassisted birth. They found that a “substantial yet selective dissatisfaction with medicine and science, education, government, consumerism, and popular culture.” These families also shared a “deep spirituality, a strong commitment to family and children, and some commitment to nature and tradition.” These two factors have led to a “constellation of values which promotes a core set of six beliefs, specifically unassisted home birth, home schooling, attachment parenting, extended breast feeding, non-vaccination, and non-circumcision as well as selected peripheral beliefs.”

From the footnote at the bottom of the page:

Holley and Brewster first used this phrase when they presented their paper in 1998. I had begun using the
same phrase before I discovered their research into RIF [Re-Invented Family]. I like the imagery of the word “constellation” — it implies a clustering of values that are interconnected, yet independent enough that the absence of one or two would not significantly change the overall contour of the behavior.

Reading that term sparked something in me. It’s just perfect to describe the phenomenon. I had previously tried to find words to describe my thoughts, and never felt like I had done so adequately — that I was lacking something… or in trying to fully comprehend what I was thinking, was going overboard. But that little phrase is a perfect summation: constellation of values. Most of the people on the various email lists I’m on certainly share these same beliefs — although not all may practice their “ideals”, due to extenuating circumstances.

In addition to the “core values,” the “peripheral values” are described as follows (on the following page):

In addition to the main six beliefs, Holley and Brewster also identified peripheral beliefs that some, but not all, adopted. Some of these beliefs affected daily home life, including vegetarianism or other dietary restrictions, cloth diapering, not owning televisions, rarely or never hiring babysitters, practicing gentle discipline, and running home-based businesses. Other peripheral beliefs included alternative medicine and natural family planning, if birth control was used at all.

I’d love to hear your comments on these topics — do you practice any of these things? why or why not? Do you sympathize with them, but don’t do them yourself? Are you strongly committed to some or all of these? Do you find yourself agreeing with most of them, but oppose one or more aspects of these values? (Page 160 of the pdf has all of these values listed in a chart.)

Birth Rape

Continuing in Dr. Rixa Freeze’s Born Free doctoral dissertation, starting on pg 118 of the pdf (pg. 104 of the dissertation), Rixa begins a discussion on “Birth-rape,” which is of course, highly troubling. Some women will choose to use the word “trauma” instead of “rape,” but the idea is definitely conveyed — outsiders doing things to a woman (specifically her genitals) against her wishes, and sometimes even against her explicit objections. The discussion goes on for several pages, and I think everyone involved in birth needs to read this, so that they can be more attuned to the concept — that some women feel traumatized by past births, or can become traumatized by future ones; that sometimes doctors and nurses can cause or contribute to those feelings; and that these things are real. Several women that were interviewed for this paper described previous birth experiences as either traumatic or “rape” — and this wasn’t restricted to hospital births attended by male doctors, but included births attended by female doctors and midwives in the hospital, as well as home births attended by a midwife. These experiences were so bad for these women, that the only way they could feel safe in birth was to go unassisted, since they could no longer trust medical personnel not to abuse their power as “professionals” or their office of trust.

One midwife who later came to believe that she had participated in “birth rape” said:

As I learned to be a midwife, I did horrible things to women in the name of education. I have held women’s legs open (“to get the baby out”). I have pulled placentas out (“to learn how to get one out that needs help or if the mom is bleeding”)….I have done vaginal exams on women who were screaming NO! I have coerced women to allow me into their vaginas for exams….I have manually dilated a cervix on a woman having a waterbirth (and I wasn’t wearing gloves) and got her cervical flesh under my fingernails.

As a doula and student, I stood by and watched as women screamed to be left alone. I watched midwives with 3 inch fingernails shove cervices from 3 to 10 [centimeters] in a few minutes. I watched as women had Cytotec inserted into their vaginas secretly….I have seen and heard women be screamed at to shut up, grow up, that she asked for it by opening her legs 9 months ago, that she gets what she deserves. I have seen a woman slapped by a midwife.

Rixa goes on to say, “Because such practices have become routine, few maternity care givers consider them abusive or inherently inappropriate.”

This is unfortunately all too true. You don’t have to look very far to find stories of women who were yelled at, sneered at, made to feel bad somehow (even stupid), forced to lie in bed, physically moved from a comfortable position into an uncomfortable one simply for doctor convenience, given unnecessary vaginal exams, given rough vaginal exams, cut unnecessarily, sutured unnecessarily, not given anesthesia for the suturing, etc. And this can happen even with “nice” midwives and “nice” nurses and “nice” doctors, which is the most troubling fact.

And this is why some women leave medical care and go unassisted — because they don’t like the way they were treated. After all, if you got raped when you went to a bar, would you go back to that bar again? I wouldn’t. And maybe not just that bar, but any bar, because that’s (obviously) where the rapists hang out, since one was hanging out there and raped you.

Average care in the early part of this century is better than average care in the 50s — there is more patient autonomy (no mandatory general anesthesia, major episiotomies, forceps births, etc.); but just because it’s better than it was doesn’t mean it’s as good as it can ever be, nor as good as it should be. Just as hospitals looked closely at their policies in the 70s with the advent of the “natural birth” movement and reemergence of midwifery, in order to keep women satisfied with giving birth there (not requiring general anesthesia any more, allowing husbands to be there when giving birth, making hospital rooms more “homey”), even so hospitals ought to look at their policies of today and address areas of discontent that many women have — including the area of loss of autonomy which the woman may process like rape.

“Born Free,” a doctoral thesis

When you see “doctoral thesis” or “doctoral dissertation,” does it almost make your eyes glaze over, expecting long words like dieythylhydroxychlorothiazide? This one shouldn’t! Written by Rixa of “The True Face of Birth” (now “Stand and Deliver”) to complete her doctoral degree, it doesn’t contain 15-syllable words like one might fear, but is written in her clear and concise style. Although it is long (368 pdf pages), a lot of it is introductory material (you know those stupid title pages that take 3 sheets of paper with 5 words apiece) and the bibliography; and it is typed, double-spaced with 1&1/2″ margins, so it’s really not as long as it seems. And it is chock-full of information.

Rixa (or I suppose I should call her Dr. Freeze, since that is her name), 🙂 had her first child unassisted, and has been a midwife assistant for both a CNM and a CPM. This paper delves into primarily unassisted birth — that is, a woman who intentionally gives birth without a midwife present — but also presents it in the background of the history of obstetrics and midwifery, discussing “Twilight Sleep”, Lamaze, the Bradley Method, etc.

Whether you’re deeply interested in unassisted birth, slightly interested, or even not interested at all (but are still a birth junkie), I think you’ll enjoy reading this paper. Even if you think UCers are crazy, at the least you’ll get a bit of understanding about who they are and why they choose to give birth without a midwife.

I’ll be blogging more about this as I read through it, so stay tuned!