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.

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“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!

“Freebirthing” on Discovery Health Channel

This TV documentary first aired in Nov. 2008, and I finally watched it the other day (my mom taped it, but I’ve been too busy at her house to sit and watch it every time I’ve gone over there)… and it’s coming on again soon. While watching it, I took notes with the intent of talking about it fully, but since I’ve found out that it’s airing in a few days or so, I don’t want to spoil it for any of you who haven’t seen it yet.

“Freebirthing” is another name for “unassisted childbirth” (UC), or giving birth without any medical professionals around. A few women take it to the extreme of planning (or wanting, but not quite planning) to give birth completely alone, without even their husbands around, but most have the baby’s father and/or one or more friends in attendance. For my part, even if I was 100% positive that absolutely nothing would go wrong with either me or the baby, I’d still want my husband there as well as a doula or midwife. I wouldn’t want a lot of people, because I think I’d feel self-conscious; and assuming it would be in my home, I would still be partly playing the part of hostess (making sure they were comfortable, had enough to eat or drink, telling them where the glasses were, etc.), which would interfere with labor. But I’d want the company in labor, for sure, as well as a knowledgeable woman who would help me, especially with back labor (which I’ve had both times I’ve given birth, so assume I would have again).

I’m in a unique position, in that I’ve had an unplanned unassisted birth. I’ve gone through labor once without anyone around, and wouldn’t wish that on anyone — or at least, not unless it’s a very short, precipitous labor and birth. If someone chooses that, then I suppose that’s fine; but when I read comments from women who promote entirely solo labor and birth as their ideal, I tell them my experience so that they know it just might not turn out the way they dream. It sucks not having anyone to talk to, or to encourage you, or to apply counterpressure when the contractions hurt your back. It just sucks, and I think women need to be prepared for that possibility, and not just assume that since there isn’t anyone around interfering with the labor space, labor energy, or labor dance that it will be the best birth imaginable.

On to my review of the show.

It follows three women who plan an unassisted birth: Claire is in London and is giving birth to her 3rd child, without the father around; Heather is in Colorado and is giving birth to her and her husband’s 2nd child, after enduring a load of unwanted interventions with her first baby; and Cleo is in Wales (I think), giving birth to her and her husband’s second baby.

Throughout the show, there are various bits of interviews with doctors and midwives who question the reasoning behind why women would give birth unassisted, and telling of some of the possibilities that might happen which could put the mother or baby at risk. One doctor, however, seems to think that “unassisted” means that the woman will be entirely alone, because he gives the “what-if” of her having a horrible hemorrhage after birth and being unable to make it even so far as to a telephone to tell someone she’s bleeding massively, so they can come in and save her. Obviously, if a woman is giving birth with a husband, friend, doula, or anyone around, this isn’t going to happen — even if the doctor is correct that she would bleed so much in just a few minutes, there would be someone right there to call emergency services immediately, without a word from the mother.

Since I don’t want to spoil it for any of you, I won’t go into the specifics of the women nor the births — I’ll let you watch all of that on your own.

I will say this about one of the doctor interviews in the early part of the show — she expresses some disbelief that women would do this, and asks why would they take the “extreme” risk, when there is every medical benefit available in the hospital. When I heard this question, I thought, “She answered her own question, didn’t she?!”

Why is “freebirthing” growing in popularity? Part of it may be hearing other women’s glowing reports about how they felt at their child’s birth — some particular something about the narrative appeals to other women, who also want to feel that way. Some women report painless or less-pain labors and births when not having a midwife, doctor, or nurses around. Some women talk about the empowerment of “the buck stops here” acceptance of responsibility when taking this step. Some women may choose UC for the same types of reasons other people choose to climb Mt. Everest or go sky-diving or something. Some women may just like to thumb their nose at all authority, so if the authorities tell them to birth in the hospital, that’s the last place they’ll go; if they say women must have a birth attendant, then they absolutely refuse. There are other facets, undoubtedly, that appeal to some women. But if doctors, midwives, and anyone else who dislikes the idea of UC really want to limit the trend or stop it altogether, they must figure out why women go to this extreme, and take the risk (which is small, but it is there), rather than to have a midwife attend them at home, or to go to the hospital. UC can’t really be outlawed — after all, a woman could just say, “Oops! It happened too fast!” and as long as she didn’t have any evidence to the contrary (such as telling people prior to the birth she was planning a UC, telling her birth story about her long drawn-out labor in which she refused to go to the hospital, videotaping the birth, etc.), what could be done? So, if doctors or midwives want to stop this, they have two choices — scare women out of doing it, or make the alternatives more appealing.

The scare tactics won’t work… or at least, not well. The plain truth is, most of the time, even in the worst of circumstances, everything goes right. Look at Sierra Leone’s statistics, which has among the worst if not the worst statistics when it comes to maternal, neonatal, and infant mortality. Even with a 2100/100,000 maternal death rate, that means that for every 100,000 women who give birth, 97,900 women survive; about 2% do not. And that is the worst country in the world, with undernourished women, early marriages and children giving birth to children, and with almost no skilled prenatal, intrapartum, or postpartum care. Their neonatal statistics are likewise appalling, but also most babies make it. No, I’m not saying that this level of mortality is okay, but if the most dangerous place to give birth in the world has this small of a percentage of deaths — without quick and easy transports to hospitals, or simple life-saving measures like blood transfusions or antibiotics — then trying to scare women that they’ll be one of the unlucky ones will not work. Playing the odds, they’ll do just fine, and so will their babies. They’ll hear one bad story but ten good ones, or twenty good ones, or a hundred good ones. They’ll “forget” the bad one, or say “it won’t happen to me because…” And, odds are, they’re right, because most births, from the most unassisted of the unassisted, to the most medical of the medical, will turn out just fine. Not all will; but they’re willing to play the odds.

Why? Because the alternative is undesirable to them. Most women who give birth at home (unassisted or otherwise) have already had one or more hospital births, so they know just what they are walking away from. What is it about hospital birth that is so undesirable to us home-birthers? That is the question those who oppose home birth and unassisted birth should really, really consider. Rather than tossing it off as a rhetorical question, they need to realize that they already have the answer. In some cases, women endured horrible experiences at the hands of those who were supposed to care for them — they speak of it in terms of rape and assault.  Heather, the American UC-er on the documentary, was threatened with a C-section at full dilation if she didn’t push right — she ended up pushing very hard and the baby came out in something like ten minutes, and she wonders why the threat when there was no need? She chose to give birth unassisted the next time around, rather than place herself in the hands of people who treated her so poorly in her first labor. Then the question becomes, are they — the doctors and others who oppose home-birth — willing to make the changes to accommodate our wishes and needs, so that we will have no qualms about hospital birth? As long as the answer remains no, home-birth and unassisted birth will continue to increase in popularity.

Dr. Rixa’s “Born Free” thesis

Some of you may already be familiar with the True Face of Birth blog by Rixa Freeze. She has recently earned her doctorate, with her doctoral thesis being written on unassisted birth. I look forward to reading it in the near future (but at 368 pdf pages, it’s a little much for Monday morning, even if 15 of those pages are bibliography). 🙂 Enjoy!

Home birth, unassisted birth

Here is a long article from the Baltimore City Paper entitled “Home Made: Inside  Baltimore’s Home-Birth Underground.” Although I didn’t read all the article — as I said, it was very long — I did read the first several paragraphs, and skimmed the rest. It seemed like a fair, well-balanced article discussing home-birth with or without a midwife, as well as hospital birth.

It also made me think about a couple of points that are more common to home birth than are typical among women who give birth at a hospital.

First, many states do not have legal home-based midwifery. While most states technically allow certified nurse-midwives (CNMs) to attend home births, most of the time they are restricted by what their back-up OB will allow. Some states require CNMs to “risk out” all but the very lowest-risk women; many times these women refuse to go to a hospital, preferring instead to give birth without any attendant other than their families. Some midwives are technically free to attend home births, but it is made very clear to them that if they do, they will lose hospital privileges where they work. For women in these states who would very much like to have a legal home-birthing midwife but cannot find one, their choices are limited to having a hospital birth, having a home birth with an illegal midwife, or having an unassisted childbirth (UC). Even in states that allow and have legal home-birthing midwives, many times if a transfer is necessary, hospitals treat the women poorly for having planned a home birth.

When midwifery is illegal, women still seek it; but there is no “safety net” in a lot of ways. First, if the midwife is incompetent, there is no revocation of her license, because she wasn’t licensed in the first place. Second, if a transfer becomes necessary, many midwives are not allowed to continue to attend the women in the hospital. Sometimes midwives show up with women at a hospital as merely a doula, so that they can continue to serve the woman who chose them as the birth attendant. Sometimes midwives might resist the idea of a transfer, even when it is obviously necessary. This may be due to fear of prosecution.

But women who choose home births tend to make the decisions instead of “oh, whatever you say, doctor.” Some women refuse a transfer even when the midwife strongly suggests it. What should the midwife do then? Should she stay and attend the birth, even knowing that the birth has moved out of her realm of knowledge and expertise? Should she leave, to show her level of disagreement with the laboring woman? If she leaves, it will be said by anti-homebirth people that she “abandoned her client when things got out of hand.” If she stays, it will be said by the same crowd that she “didn’t transfer when she should have.” Talk about a rock and a hard place!

The above-mentioned article also talks about how that statistics are grouped into fairly large categories. For example, some stats have all out-of-hospital births in one category — whether the birth was a planned out-of-hospital birth or not, regardless of who attended the birth (midwife, father, construction worker on the side of the road, taxi driver, EMT). It also said that in many states where certified professional midwives (CPMs) are not legal, the births are recorded as unassisted “to keep the midwife off the bureaucratic radar.”

Here is the paragraph in which the mother featured in the article explained her decision to have an unassisted home birth:

“The first two times there were a few issues with both my care and the baby’s care,” she says wryly. While in labor with Joseph, Alana says she was given pitocin (a synthetic hormone that speeds up contractions) without her knowledge or permission, and another drug caused her to hallucinate. During Keira’s birth at a now-defunct birth center, each time Alana’s labor plan diverged from birth-center policy the staff threatened to transfer her to the hospital for a cesarean section; even worse, immediately after Keira was born, they took action that potentially endangered the neonate. There was meconium stain–feces passed by the baby in utero, which happens in approximately 13 percent of births–when Keira was born, and, as Alana explains, “studies show that if the baby is alert and crying, suctioning in the presence of meconium will do more damage than good–it can cause pneumonia. I repeatedly told them not to do it, and even gave them the reference number of the article, but they just did it anyway. It was maddening.” [emphases mine]

While Dr. Amy of course had to weigh in (the comments after the article are quite lengthy as well!) trying to scare everyone out of giving birth at home, it made me think, “If some people are concerned about women choosing home birth, I suggest that the better way to deal with the situation is to see why women choose home birth, and to see what they can do at hospitals to make them more attractive than home for birthing. Instead of legislating away a woman’s choices, they should actually **listen** to women and respect them enough to be accommodating to their desires, instead of just ignoring them like second-class citizens, whose desires and wishes are unimportant, compared to doctors and hospitals and protocols.”