Tuesday, April 29, 2008

Guest Post #2: Judgment, Fear, and Focus

Laureen is the technical editor and online community advocate for java.sun.com and developers.sun.com at Sun Microsystems, a freelance editor for Hunt Press, and a contributor to several peer-reviewed group blogs. She's a blogger, a podcaster, a website manager, and an enthusiastic geek enabler. She's the mother of two gorgeous children, and the wife of a man who understands her birth passion. She's had one iatrogenic unnecesarean, and one triumphant HBAC.

Judgment, Fear, and Focus

For only having two children, I have pretty much the range of birth experience; my first was a planned birth center birth turned hospital transfer with epidural turned cesarean. So there's the complete spectrum of medicalized birth. (At the time I was planning it, I thought my birth center birth was non-medicalized. I learned the hard way about medical midwifery.) My cesarean was brilliant, as these things go. The doctor was near retirement, had a 40% cesarean rate in his private practice, and knew what he was doing. I was too ignorant to even ask for things, but upon examination of my medical records, I got a Cadillac of a cesarean. Sheer dumb luck, that was. But despite that, due to hospital protocols, my baby spent the first four hours of his life with strangers; four hours we'll never get back.

For my second birth, I had an unassisted pregnancy, followed by a home birth with a midwife.

The move from home to hospital for birth in our culture involved a paradigm shift, whereby medical professionals convinced women that they were incompetent to birth without assistance, despite millennia of successful field testing to the contrary. The move to reclaim women's power by bringing birth back under their control is involving another paradigm shift, and that's going to be uncomfortable, and it's going to upset people. I think it matters that I know all kinds of women who've gone from hospital births to home births, but only two who've gone the other way, even if the home birthers ended up transferring ultimately. Because of my own experience, I am strongly biased towards home birth, and I admit that up front. On the other hand, because of the experiences of women I know personally, I would rather gnaw off my own arm than deny women the right to choose to birth in a hospital.

One of the things that really bothers me about the comment-foo on Rixa's blog is the complete abandonment of logic. Instead of classical logic, symbolic logic, the construction of actual arguments based on fact, we saw logical fallacies. Use of fallacy in argument invalidates the whole thing, in addition to bringing the entire discussion down to blows in short order. This does nothing to contribute to the betterment of women and babies; it sets us against each other for no purpose whatsoever. The thing about a good, solid, well-constructed argument is that invariably, both sides of the issue learn something and see further into their opponent's mindset. Everyone is bettered, perspective is gained, and we're that much closer to being a unified force...unified behind the true betterment of the situation here for mothers and babies.

I'd like to address a few of the real arguments brought up in the course of the commentary on Rixa's post...

Always be suspicious of motive when someone tries to make you do something that makes a lot of money for them

Maternity "care" is critical to the profitability of a hospital, and the more this can be managed, the more profit a hospital makes. The cesarean rate in the US is at levels so high (31.1% in 2006) that the World Health Organization considers it to be a "crisis." Scheduled cesareans are the epitome of optimally profitable managed birth. UnitedHealthcare sends maternity patients a brochure in late second trimester, offering them the option of a scheduled 39-week cesarean.

My cesarean, NICU stay, and hospital stay netted the hospital nearly $27,000, the anesthesiologists nearly $11,000, and a heap of other people other monies, and cost my insurance company a bundle.

My home birth cost my insurance company $3,000. Period.

So who stands to make money off my choice of birth? Hmm...

"You should be grateful you have a healthy baby/All that matters is a healthy baby"

Well, yeah, of course. But that's so not the whole story. Read Gretchen Humphries' brilliant essay "You Should Be Grateful."

There is room in this world for good experiences for both.

"Birth is about the baby, not the mother"

This letter, published in the ICAN eNews a little while back, says it all.
I am a lawyer who went to a top ten law school and then to a top tier firm. I used to be very mainstream in my views. I thought women who chose to give birth at home were reckless. When I got pregnant and was given the option of having a c-section, I readily agreed. I never went into labor and my c-section went flawlessly. I researched it, so I expected that my arms would be tied down, that I would likely shake from the anesthesia, and that I would not be able to hold my baby. That was ok, because I was ready for it. I handled the drugs well and, as a result, actually remember the first 24 hours. My recovery was uncomplicated.

My daughter, however, got the worst of it--which isn't even really that bad considering other stories I've heard. She was so sleepy and zoned out from the drugs that we had to put ice on her bare skin to wake her up enough to feed. She developed jaundice as a result of not eating enough. Because she couldn't feed properly (because she was so drugged), my milk never came in properly--which was a problem since it turned out she was allergic to all of the formulas they had. Given her allergies, breast milk would have really helped. She kept losing weight. She was diagnosed with failure to thrive. It was a very scary time, because we thought she might die.

On a long term basis, because she never came through the birth canal, her gut didn't get colonized with the right bacteria. That translates into the gut and immune system dysfunction she has today and the medicine that we give our 3.5 year old 5 to 6 times a day. She is also on a severely restricted diet--no wheat/gluten, dairy/casein, soy, citrus, etc. Bacteriologists say that the first germs that the baby is exposed to will set the tone for the baby's life. Those germs really need to come from the vagina.

The c-section went well for me, personally. I was very, very lucky as you will see from other stories you read. It did NOT go well for my daughter. I am now pregnant with a second child and plan to do all I can to deliver vaginally. A c-section still seems like an easy choice sometimes. Indeed, if I were giving birth to a tumor, not a baby, I might be inclined to do it, in spite of the crazy risks. But I will not put this baby at risk.

I'm a litigator and I love evidence. Crazily enough, the evidence is strongly in favor of vaginal birth. I believe that the cavalier attitude of OBs toward this major surgery is a result of a combination of factors (preference for control, fear of malpractice, higher payment, surgery is more "fun," lack of education on natural birth as opposed to how to manage an impending crisis, etc.). But carefully look at the evidence first, before you make up your mind. The evidence really does speak for itself and I'll let someone else who is better versed in the evidence point you in the right direction.

And with cesarean delivery, the baby itself is more likely to die. The US has the second worst newborn death rate in the developed world, despite the fact that we spend more money on "medical care."

How is it that we forgot that babies and mothers are a dyad? You can't truly separate the well-being of the mother from the well-being of the baby, not even with a scalpel. Go ahead; tell me that a mother who lives and a baby who dies, or a baby who lives and a mother who dies, deserve to be a separate statistic. I don't know a mother or a child in either circumstance who doesn't have a little bit of them die too, even if the statistics don't neatly account for it.

"But women used to die in childbirth!"

Read the news; they're dying now. Ask the families of Tatia Oden French, Valerie Scythes, Melissa Farah, Caroline Wiren, how they feel about the safety of hospital birth. Ask Claudia Mejia. Ask Amber Marlowe. Ask Dennis Quaid how safe hospitals are for babies.

Disaster can strike anywhere. But the idea that hospitals are inherently safe is not valid, and demonstrably so. There is no choice you can make that's an automatic get-out-of-jail-free card. The reason most women default to hospital birth is because that choice is presented as being blameless. If something happens in the hospital, well, that's just bad luck, but if it happens at home, that's bad decision making, with the mother occupying the role of bad guy, all by herself. This is not fact, this is not logic; this is marketing spin.

On Judgment

I have been told that my cesarean was a personal failure. I have been told that having a midwife present for my second birth was a personal failure. I have seen fully-medicalized birthers rip midwifery advocates apart, both live and online. I have seen women spend an ungodly amount of energy and time shredding at each other.

For what? I deeply believe that women who choose hospital birth do so because they want the safest and best for their babies. I deeply believe the same thing of the home birth set. So why are we still attacking each other?

Fear. And Judgment.

In the final analysis, birthing carries risk. Living carries risk. There are no guarantees anywhere that if you make all the "right" choices, you and yours will be saved from tragedy. Lightning strikes, and all the planning and research and analysis in the world will not save you from that. It comes down, in the end, to supporting each other the best we possibly can, to making our choices from a place of confidence, not a place of fear. If you're birthing in a hospital, do so because that's what feels safest to you. If you're birthing unassisted at home, do so because it speaks to you and feels right to you. Fear has no place in any decision about birthing.

A friend of mine who just had what she calls her "victorious homebirth after two cesareans" says:
Since our life-changing home birth I've encountered so much more support than we imagined possible. I cannot believe how many friends and acquaintances have said, "I sure wish WE had seriously considered birthing our children at home." Obviously there is a slow shift being made in the birthing climate of America. But there are also many other comments we've heard like, "I'm glad it worked out for you," which I now see as such a pitiful way to view birth--like it's a matter of luck. But I know that's the reality for most people. If these critics knew the amount of time, prayer, and research we put into this decision and into the type of provider we selected, they might have to consider why EVERYONE doesn't invest that kind of time and prayer in their own birthing decisions. For us, the search was priceless and ultimately put us in far better control of our decisions. And beyond the stats and truths we uncovered during this journey, we discovered something far more valuable: faith. After asking for guidance, begging for deliverance, and recognizing our answer, I was overcome with a peace that I have to say I've never experienced after praying before--and as the preacher's daughter I've spent a good many years on my knees in prayer. It was amazing to simply ask and to find the undeniable peace we so desperately desired. So THIS is what answered prayer feels like. I understand that's not much of a factor in modern society, which makes me incredibly sad.

We've also had to endure a number of horrible birth stories where someone nearly died "even in a hospital birth" (the fetal and maternal monitors didn't discover there was a problem until it was too late). I'm never sure how to take this kind of response to the introduction of our new baby. If these tactics are in an effort to get me to debate the home vs. hospital issue, I'm not taking the bait. My decision isn't up for debate--especially with those who've invested little in the search for truth other than personal experience and hearsay. I can respect your birthing decision if you can respect mine.

Standing together, we can do so much more good for everyone, than we can by compartmentalizing each other and shredding on anyone who doesn't share our precise set of birth circumstances. Different does not have to equal wrong. But the way things are right now, fear is controlling the cards, and we need to put down our differences, and stand together for a set of choices in birth and baby care that puts the U.S. back up at least in the top 10, because when it all comes down...the choice between home and hospital is not the point. The point is that women and babies are dying in utterly unacceptable numbers, and they're dying because our social, medical, and economic systems are not supporting women.

And women are not supporting women either. So let's focus on what matters.

24 comments:

  1. Yup, yup, yup. Just nodding my head in agreement to this whole post.

    Also don't forget that maternal mortality used to be so incredibly high thanks to doctor's total ignorance of pueperal fever, no antibiotics, lack of blood donations for transfusions, and no adequate medical facilities for when true emergencies DID arise. It's not simply a matter of OBs themselves swooping in and saving women from their dangerous bodies. It's medical science as a whole improving. Hell, women and babies are STILL dying from infections running rampant in hospitals (MRSA anyone?), even with our current knowledge of sterilization and cleanliness in general.

    I read somewhere (don't remember where) that birth mortality rates in the 1400s in Europe were nearly the same as they are now in the U.S. - somewhere around 14 in 1,000. Pretty damn good for the Middle Ages!

    Oh, and I really, REALLY hate the "you should be grateful" schpiel. What a misogynstic attitude. You're just a pitiful WOMAN, you don't matter, you are just a baby vessel. Whatever trauma you endure means nothing, as long as your baby is okay! Need we remember that a mentally, psychologically, or even physically damaged mother is sometimes not a very good parent for that precious baby? Now there's something to consider...

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  2. Excellent post. I'd love to say more, but that sums it up.

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  3. I am really let down. I though since you are a lawyer, you would give me reasonable evidence. CNN and anything they do in Austrailia are not good arguments!

    BMJ I would accept. Even though I feel they are biased.

    There are studies in the Medical library that state "If you have a C-section, you are at much higher risk of a hysterectomy." I witness two this week. "IF you have a C-section you are more likely to have subsequent miscarriges."

    I am going to go look these up now.

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  4. Who's a lawyer? I'm not!

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  5. Jen.b.in.az4/29/08, 4:36 PM

    I think Pinky is referring to the quoted letter from ICAN, and mistook the guest author as that author...

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  6. Heya Pinky...

    Nothing from Australia is worthy? Goodness. That's a bit broad, don't you think? I wonder what Dr. Sarah Buckley would think of that.

    In the interest of not writing a small novel, I edited out the hunk of my post where I discussed my personal perception that folks seem to beat each other to death with research, without actually making any real progress. It's been my experience that anyone can find a source of varying robustness to back up pretty much any claim, and if you don't like what science is saying today, hey, wait for a shift in the global economy to see something new.

    And I am not a lawyer. =)

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  7. I don't think she meant Sarah Buckley but me. Luckily I'm Welsh and not Australian.
    I Agree with you Laureen, "There are lie, damned lies and statistics".
    Thanks for the great posts Rixa and guests.

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  8. I thought the poster was a lawyer. No? Well, my bad.

    Austrailia is very different from the USA in terms of how they do things. Just like it depends on where you are located, how the hospital behaves. I have heard horror stories that I don't doubt are true from other nurses in other parts of the country.

    I am interested in the research because that is what is used to decide what to do in my hospital. So when you point my into a direction, I look. So I was disappointed.

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  9. Lisa I wasn't thinking of you. I had a family member who did a fellowship in Austrailia and yes, it has colored my perception of medicine in Austrailia. I mean if you can't get sterile technique down in the surgical area, you have big problems. That problem will mean more infection. More post C-section complications.

    I have heard the same complaint by our Surgical folks who do time in Iraq.

    What you can complain about problems in the US Hospital system, but I cannot complain about Austrailia?

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  10. I liked the remark that the choice of hospital is the BLAMELESS choice; a bad outcome there is bad luck and everyone's conscience is clear.
    Sympathy during a tragedy is a basic human need, but when I chose home birth, I couldn't be sure any more that I would receive sympathy if a tragedy did occur.
    I wonder how many mothers who say they wouldn't be able to live with the guilt if anything happened at a home birth are also desparately thinking, they wouldn't be able to endure all the scorn and contempt, unspoken or not. I wondered if I would be able to. See the reactions to an innocent post about a pretty placenta print?

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  11. With all this fuss about Australia, did anyone bother to actually read the article? It's an Australian news source discussing research from *America*, not Australia.

    "The study [published in _Birth_], which involved more than 8 million births in the US over four years, is the first of its kind to focus on full-term babies born to women with no medical reason for choosing a caesarean over a vaginal delivery."

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  12. Yes, but watch out, the study " should be treated with caution [as]It's been done by statisticians, not obstetricians or midwives," wink

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  13. I think we have the journal "Birth" in the library. I will look it up. Thanks

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  14. This is a fantastic post!!

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  15. What an excellent post. I also don't think it's fair to a mother who's experienced a c-section to say "you should be grateful...".
    If I had a friend whose child had emergency surgery, and she was telling me how emotionally difficult it was, the proper response is not, "well you should just be grateful she's healthy now, that's all that matters."
    I really hoped that someone would have just told me "I'm glad your baby is healthy, but I'm sorry you didn't get the birth experience you were hoping for."

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  16. Sarahlianne, I appreciate the spirit of your comment--but I want to point out that perhaps even referring to a traumatic birth as not the experience the mother wanted kind of makes her seem picky. It's just too reminiscent of the cliche that birth isn't about having an "experience".
    Saying something along the lines of Glad your baby is OK, was that really scary? are you hurting? how are you doing? etc. When my SIL had a cesarean when I was 36 weeks pregnant and obviously super empathetic, all I could think to say was You have been through so much. You've just made an enormous sacrifice for your daughter. I think it needs to be acknowledged as a sacrifice.

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  17. I loved this post, especially this quote...
    "It comes down, in the end, to supporting each other the best we possibly can, to making our choices from a place of confidence, not a place of fear. If you're birthing in a hospital, do so because that's what feels safest to you. If you're birthing unassisted at home, do so because it speaks to you and feels right to you. Fear has no place in any decision about birthing."

    If we can support each other and help moms let go of their fear of birth, than much change can be made for birthing women!

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  18. I was really inspired by this statmement: "This does nothing to contribute to the betterment of women and babies; it sets us against each other to no purpose whatsoever. The thing about a good, solid, well-constructed argument, is that invariably, both sides of the issue learn something, and see further into their opponent's mindset. Everyone is bettered, perspective is gained, and we're that much closer to being a unified force... unified behind the true betterment of the situation here for mothers and babies. "

    In fact, I'm working on my own blogpost about it.

    And as a woman who has experienced trauma (both birth and otherwise), I can tell you that a woman's birth experience is *hugely* important and has effects much beyond the actual day of birth.

    I've spent a lot of time reading women's birth stories, and time and time again, when a woman feels disempowered, disrespected, violated; she feels traumatized.

    This *is* important. So important that I'm working toward change. Along with another therapist, I am designing a program to educate mental health and birth providers about the impact of traumatic birth so that women's experiences are validated.

    Thank you for sharing your experiences and thoughts in this fantastic post!

    Christie, NY

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  19. This was an excellent piece of writing, really. I am going to link to it from my blog so that others can find it!

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  20. Terrific post! I especially loved the breakdown of cost & this section "If something happens in the hospital, well, that's just bad luck, but if it happens at home, that's bad decision making, with the mother occupying the role of bad guy, all by herself. This is not fact, this is not logic; this is marketing spin." The whole mother/baby dyad concept is discussed at the end of the book Pushed, too - I thought it was a great take on it - that the goal should be to have a healthy FAMILY, because mothers don't make decisions without thinking about the healthy baby (pg. 271).

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  21. Excellent post & most comments.

    Independent of where I stand on this debate (and the not-a-lawyer-author knows my take), PLEASE, pinkie, do spell Australia correctly if you use that word so often...

    ;-) FR

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  22. "The study [published in _Birth_], which involved more than 8 million births in the US over four years, is the first of its kind to focus on full-term babies born to women with no medical reason for choosing a caesarean over a vaginal delivery."

    Sorry Rixa. I read the article. She used Birth certificate information. That is how she was able to get 8 million birth in there. Birth certificate data is not very reliable. Historically Birth certificates are not filled out correctly addressing the mothers preadmission medical history.

    I have a copy if you want me to email it to you.

    I viewed a few articles in the Birth Journal and they all seemed to follow a certain theme of babywearing, breast feeding, scandinavia is fabulous jist....

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