Rebekka Visser: Guidelines and Realities, Dreams and Controversies

First International Breech Conference, Day 1

Rebekka Visser

Guidelines and Realities, Dreams and Controversies

A Dutch midwife from Usquert, Rebekka Visser is an advocate for women who want hands-off, self-directed breech births. Her midwifery practice is called Springtij.

In lieu of posting a summary of Rebekka's remarks, I will direct you to her blog, where she posted her presentation: "Let's Look Beyond Our Fishbowl."

At the end of Rebekka's lecture, an audience member asked other attendees about how breech skills are taught in their locations. Is breech taught as an emergency procedure? Or is it taught as a normal birth skill?

We had responses from many other audience members. I remember hearing someone comment that when breech is taught as an emergency skill, the rate of vaginal breech birth in a maternity unit actually goes down. This emphasizes the importance of teaching breech as part of normal birth skills, rather than labeling it as an "emergency."

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Goodbye, Sheila Kitzinger

I just saw the news that Sheila Kitzinger passed away today. Kitzinger's books were some of the first I read when I was first discovering midwifery and home birth. Typical of her spunky self, she was, according to her husband of 63 years, "drinking Kir Royale and champagne and eating chocolates three days ago, knowing she didn't have long."

I'm so sad to lose this wise woman. She's done an enormous service for childbearing women around the world.

Read more about Sheila here at the BBC.

Now, readers, I'd like to know...what are your favorite books by Sheila Kitzinger? (ps...her autobiography is coming out next month!)

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Review of Birth Boot Camp

Below is a review of Birth Boot Camp, an online course to prepare couples for natural childbirth.

Review of Birth Boot Camp

By Diedra S. Jardine

As an expectant first-time mom, I wanted to have an unmedicated birth, and for medical reasons I needed to be in a hospital setting. I knew that I’d need to thoroughly prepare not only to give birth naturally in a hospital but also to avoid unnecessary medical interventions. Birth Boot Camp ($300 for the 10-class course, available at www.birthbootcamp.com) gave me the knowledge and tools essential for preparing for unmedicated birth, and also bolstered my confidence in my ability to succeed. I highly recommend Birth Boot Camp to other women who are looking for tools to help them have a successful unmedicated birth, whether in a hospital, birthing center, or home birth setting.

Birth Boot Camp is a series of ten online classes aimed at couples—not just mothers—preparing for an unmedicated birth. I took some of the online classes on my own and had my husband watch others with me, depending on the lesson material. Each class lasts from one to two hours and is available whenever students wish to view it online.

While the online format inherently precludes interaction between instructor and students, the instructor and other presenters supply sufficient information about most topics as to answer most basic questions that participants might have. A significant number of additional resources, presented as part of each class, guide students in finding further information.

The supplemental resources include stand-alone videos and online resources related to each class, a training manual with weekly assignments and further resources, recommendations for further reading, and a DVD. The supplemental resources offer students further reading on material presented in each class. The weekly assignments contained in the training manual reinforce concepts taught in each online class and assist each student to apply the concepts taught in preparation for the upcoming birth.

Donna Ryan, the course instructor, speaks from her perspective as both an experienced natural childbirth educator and woman who has had multiple unmedicated births. Donna is knowledgeable and her presentation style is engaging. Also a part of each class are medical practitioners—from midwives to obstetricians—who offer medical explanations of certain concepts, as well as couples who prepared for natural childbirth and subsequently had various birth experiences, from unmedicated births to births with various medical interventions.

The ten classes cover topics including the advantages of natural childbirth, prenatal exercise and nutrition, various birth settings, the phases of labor and the immediate postpartum period, support for birthing mothers, tools for identifying when medical interventions are and are not necessary, birth plans, adjusting to life with a new baby, and breastfeeding.

The materials presented as part of each class are thorough and, for the most part, unbiased. Donna does share numerous anecdotes throughout and rarely cites sources when presenting information; women who want a strictly factual course may be put off by Donna’s anecdotal, conversational style. At first I disliked how anecdotal it was, but that only lasted through the first class or two as she was introducing the material. The classes are organized logically, with information presented in each class building off that which was presented previously.

Birth Boot Camp offers thorough preparation for couples interested in unmedicated childbirth. Both first-time parents as well as couples who have had medicated births but would like to prepare for an unmedicated birth can benefit from this course. The course is convenient, informative, generally unbiased while being oriented towards unmedicated births, and well worth the cost. Birth Boot Camp helped me reach my goal of an unmedicated childbirth—which happened for me after four hours of active labor, all of which occurred at a hospital—and helped this be a positive experience for me, my husband, and my new son.

My sister and nephew

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Grand finale

I came home from this evening's orchestra concern on a post-Beethoven high. There's nothing like playing Beethoven's 5th to get your muscles working and your spirits soaring. I was hoping for a nice relaxing evening. But instead, I found a string of posts that got me worked up all over again.

Jill at The Unnecesarean started it all with two posts: Stuff White People Like: Talking About Birth and Convincing White Women that Birth is Painless Will End 'Race Suicide'

Which got Reality Rounds' creative juices flowing with A Birth Blogger Rap

And our intrepid OB/GYN student over at Mom's Tinfoil Hat wrote three replies-turned-posts.
Reply turned post, need to walk away style
Reply turned post, Dr. Amy is still there? style
Reply turned post, Dr. Amy style

I am doing my best not to get sucked in...you know, like this person:

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Wednesday wrap-up

I might start doing a weekly wrap-up of miscellaneous news & articles that I find interesting. If I wait much longer than week, they start piling up rather quickly:

Speaking of upright/vertical birth...

• This midwife-designed stainless steel mirror is designed especially for women adopting upright birthing positions
• Mom's Tinfoil Hat had some thoughts about Standing up for birth

Home birth

• The "Authorities" Resolve Against Home Birth: a recent editorial by Nancy K. Lowe, editor of the Journal of Obstetric, Gynecologic, & Neonatal Nursing ( Volume 38, Issue 1, Pages 1-3). Click on the article title for the full text. An excerpt from her editorial: "The point is that we have no system of maternity care in the United States that provides a healthy woman the choice of giving birth at home and if she needs to transfer to a different type of care during labor, the transfer is easy. We do not have a system in which this woman is treated with respect and kindness, and her provider either maintains responsibility for her care or professionally and respectfully is able to transfer responsibility to another provider. Interestingly, while ACOG and AMA have declared that hospital grounds are the only safe place to give birth in the United States, the National Perinatal Association (NPA) adopted a position paper in July 2008 titled, 'Choice of Birth Setting.' The paper supports a woman's right to home birth services....Further, in Canada following the model of British Columbia, the province of Alberta has recently expanded its health care system to include women's access to midwifery services 'in a variety of locations including hospitals, community birthing centers, or in their homes.' "
• Two Charleston Gazette articles: Midwife delivers babies in mothers' homes and Home delivery: After three hospital births, fourth-time mom was determined to deliver the old-fashioned way
• A Herald Tribune (FL) article narrates how a home birth unfolds in Home Delivery
• An article featuring Womancare Midwives of North Idaho
• Tribute to Maude Callen, a nurse-midwife serving rural South Carolina for over 70 years. Make sure you click on the Life photo archive for lots of fantastic pictures!
  
• Adventures in (Crunchy) Parenting wishes to move beyond binary views of safety
  
• Future Search Conference on Home Birth currently being planned. From the description:
• It will be a multi-disciplinary consensus conference of key stakeholders around the provision of home birth services in the United States, to be convened by the University of California San Francisco and various organizations, including the American College of Obstetrics and Gynecology the American Academy of Pediatrics, the Association of Certified Nurse Midwives, Mothers and Midwives Associated, Lamaze International, Association of Women Hospital Obstetric and Neonatal Nurses, and the International Center for Traditional Childbirth. Further, it is hoped that public health practitioners and students, insurers, government agencies, health economists, medical anthropologists, state and national legislators, and women who have given birth will be among the eventual participants. The purpose of the conference is to start to bridge the "divide" between the medical and midwife communities over out-of-hospital births in the United States. Safety of birth in any setting is of utmost priority. Rights to choice and self-determination and culturally appropriate healing are also core values in American discourse that influence this issue. The purpose of this multidisciplinary conference of key stakeholders will be to craft a consensus policy and strategy on provision of home birth services. The project may also inform regulatory discourse, alternative funding structures, and the required modifications of curricula to prepare physicians and midwives in urban, rural and remote settings to provide maternity services across birth settings.

Research studies & articles

• Evidence-based labor and delivery management. Berghella V, Baxter JK, and Chauhan SP. Am J Obstet Gynecol. 2008 Nov;199(5):441-2. From the abstract: "Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided." (Email me for full text).
  
• Born in the USA: Exceptionalism in Maternity Care Organisation Among High-Income Countries by Edwin van Teijlingen, Sirpa Wrede, Cecilia Benoit, Jane Sandall and Raymond DeVries. Sociological Research Online, Volume 14, Issue 1. From the abstract: "In lay terms, childbirth is regarded as a purely biological event: what is more natural than birth and death? On the other hand, social scientists have long understood that 'natural' events are socially structured. In the case of birth, sociologists have examined the social and cultural shaping of its timing, outcome, and the organization of care throughout the perinatal period. Continuing in this tradition, we examine the peculiar social design of birth in the United States of America, contrasting this design with the ways birth is organised in Europe."
• Postnatal quality of life in women after normal vaginal delivery and caesarean section. Behnaz Torkan, Sousan Parsay, Minoor Lamyian, Anoshirvan Kazemnejad, and Ali Montazeri. BMC Pregnancy Childbirth 2009; 9: 4. From the conclusion: "Although the study did not show a clear cut benefit in favor of either methods of delivery that are normal vaginal delivery or caesarean section, the findings suggest that normal vaginal delivery might lead to a better quality of life especially resulting in a superior physical health. Indeed in the absence of medical indications normal vaginal delivery might be better to be considered as the first priority in term pregnancy." (full text available by clicking on article title).
• Health Care Reform in the U.S. Organisation for Economic Co-operation and Development Working Paper #665, Feb. 6. 2009 by David Carey, Bradley Herring and Patrick Lenain. From the abstract: "In spite of improvements, on various measures of health outcomes the United States appears to rank relatively poorly among OECD countries. Health expenditures, in contrast, are significantly higher than in any other OECD country. While there are factors beyond the health-care system itself that contribute to this gap in performance, there is also likely to be scope to improve the health of Americans while reducing, or at least not increasing spending. This paper focuses on two factors that contribute to this discrepancy between health outcomes and health expenditures in the United States: inequitable access to medical services and subsidized private insurance policies; and inefficiencies in public health insurance." Full text PDF available by clicking on the article title.

VBAC & Cesarean Section

• List of abstracts on VBACs with twin gestations
• Some NHS trusts will no longer offer primary elective cesareans because of cost and safety issues. Read more in Caesarean births rationed by hospitals in order to cut costs
• A midwife-led initiative in Southampton has lowered cesarean rates and boosted VBAC rates

Birth Centers
For Expectant Moms, a Happy Medium Between Hospital and Home Births: profiles the struggles of one birth center to obtain permission to open

Breastfeeding
Pedialyte Alternative recipe (not necessary for breastfeeding babies, but great for older children & adults)

Gardening
25 plants you should consider growing

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Journey into Motherhood

Sheri Menelli has recently made her book, Journey Into Motherhood: Inspirational Stories of Natural Birth, available for free as an e-book. Click here to download it as a PDF. Of course, if you can spare the money I'd still suggest buying a new copy so she receives royalties for her hard work. I haven't read this yet and am glad to have something new to read.

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"I could NEVER do that"

Thanks to The Human Pacifier for an intriguing post about how achieving a "natural" birth in a hospital is an incredible feat. She raises a very important point that having an unmedicated birth at home or in a freestanding birth center is worlds apart (and arguably much, much easier) from a "natural"* hospital birth. Women who achieve this in a hospital really DO deserve a medal! It's so much more challenging than doing it out of hospital. I think women sometimes assume that it would have been/felt the same no matter the location. Perhaps when we're holding conversations about this, we need to emphasize that a lot of the things that cause pain, discomfort, and stress aren't present when you birth outside a hospital, so things are usually much less painful in the first place.

Now, I don't want to turn this into a simplistic home vs hospital kind of post. But that is one of the fantastic advantages of laboring outside of a medical institution! No IVs or heplocks.** No Pitocin augmentation. No fetal monitor straps. No internal monitors. No restrictions to bed. No one asking you to "rate your pain 1 to 10" or "would you like something to take the edge off/help you relax/help you sleep." Generally vaginal exams are limited-to-none or only on the mother's request. No mandatory birthing in the stranded beetle position. No Valsalva pushing ("hold your breath and count to ten and push Push PUSH!!").***

In some ways, I feel like I got off easy. All I had to do was labor and give birth! No fuss, no fighting, no declining this or that. Just birth.

* I really dislike the term "natural birth." It's too vague to be useful and carries a "holier-than-thou" connotation. You know, "natural" is better than "artificial" kind of thing. So I generally use a more specific word depending on what I am trying to convey: unmedicated, physiological, undisturbed, etc.
** Occasionally you will see IVs/heplocks used outside a hospital setting, usually to administer abx if the woman is GBS positive and requests that treatment, or to correct severe dehydration due to vomiting. But these are really exceptional circumstances.

***Okay, okay, I betcha some out-of-hospital birth attendants have done this...and I know that not every hospital does either. But it's true generally.

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Blame the woman

Once again, women are simply too fat and too old, according to this recent article about rising maternal mortality rates in England. Oh, and they have the audacity to want a natural birth--which of course the article didn't bother to define--another alleged culprit behind rising mortality rates!

From the article:

But some medical staff and patient groups also fear the NHS’s policy to encourage “natural” birth without medical assistance is putting women at risk by denying them medical care in pregnancy and labour. Professor James Dornan, director of foetal medicine at the Royal Maternity hospital in Belfast, said: “Nature dictates that one in every 100 women will die while having a baby. The mortality rate in parts of Africa is now about 850 to 1,000 per 100,000. Left to nature that is what nature will do. I believe in women having choice but it has got to be informed choice.

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