Saturday, December 29, 2007

The Best of Both Worlds?

Freestanding birth centers often advertise that they are the "best of both worlds." For example, the Connecticut Childbirth and Women's Center states that "the birthcenter provides women with the best of both worlds--expert care provided by certified nurse-midwives, while emergency care is just a stone throw away" at the nearby hospital. I've often wondered about freestanding birth centers. I think they are fantastic for women who have a need to birth in some kind of institution (whatever that need might be: mental, emotional, lack of a safe home environment) but don't want the whole hospital runaround. I wish that there were more birth centers, so that it would be an option for any woman who desired it.

However, in light of some of the discussion about the photo essay about "homelike" birthing spaces, I'd like to offer up another view of birth centers as the worst of both worlds. Here's why:

Freestanding birth centers offer no technological or pharmacological advantages over home births. Midwives in both settings carry nearly identical equipment. It might vary slightly from midwife to midwife, of course, but there is no additional technology available in FSBC's compared to midwife-attended home births. In both settings, women will likely have access to:
- anti-hemorrhagic treatments and equipment (ranging from herbal tinctures to Pitocin, Methergine, Cytotec, IVs to replace fluid loss and/or stablize in case of transport)
- maternal and neonatal resuscitation equipment and skills (bag & masks, oxygen tanks, suctioning equipment, possibly meds & intubation supplies)
- suturing equipment and local anesthetic
- fetoscopes/dopplers for listening to baby's heart beat during labor
- other equipment for monitoring vital signs (BP cuff, stethoscope, thermometer, etc)

Women in both settings will need to transfer to a hospital for interventions such as:
- operative deliveries (vacuum extraction, forceps, cesarean section)
- analgesia (except in rare cases where some birth centers supply IM narcotics)
- anesthesia (spinal, epidural, etc)
- continuous Electronic Fetal Monitoring (external or internal)
- blood banks if a transfusion is needed

In a home birth, a woman is on her own turf. The midwife is the invited guest. In a FSBC, however, it is the midwife's turf. Often birth centers have a set of protocols that govern when a woman must transfer to a hospital or to OB care. The midwife at the birth center has final say over whether or not the woman can use the facilities. Like Tabitha and others have commented, no matter how nice the decor, it isn't the same at someone else's place. You don't usually feel the same sort of liberty or comfort or lack of inhibition as you would in your own space.

So perhaps birth centers are the worst of both worlds. There is no additional safety or access to technology in a freestanding birth center compared to home, and the woman is not on her own turf and ultimately cannot make the final decisions of when to stay or transport like she could at home.

Thoughts on this?
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Saturday, December 22, 2007

mmmm....German cookies

Some cookies we always make during the holidays, from my German grandmother.


Lebkuchen is German for "bread of life"

2 lbs honey
1 lb butter (4 sticks)
2 tsp ground cloves
2 tsp ground cardamom
2 tsp ground allspice
2 tsp nutmeg
1 tsp salt
2 Tbs cinnamon
2 1/2 Tbs cocoa
1/4 cup brown sugar
6 eggs, well beaten
2 tsp vanilla
1 ½ tsp lemon extract
6 + cups flour
3 Tbs baking powder

Melt together the honey and butter. Mix spices, salt, cocoa and sugar. In a large bowl add spice mixture to melted honey/butter. When cooled, add eggs, vanilla, and lemon extract. Mix together 6 cups flour and baking powder. Add 2 cups at a time. Add extra flour (usually a few more cups) until dough is just stiff enough to roll out.

You can refrigerate this dough for a long time. Roll out and cut into shapes. Bake at 350. I don't know exactly how many minutes, but it depends if you want them chewy or crunchy. Frost with a thin glaze of lemon juice and powdered sugar. Add decorations.

Radar Kuchen

1 cup sugar
1 stick butter, softened
4 eggs
Finely grated lemon rind
4 cups flour
1 tsp salt
1 Tbs water
2 tsp baking powder
1 tsp cardamom
Cream together sugar and butter. Add eggs, lemon rind, and water. Add dry ingredients. Refrigerate for 1 hour. Roll out on floured surface until 1/4 to 3/8 inch thick. Cut into a 4x2 inch diamond shape with a 2-inch slit in the middle between the two points. Take one pint and fold through the middle slit. Fry in deep fat at 350 in an electric frying pan or medium-high on stove. Remove when brown on both sides. Place on a paper towel to remove excess oil. Sprinkle with powdered sugar.
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Friday, December 21, 2007

Q&A with Carla Hartley

Carla Hartley, founder and director of the Ancient Art Midwifery Institute, gave me permission to repost this recent email correspondence.


Dear Carla,

I am really confused by the unassisted birth movement within your midwifery study course. Why do we study all of this stuff to be educated midwives and right along side of this tell moms to just trust birth and have no one there?

Thanks for any time you can take to answer this for me.

Here is where I am coming from:

A: My course is really really really hard. It is comprehensive because I want midwives to KNOW more, so they are comfortable doing less. I saw a lot of midwives meddling with birth because many of them did not know enough to recognize variations of normal. Their education was based on EXPERIENCE only. Now in my grandmother’s day, experience was enough because it was NOT fear-laden. Birth was, as Sheila Kitzinger says, domestic, part of life. The experience of most of the midwives I had any contact with in my early days was based on fear. They did not start going to births because they believed in birth, so much as they wanted to help women avoid the hospital. Yet their lack of knowledge and trust of the birthing process meant that a LOT of women who started out at home ended up in the hospital anyway.

I recognized early on that because I had studied sooooooooooo much before I started apprenticing, things that panicked experienced midwives did not at all panic me. I understood the physiology. I knew that there were many possible birth scenarios that were NORMAL. I also saw that clients almost always depended on the midwife's knowledge and trusted her opinion on almost everything. That made me uncomfortable. One of the things that I believe people gain having a home birth is a sense of their own ability to make decisions about their children. If we as midwives don’t leave families CHANGED then I think we have missed a great opportunity to affect society in a very positive way. MUCH of what my students do is client education and the constant reminder that parents are their own authorities and the rest of us (doctors, midwives, doulas, childbirth educators) are merely paid consultants. Once that resonates with a couple, and they accept the responsibility that comes with authority, they change. They believe in their ability to make good decisions. That is HUGE!

B. I trust birth. Birth is inherently safe. Messing with it in any way compromises safety. It is an innate biological capability for most women to grow a baby and then EJECT a baby with no help from anyone. Midwives are NOT the guardians of normal birth. Birth is normal with or without midwives. But what midwives should be doing is acting as the guardian of the mother and baby's space, so they can do what they were made to do. Most women want that--but some don't. They just want to be in their own little world with no intrusion. That doesn't mean that birth is any less safe.

Midwives know a lot of things that can go wrong. That is why I think we do have to study and prepare to an extreme degree. We have to be sure that we don't CAUSE anything to go wrong. I think much of what we do has the potential to cause problems. I don't have time today to list those but they start with what we say, our own body language, what we wear (I hate scrubs in a home birth) and the things we think we have to measure, poke and prod.

Have you read my blog and the site? I trust birth—not birth attendants—for if you only trust birth that is attended then you really don't trust birth at all. You trust the attendant. And then you start over. Who? Doctor, surgeon, CNM, CPM, SIM*? And it goes on and on....NO, the truth is that women and their babies are quite capable for the most part to do it without anyone. Most women who chose home birth want a midwife and my goal is to help there be MORE midwives for them to choose from and midwives who are truly WITH WOMAN midwives and not birth managers.

I don't want to insult you in any way and I am glad to have the opportunity to help you understand what seems to many a real mystery but look at what you said in your post to me:

"Why do we study all of this stuff to be educated midwives and right along side of this tell moms to just trust birth and have no one there?"

Doesn't that sound a LOT like what docs believe about birth? Doctors don't own birth. Midwives don't own birth. Just because you study and sacrifice and put yourself in debt to become a midwife or doctor does not mean you own a woman's experience. It also does not mean that you are necessary. (OUCH!) Women and babies know how, if we will step back and let them. And we understand that our job is to serve them.

And I don't like the word "support" here because she is not a table we are holding up. I like "SERVE" because I think that is what midwives—well, everyone involved in birth—should be doing. SERVING.

In that framework—servant, consultant—it is quite possible to be a midwife who trusts birth and trust the woman and her baby. It is possible to be a midwife whose client calls AFTER the birth and says it just never occurred to me to call you, that the midwife would not be offended.

My very first official paying clients decided a couple months before the birth that they were going to DIY, as we called it back then, because I was uncomfortable about something I thought might present a problem. I was a rookie and was ultra cautious. Not afraid; I just wanted them to know that there could be a problem. After talking about it for a while they came to see me and said, “Carla, we are going to let you off the hook. We know you are concerned, but we really are not. So we are not going to call you when labor starts.” I cried. They said, “Oh no, don't be sad. You helped us realize that birth is safe and that few things go wrong if you don't mess with. You encouraged us to listen to our own instincts about birth and we know everything is going to be fine.. But YOU don't. And we understand that and we don't want to put you in a position of being concerned. We will call you when the baby is born and you can come see for yourself that we were right!!!!”

I quickly corrected them that my tears were not of rejection but absolute humble appreciation for what they were telling me. Just because I did not go to the birth (I went a few hours after) did not mean I did not serve them well as their midwife. I did not have to be the one to catch the baby. I did not have to watch or guard a perineum in order for her to have a baby without tearing. I helped them believe in themselves and THEIR ability to parent this child before, during and after birth. I did good! In my dictionary, I WAS their midwife.

If this doesn't answer your questions, please, please feel free to write again or call me. I am honored that you asked, actually. I do not see my job helping women become midwives and also supporting women who want to have their babies alone as a contradiction in any way because of what I believe that midwifery should be in the first place.

Carla Hartley

*SIM (Self-Identified Midwife) is a term used (often derogatorily) to describe midwives who choose not to become certified through a professional organization.
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"Homelike" birth spaces: a photoessay

These are photos I took for a research paper about the meanings of "home" in institutional birth spaces. The first set of pictures are from the University of Iowa's new Maternity Center. The second set are from a freestanding birth center in Des Moines, the Almost Home Birth Center.

UI Maternity Center
Text reads:
Labor/Delivery/Recovery room.
Labor & Delivery rooms adjacent to NICU.
Technology is hidden but still accessible.
Internet access.
Rooms offer a home-like environment.
Custom beds.
Whirlpool bath.
A La Carte menus available.
DVD/CD players.
Beautiful views from many rooms.
The "home-like environment" of the L/D/R room
The Stryker Adel bed, covered and uncovered
Equipment closet inside room
Sliding artwork

Almost Home Birth Center
Birth Room 1
Birth Room 2
Living/waiting room
Library/reading room
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What direction?

I've been having a mini crisis of identity with this blog. I am so tired of "debating" birth choices endlessly and wonder whether all of the energy I (and many readers/commenters/bloggers) spend makes any difference. We're either preaching to the choir--fun but not really necessary or life-changing--or debating people who most likely won't change their minds anyway. On top of that, I'm feeling discouraged about the state of maternity care in North America and at the few real changes birth advocates have made in the past several decades. Floral wallpaper, tacky artwork, a table lamp, and a polyester comforter covering a hospital bed just doesn't cut it.

But it's almost like home! We'll hook you up to your Pit drip, your epidural, your catheter, your fetal monitor, and your automatic blood pressure cuff and you can watch TV, just like at home! Two-thirds of you will come away with a surgical scar in your belly or in your vagina. But you'll feel comforted by the "home-like environment" while you heal from your wounds!

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Saturday, December 15, 2007

Bouncy ball!

We finally made it to Canada last night after many days of traveling. We broke up the long drive and visited three of our siblings and their children along the way. This video was taken at stop #3 at Eric's sister's house. She has two young children and another on the way. This was the first time Zari had ever seen her cousins.

It's a chilly -15 (Celsius) today. Eric is stranded right now and waiting for roadside assistance to arrive; the fuel lines froze in our VW diesel Golf and then the battery died after he put in a diesel antifreeze. Luckily he's only a few miles away and his dad is helping out with his car and cell phone. (And actually it was Eric's mom who was driving the car when the fuel lines the middle of helping another of his sisters and her family move.)
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New midwife blog

Housefairy's midwife just started a blog, Close to the Root, and I wanted to share it here. Lots of interesting questions and discussion are already sprouting up there!
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Tuesday, December 11, 2007

A nursing woman is a gift to the future

Read this thoughtful post about how "a nursing woman is a gift to the future."
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Saturday, December 08, 2007

Under pressure

I contacted one of my advisers about deadlines for finishing the dissertation and graduating. If I want to graduate this spring semester, I have to have the dissertation finished a month before my defense date. Which means I have to have it done by early April! So the pressure is on to get the last two chapters written so my dissertation adviser can read them and give me feedback. Then I will do a round of revisions and send each revised chapter to my four other committee members. Once they read each chapter and give me comments/suggestions, I will do yet another round of revisions (hopefully fairly minor at this point) and have the finished product done about 4 months from now.

Some goals to get me from point A to point B:
  • Finish chapter #5 by this weekend
  • Write chapter #6 in December (chapter about the interplay of midwifery and UC)
  • Write chapter #7 in January (conclusion: looking at existing birth paradigms, suggesting new conceptual models that include UC)
  • Start sending out revised chapters to committee members in January& early February (this depends on how quickly I get comments back from my adviser)
  • Receive comments from all committee members on all chapters by early-mid March
  • Do final revisions last few weeks of March
Can I do it? We'll see...I really don't want to delay this any longer, since I am now paying tuition (over $800/semester for a zero-credit continuous enrollment) for the privilege of writing my dissertation.
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Value of skin-to-skin contact

This article from the Daily Mail shows how skin-to-skin contact--an element of kangaroo mother care--saved a very premature baby weighing only 20 ounces that doctors had given up for dead.
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Wednesday, December 05, 2007

2006 US Cesarean Rate

The CDC just released its preliminary birth data for 2006. For yet another year, the US cesarean rate has hit a record high at 31.1%. This is a 50% rise over the past decade, and almost a six-fold increase since 1970, when 5.5% of women gave birth via cesarean section.

A 31.1% cesarean rate translates into 1,326,725 surgeries. 1,326,725 women recovering from major abdominal surgery while taking care of a newborn baby.

Let's imagine for a moment that we had a radically different maternity care system that put the basic needs of laboring women first. Even if most women continued to give birth in hospitals, we could do things very differently. What if hospitals implemented changes similar to Michel Odent's maternity clinic in Pithiviers Hospital. These changes were inexpensive and low-tech, including:

  • soft, large mattresses--no delivery tables
  • large, deep birthing pools
  • birthing chairs
  • cozy and private rooms
  • extremely limited use of Pitocin (around 1%) and pain medications
  • low-profile midwives overseeing births and consulting obstetricians for complicated cases
  • mothers encouraged to labor and birth in whatever positions felt most comfortable to them.
  • emphasis on creating a private, warm, and safe environment for the mother to labor in

Odent's hospital was able to achieve a 6-7% cesarean rate while at the time having one of the lowest neonatal mortality rates in the world. Other hospitals were only able to achieve such low mortality rates via a very high cesarean rate. The Pithiviers clinic served an unselected population; in other words, it didn't weed out unhealthy or "high risk" women and send them to a larger facility. Read more about Odent's clinic in Birth Reborn (pictures below are from the book).

If our country had a 7% cesarean rate, we would only have 298,620 cesarean sections performed each year. More than a million women and babies would avoid major surgery with all of its physical and emotional costs.

A typical French delivery room
Pithivier's new birth rooms
Midwife and laboring woman
Upright, physiological birth
(Michel Odent is supporting the woman's weight
while the midwife waits for the baby to emerge)
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A different approach to pain relief

Britain's National Institute for Health and Clinical Excellence has just recommended that "all expectant mothers should be offered a water birth for the safest form of pain relief." Birthing pools are the most effective non-pharmacological form of pain relief and second-most effective overall. NICE has published clinical guidelines on intrapartum care. You can also read a summary of its findings here.
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Tuesday, December 04, 2007

A midwife's unassisted birth

I just came across this midwife's UC story--what a powerful, determined mama! She faced a rare but very serious emergency situation during the birth, a shoulder dystocia. Here is an excerpt from her story, right after she discovered the shoulder dystocia.
There are moments in life when adversity stares you in the face like a hangman daring you to overcome, all the while taunting and mocking your own inadequacies. For a fraction of an instant I felt crippling despair for that which there was no solution for. There was no one to help me or tell me what to do. There was no answer to the question "How"? I was going to lose my child and be condemned with guilt. I would fail to do the one thing my body was built best to do, right in front of my daughters and husband.

My husband broke through my paralyzing haze in the next instant by calling time (how much time had passed since the head had crowned). Reality struck me hard in the face as a contraction built up. I concentrated with all of my might and commanded myself to do this impossible thing. This was my birth, my baby and my body and I would make this happen RIGHT NOWWW!!!

I became instinctual. I opened my legs as wide as I could and braced my feet into the mattress. Then I reached over and behind my head and gripped the back board of the bed. Pulling on the back board, I hoisted my butt up off the bed, arched my back, rotated my hips in the air and pushed with all of the power any one woman can command from heaven and earth. I caught another breath, kept the movement of elevated hip rotation constant with the pressure of bearing down. I was not going to lose this child without a fight. The pain that always invaded my births dulled as I lost my temper and roared loudly through the pushes that brought to birth my child. Finally, I literally felt the release of her shoulder pressure from under my pubic bone as my child gushed forth into freedom.
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Midwives and doctors talk about breeches

I have interviewed several midwives and doctors as part of my dissertation research, and I thought I would share these comments about breech births with you (with their permission). Both of the midwives quoted here are very hands-off; parents almost always catch their own babies, and the midwives try to be as invisible as possible during the birth.

Dr. Sarah J. Buckley gave birth to her fourth baby at home unassisted, a surprise breech. I haven't interviewed her yet (although I will be meeting her this spring!), but the birth story is worth reading.

"Sarah" practiced for a midwife for a while in two Midwestern states. She currently lives in a state where midwifery is illegal and has decided not to continue her practice. She has given birth in a variety of settings, from UC to hospital.
I have attended a few breeches and I have given birth to a frank breech of my own. Most of the time I think breech is a variation of normal but that it should be approached with respect. (The casual attitude some UC folk have about it bristles me a bit. Breech is like any other birth, you see a couple go well you have that honeymoon feeling, what's all the fuss? But if you ever see one go bad, well, it will stay with you a while.) I don't want to live in fear of the what ifs, but I do think it's important to respect the possibilities and be prepared to take responsibilities. I have seen enough to know that breech births have their increased rates of complications for good reason, probably the greatest of which is simple mishandling by caregivers. I think even well trained attendants tend to panic a little with breeches. They miscalculate how much time has passed and start maneuvers too soon. Dr. White advocated a serene labor (including semi recumbent [to prevent cord prolapse or premature urge to push] position for mom once the waters spontaneously rupture), a hands and knees position for breech birthing, and completely hands off approach. I am with him on that completely. I have seen the arguments for maneuvers and what not, and having seen a few breech births and watched even more videos, I can tell you his way is non-violent and so much more conducive to a good outcome. Basically I believe that if you follow those simple guidelines and you get a less than perfect outcome, well, there is nothing that could have been done to prevent it. While a cesarean will prevent entrapment and cord prolapse, it won't prevent a host of other issues for mother and baby. If the baby is breech because of a defect of some sort, giving birth by section will not change it. The stats are there...breeches are more complicated with or without section. So why have surgery?

Recently I've heard some UC folks make very casual comments about how easy it is to sweep an arm on a breech. Well, it often is, especially if the baby is small and the mama is roomy, has given birth before and is not in a panic. But, if the baby is full term, good sized it may not be so easy. Again not something to fear, but I think that one place where UC folks scare me a little is when you have someone who knows little about birth and there is this prevalent attitude of everything is normal, everything will be OK, don't say anything that might be negative or scary. But scary or not, birth is not a safe event. It is a life event and while most of the time it will all go just fine; sometimes it won't. I see it kind of like amusement park rides or getting on a plane. You're not going to tell somebody never to get on a plane or ride a roller coaster when we all know that it is generally safe and a good experience...but you wouldn't tell somebody that a plane crash or a roller coaster derailment is no big deal either. That's how I feel about complications. Not a reason not to UC, but not something to sweep under the rug and pretend scary stuff can't happen.
"Mary" is a practicing home birth midwife and shares these experiences with breech births:
I have had three experiences on my own. I had three within six months of each other. I had never before and never since had any. Weird. But I did learn that doing nothing and letting the mother rest as much as possible lying down are useful for the labor but not for the birth. Most of them did this and stood up right at the end when the baby was coming butt first. The one footling was in the pool, and the mom stood up at the last seconds for the head. I only helped one of them hands-on after the body. His arms were not coming down. The mom got to the edge of the bed and I supported him to hang, then reached around his back and pulled down each arm. The babies did fine though they needed a bit of work. One was 9 lbs and a first baby; he had some fluid to get out. But his cord was attached until hours later so I think that helped him. All the babies' cords were left intact. Always a good idea with any birth...I am a big Lotus birth advocate. Anyway, the others were fine except the footling one needed some rubbing up and a suck and blow over her mouth which her mother gave her. The other one came out wailing. I think it was strange to have three within such a short time.
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