What Not To Say To A New Mother: The Hospital Edition

The other day I was visiting a family and their just-born baby in the hospital, and in the few short hours I was there, I heard a bunch of surprising comments:

•  A nurse told a new dad (who was standing up, holding his 20 hour old baby) to put the baby down in the bassinet, warning him that his son was safer in the bassinet — otherwise Dad might drop the baby.  

• A different nurse told a new mom (who was holding her 8 hour old baby) that her daughter would be safer in the bassinet because Mom might doze off and “co-sleeping is not allowed.”  

These comments, by two different staff members to two different families, are, to me, eye-rollingly laughable — obviously babies can be safely held by parents, both seated and standing.  Obviously babies don’t need to lie in a plastic bucket all the time for fear of being dropped.   

Probably the first nurse meant: “if you did drop him, we’d end up with a law suit,” I.e., it’s potentially dangerous to us, the hospital, not: “it’s actually likely you’ll drop him.” 

And probably the second nurse meant, “I have been trained to warn mothers not to fall asleep with their babies in bed because for non-breastfeeding babies there are certain risk factors to bed-sharing, and I see so many new moms per day that I can’t be more specific on an individual level,”  and not:  “it’s actually dangerous to for you to hold her right now, in bed, with visitors in your room.”

And, happily, both families took the comments with a grain of salt.  (The mom paused, concerned for a moment, but then looked around the room for encouragement and said, calmly, “well I’m awake right now.”  The dad made a comment under his breath about Americans’ fear of liability.) Both families have older children at home.

Here’s what I worry about, though:  first-time parents who have no other experience, and those who don’t have visitors to help them remember common sense.  Or who are just so tired and impressionable that they can believe that their urge to hold a newborn is wrong; and that he’s safer in a plastic box.  

It’s not that I think one statement, in isolation is so damaging, but, rather, the tide of small comments like this, pervading the new parents’ experience in the hospital.  Because while I was there, I also heard: 

1.  by a pediatric resident, re: a well baby:  “we’re taking the baby’s temperature to make sure she doesn’t have a fever.” (which suggests that she might have a fever, or might develop one),

instead of: 

“we’re doing our well-check up of the baby’s vitals so we have a record of how healthy she is.”)  

AND

2.  by a nurse:  “Here’s the breast pump.  If you don’t get enough to put in a bottle, we can give it by syringe.” (which suggests that mom might not make enough milk — a common fear), 

instead of: 

"one-day-old babies can only handle a tiny volume of colostrum because their stomachs are so small, and there’s no bottle small enough to appropriately feed a baby this young — so, we’ll give you a syringe you can put in her mouth, to give her the precious colostrum you get.”)  

(Or even better: "I hear you asked for a breast pump, so we’re sending one over along with an IBCLC who can teach and advise you, and help you figure out your options.”)

AND

3.  by an OB, to parents being discharged early after a healthy birth (unprompted, without previous discussion of infant feeding):  “Definitely take home some of the formula. You can top him off after each feeding to make sure he doesn’t get dehydrated.” (which suggests that the baby will get dehydrated if “only” breastfed) 

instead of: 

"I’m not an expert on lactation, but if you have concerns about breastfeeding, let me get someone who can help you."

See how insidious this is?  Each remark alone might be a smallie (I don’t think this last one is a smallie, though), but the cumulative message, over and over is:  

Things are about to go wrong.  You can’t trust yourself, or your judgment.  That feeling of relief that the baby is healthy and in your arms?  It’s probably just wishful thinking and the rug is about to get yanked out from beneath you. 

Newborn parents, who, for the moment, are tired, sometimes overwhelmed, understandably confused and facing lots of new stuff, are more vulnerable to suggestion than the rest of us.  They need encouragement and support so that they can:

• learn to take care of themselves and their babies, 
• learn to distinguish “emergency, requiring medical care” from “common sense situation I can handle myself,” and
• learn to cope with the normal new-parent anxiety.

They deserve to encounter staff who understand their concerns, worries and knowledge level. They deserve staff who don’t plant seeds of self-doubt and a culture of fear.  We patients pay huge sums of money to be cared for while we are vulnerable — it shouldn’t be “caveat emptor”: let the patient beware — any advice you get may be misguided.  

So, but here’s the thing:  I don’t think that hospital staff who say stuff like this mean any harm.  I don’t think they intend to undermine parents’ confidence or give faulty guidance.  At all.  I do think they may be influenced by the pressure to think about liability avoidance, and they may be too overworked to individualize service and attend to each new family’s particular needs.  Any of us can say the wrong thing when we’re under stress, because we’re human.

But I think it should be a priority, for all who work with pregnant folks and new parents, to try to get that tone right as often as possible.  To slow down, remember that that new dad holding his baby is, inside his head, probably worried, anxious and far more likely to be riddled with insecurity and self-doubt than he is to actually drop the baby.  It’s so unfair to saddle him with the hospital’s fear of a law suit, when what he needs is to be reassured that he is competent and has good instincts.  When we talk to him as though he already knows he’s competent, we are not reaching our audience. 

By the way, you know who *does* understand how to reach their audience?  You know who never gets so tired or busy with their other priorities that they get off message?  You know who’s really good at sending the message they mean to send? 

Advertisers.  

Advertisers think, all the time, about how their message will be received.  That’s what they’re paid to do.  And that’s why, when I see a sign like this (text at bottom)

in every single baby’s bassinet in the hospital, with the Similac logo, and a completely horse-shit ambiguous message about infant feeding, I become pretty annoyed.  I have two Ivy League degrees, a pretty decent comprehension of English, and even got a full night’s sleep last night, but reading this message, I feel completely confused.  

That’s because the message is meant to confuse me.  I am meant to conclude that infant feeding decisions are very important and confusing and require far more complex micro-analysis than a normal person with normal breasts and a normal brain could possibly figure out, which is why, thank god, there are doctors, nurses, nutritionists (note absence of IBCLC in this list) and, most of all, Similac, bringing me this lovely “keepsake,” a reminder that I am completely incompetent.  

Note also that this solemn, authoritative missive about infant nutrition doesn’t mention breastfeeding.   

See how savvy this bit of marketing is?  Similac donates these advertising cards to the hospital.  The flip side of the card, which faces into the bassinet, says the baby’s name, age, and birth weight; the hospital accepts the cards so they don’t have to pay to make and print thousands of name cards.  The side with the Similac message faces out through the plastic and is positioned at eye level — it’s the first thing you see every time you look at the bassinet to check on your baby.

Unlike hospital staff who are, I think, unintentional when they undermine parents’ confidence, advertisers are cleverly exploiting parents’ fears.  This marketing message is aimed — visually — right at parents who are already a little confused, tired, worried that they don’t understand everything. The message is:  you can’t understand this stuff. 

It’s marketing designed to reinforce your worry and then sell you something to ease it.

Now look, we are lucky, in this time and place, to have ways to care for our babies if things do go wrong.  But we shouldn’t be starting there.  Scare tactics, and undermining messages should not be a part of routine patient care, whether by advertisers who do it on purpose, or by well-meaning, but careless, staff persons who do it because they’re not paid to prioritize anything else.

We can do better than this. 

WHAT YOU CAN DO IF YOU’RE AN EXPECTANT PARENT:

• New moms should not be isolated for long stretches.  Have someone who knows and loves you with you, not only during labor, but to stay with you while you’re in the hospital postnatally, to hold the baby while you nap, tell you how awesome you are, and to help you make sense of everything else that happens.

• If you’re feeling confused by what anyone has said, ask them to explain why they’re recommending whatever they’re recommending.

• If someone is saying or doing something that’s making you feel nervous or anxious, ask for more information.  Explanations demystify a lot.

• If you’re told something that sounds like it doesn’t make sense, entertain the possibility that you’re right and ask for more information until it does make sense.  

• If you have a clinical question about breastfeeding, it should be directed to an IBCLC.  If someone is giving you breastfeeding advice, ask them what training they have had. Anyone can call herself a “lactation consultant.”  Is this person an IBCLC or not?

• Take the damn card out of the bassinet and throw it away.  Put in a new piece of paper with your baby’s age and name and weight.  Or turn the bassinet so the card faces away from you.  If you’re feeling energetic, tell someone at the hospital that you don’t like the Similac logo in your face.  (After you get home, when you have the energy (and this could be months later) write to the hospital and/or your caregiver and let them know what you liked and what you didn’t like.  You can use these form letters as a model.  Things change when people complain. 

• If you’re feeling like everything is desperately hard, it is a good sign that you need help, not that you’re a failure already.  Ring the nurse.  Ask for help, and if it’s not something she can help with, ask who can.  Ask for help finding local resources for new parents in your neighborhood.  

I am sorry if this feels like all the burden is on you to ask.  But until our world changes so that all these things are just the routine, expected care of new parents, you do have to ask for the help you need.  When you do, you’ll find that competent, compassionate care helps.

(You can read more “What Not To Say” posts here (grandma edition), here (why comebacks are hard) and here (general dumb remarks), and you can read a followup to this post (what TO say) here).

10/9/12 update:  I’m sorry some readers can’t see the photo clearly enough to read the text.  This is what the Bassinet Card says:  

Deciding what to feed is an important decision, one that should be made by those who know your baby’s nutritional needs best.  Don’t make any changes in the feeding that has been specified for your baby without talking to your baby’s doctor, nurse or nutritionist.

Provided as a keepsake from Abbot Nutrition, Makers of Similac

In addition to the other problems with this card, deciding what to feed is a decision that should be made by parents, even if they have no nutritional expertise.

Getting Away From An "Either - Or" Mentality About Childbirth

Recently there have been a bunch of good essays (links below) discussing how the birth location, and type of attendant, affect outcomes.  These pieces all take the time for some non-propaganda, nuanced thought and reflection about what would improve things for a diverse American population of mothers.  It’s a welcome change from some of the less rigorous thought we often see on this topic.  Instead of having a pitched battle about whether ALL HOMEBIRTH IS VERY DANGEROUS AND IRRESPONSIBLE AND RISKY!  and whether ALL HOSPITAL BIRTH IS TOTALLY OVERMEDICALIZED AND DANGEROUS AND HATEFUL AND NOT EVIDENCE BASED, these essays look at the improvements we need, overall, to our maternity care system.

Here’s a brief summary (but honestly, these are issues that aren’t well suited to brief summary):

• we need a standardized care practice for doctors, nurses, and midwives who attend hospital births.  The practice should minimize separation of mother and baby after birth to true medical need, appropriately support normal infant feeding,  prioritize comfort, dignity and infection-avoiding after-care for mother and baby, eliminate practices associated with post-partum depression and PTSD, and train all hospital personnel in all of these areas.  And this should be available to all women in every hospital across the land.  

     Is that really too much to ask for in 2012 in the United States of America?

• we need a nationally standardized training practice for midwifery that encompasses homebirth and hospital care, so that “midwife” means one thing, everywhere.  Without that, it is impossible to accurately say how “midwifery” care compares to OB care, or how home-birth compares to hospital birth.

These changes would create a more functional system in which each woman could get care appropriate to her particular needs, not the needs of women in general.  This is called reproductive choice, and it should be available to everyone, not just educated, white-glove-insured people in major cities.

A functional system would also get us away from the kind of strident hysteria that too often accompanies discussion about birth, which, when you care about these issues, become truly a pain in the ass to read.  (don’t get me wrong — emotional discussion of one’s birth when you’ve just had a baby is totally appropriate.  Ideally, though, that personal topic is handled separately from a policy discussion of how care can be improved for everyone.)

Here’s what you can do, meanwhile:

• If you’re pregnant and planning a hospital birth:  take the time to talk to your care provider about her training and experience, including her experience of this hospital’s post-natal care, which she may or may not be familiar with.  If you’re in New York state, you can look up your hospital’s stats including breastfeeding rates.  Take a childbirth class that covers infant care and breastfeeding.  In my childbirth classes, we do role-playing to help students get comfortable with how to talk to personnel in the hospital in a way that gets the information they need and reduce unnecessary stuff happening.

• During and after your birth, remember that you are the customer.  If you’re not getting good customer service, ask for better.  If that doesn’t happen, write a letter to your care provider’s office and/or the hospital, later, and let them know you weren’t happy.  Policies change when people do this.

• If you’re pregnant and planning a home birth:  take the time to talk to your care provider about her training and experience in, and out of hospital, and learn about the laws relating to midwifery in your state.

• Write to your legislators and propose standardized care practices for hospital births and midwifery training.  Send a copy of the letter to all your facebook friends and ask them to do it, too.

Here are the links to the essays:  The original piece in Slate by Emily Willingham, an article about it on Babble by Ceridwen Morris, Emily Willingham’s blog followup, and a Comment by Midwife Amy Romano.

This stuff matters.

How did it go for you?  If you gave birth in the hospital, how did you feel about the post-natal policies and the care you received?  If you gave birth at home, were you in a state where you had access to a CNM?  And what was her home-birth training?  You can email me comments or use the Disqus feature below.

Guess How Many Times A Day Someone Barges Into A Hospital Room On A New Mom?

Here’s one for the “I Can’t Believe We Needed A Study To Tell Us This” file: an article I read this morning from lactationmatters.org, entitled “Do Interruptions Interfere with Early Breastfeeding?”

I don’t mean that the article was stupid (at all!), and in fact, there’s something validating that someone actually recorded how frikkin’ often new moms and their babies are interrupted while they’re still in the hospital.  Want to know how many times? 

53.  Fifty Three interruptions in a twelve hour period.

This topic came up last week at the new MOMs group — I’d asked a group of new moms who’d just met to talk about what was most surprising since their babies’ births, and although that conversation can go lots of different ways, this group mostly talked about how the births had gone, and the first couple days in the hospital.  Several moms talked with annoyance about how frequently people barged into the hospital room, (“it felt like someone was constantly coming in to do something”) and how difficult it was to get any peace, privacy, or even just a little time to think straight.  

Well, they’re right:  The study found that over the course of a twelve hour period, mothers in the hospital were interrupted an average of 53 times.  There were more than twice as many interruptions as periods of alone time.  That means that a new mom had to deal with someone coming in to do something to her pretty constantly; and the study also found that the interruptions themselves lasted longer than the stretches of alone time.  In fact, half of the “uninterrupted” stretches were less than ten minutes long.

Guess what?  Moms didn’t love that.  

In my New MOMs group, many of the same moms were also complaining that they didn’t have enough help with getting the hang of nursing, or that they were “left alone” to figure it out by themselves.

These things aren’t at odds, at all:  New mothers are not supposed to be left all alone, isolated, without help or company or support.  They are supposed to have easy access to supportive, knowledgeable people who can help them, and who can attend to their needs as they learn to get the hang of dealing with the baby.  They are not supposed to be isolated and when they are, they languish.  And all too often, they not only don’t complain, they feel guilty and weak for not being able to figure everything out themselves.

Isolation is bad for mothers.

But isolation is not the same thing as privacy, and all interruptions are not equal.  One mom I spoke to described how frequently people came in to take her blood pressure and temperature, or to check on the baby, or to have her fill out forms.  Did anyone come in to just sit with her and keep her company?  No.  No one in the hospital is paid to provide company. Did anyone come in saying, “Good morning, what can I do for you that might help you feel more comfortable today?”  Of course not.  The hospital does not provide a concierge.  Did anyone give her a list of resources that might help or educate her if she wanted that?  No, the hospital is not a school that provides education for its customers.

Did anyone assess her breastfeeding before the baby was discharged and provide her with detailed, evidence-based guidelines about how to proceed?  No.  Apparently the hospital is also not concerned with infant growth and nutrition.  You and your boobs are expected to figure it out for themselves.

What did they do?

Well, lots of people commented that she should be breastfeeding.  People talk and talk and talk about how “best” breastfeeding is.  People gave varied opinions about how frequently she ought to nurse and how long the baby ought to stay on the breast.  Most of them disagreed with each other.  

And they got all the data they wanted, about her temperature and blood pressure and wound-healing, and her paperwork was all complete.  They did that on their own schedule, in the way that was most streamlined for the hospital, not for the woman who’d just done a day of labor followed by major abdominal surgery and whose nipples were cracked and bleeding and whose baby had lost a lot of weight.

This. Is. Not. Good. Customer. Service. 

Newborn babies need lots of skin to skin time with their mothers, but new mothers (understandably) often feel modest about showing skin to strangers.  Having the door of your room burst open while your shirt is off can throw even the most unflappable new mom, especially when it happens multiple times per hour.

New babies also need frequent feedings, but new moms getting the hang of nursing often don’t appreciate someone barging into the room just when they’re squeezing the breast and looking at the color of their colostrum.  New moms are human beings; they need privacy.  When they don’t get it, they cover up.

The study found that moms perceived that interruptions interfered with breastfeeding.  This does not mean that doctors and nurses came in and literally said “You need to stop feeding now” or that the moms were told to ignore their babies’ cues to feed if someone else was in the room.  What it does mean is that as a practical matter, the moms felt that being on the other side of a revolving door was getting in the way of learning to nurse.

Why aren’t we making it easier on new moms?  How about some hospital protocols that group necessary clinical interruptions together in a way that makes it a priority to get new moms longer stretches of privacy?  

And how about making sure that, if someone’s going to enter a new mom’s room, that person:

(a) ask the mom “were you about to feed the baby?” and offer to come back later if it’s easier for the mom, so that no mom leaves the hospital feeling like someone was barging in on her every five minutes, and

(b) be prepared, qualified, trained and equipped to ask about nursing, assess the breastfeeding dyad, and provide appropriate, supportive help OR ELSE SUMMON SOMEONE WHO IS, so that no mom is discharged from the hospital without a breastfeeding assessment by an IBCLC.

People like to feel like they know what they’re doing — that’s because we’re human.  And when you’ve just had a baby, you often feel the opposite.  No one wants strangers barging in on them constantly when they’re feeling like a big messy work in progress — that can make you feel like giving up on whatever you were working on.  Instead, what new moms need is enough privacy to get the hang of things, and enough help to be guided in the right direction.  

Here’s what you can do:  

If you’re pregnant and planning a hospital birth:  Make a sign for your door that says, “Please, Only Urgent Interruptions; I Am Feeding The Baby.” Hang it at will.  Feel free to ask anyone who comes in whether they can come back in half an hour.  Have contact information for an IBCLC who can help you out as you begin breastfeeding.

If you’ve just had a baby:  The hospital will contact you with a generic call or letter to ask how your experience was.  I know you have a baby and you’re tired.  But take the time to answer their questionnaire and answer honestly.  If you got lousy customer service and know what would have helped, tell them.  You don’t have to figure out how they should conduct all their business, let them sort out the logistics.  But you ought to let them know you have a complaint with the way they do it now.

If you are a friend of a new mom, and can see that she had a lousy hospital experience because of this: write to the hospital and complain.  

Things don’t change when no one complains.

Childbirth is Natural

     Back in the 1970s, a lot of oat-filled snacks appeared in my lunch box, labelled: “all natural,” “naturally sweet” etc.  At the time, we all thought we were sort of virtuous and extra healthy for eating these. 

     The thing is, “natural” didn’t, apparently, mean anything on food labels; it was just a phrase marketers realized people like.  Granola bars had as much sugar as cookies, though we all thought of cookies as “dessert.”  When I learned that the phrase meant nothing, I felt a little cheated.  After all, the granola bars claimed to be from Nature’s Valley!  

     But then I thought — isn’t any valley just a natural formation between hills or mountains?  Are there unnatural valleys?

     The funny thing is, it’s the same thing with childbirth.  When I’m teaching, invariably a student will use the phrase “natural childbirth,” either to say, “I want a natural childbirth” or “I’m not interested in natural childbirth.”  

     We all know what it means.  And yet, it’s just as empty as the granola bar packaging, and I dislike it just as much, and I suggest we stop using it altogether.

     Because isn’t all childbirth natural?  

     What could be more natural than reproducing?  For adult women who like men, reproduction is so natural that you have to work to avoid it.  Whether you’re partnered or not, your body prepares for pregnancy a dozen times a year.  If you get pregnant, the natural culmination is birth.  Somehow, whether it’s a vaginal birth or a c-section, spontaneous labor or induction, pain medication or no, the natural conclusion of the labor is that the baby comes out.  

     I said “we all know what it means,” but that’s not exactly true either.  Sometimes people use “natural” childbirth to mean “no c-section,” and it’s just a way of avoiding the word “vaginal.”  

     Here’s the thing about that:  I do know that regular people who aren’t childbirth educators aren’t, usually, comfortable with the word “vagina.”  And I remember, when I was a lawyer, one time when the guy in the office next to me (who had overly-long greasy hair and a chronic post-nasal drip, so I’d hear him hawking phlegm, daily, as he berated first-year associates with the door open) told me about his wife’s birth and managed to say “vaginal” eight times, gratuitously in the span of two minutes.  

     The image of him schnuffling beside his wife and her vagina — eight times — was really gross, and I felt, distinctly, that the point of this, for him, was that he got to say “vagina” eight times to the cute, young associate next door, which pretty much sums up why I didn’t like the practice of law, butanyway.

     Still, in truth, if he’d said “natural” it wouldn’t have been much better.  My objection was to him and his slavering TMI, not to the word “vaginal.” 

     So, I get it on the “vaginal” birth thing, but, hey folks, get over it.  Say it quickly, or just say, “I gave birth,” and lets have that mean vaginal birth without having to talk about your Nether Regions.  It might help us remember that c-section is supposed to be a last resort.

 **

     Some people use “natural” to mean “no pain medication,” but that’s tricky, too.  The idea is that a woman who relies on her own internal coping tools is closer to “nature” than someone who gets an infusion of chemicals injected into the epidural space.  But both women — all women in labor — naturally respond to pain by looking for *some* way to cope with it.  A woman who doesn’t use medication isn’t more stoic, she is just using different, non-chemical tools to get through the labor.  It is natural to look for pain relief.

     And the meds argument is tricky:  If you have Pitocin but no epidural, is it natural?  

     Suppose you have no medication at all, but you have IV fluids because you were dehydrated at the beginning of labor?  Natural? 

     Suppose you go into labor on your own labor at home in the tub and using massage and stuff, and, after 4 days of labor, are still a few centimeters dilated and request a c-section because you’re too exhausted to carry on?  Unnatural?  To me, the natural response to exhaustion is to look for something to help you deal.

     And, on the other hand:  suppose you planned to have an “all natural” birth but your placenta is completely previa and there’s no option besides surgical birth.  Do you lose your all-natural status?  Points for having wanted it?

** 

     I hate the way “natural” can sound like a badge of honor: “She went all natural!”  If “natural” is good, it seems like all the women whose labors don’t fit into the “natural” box are less entitled to bask in the accomplishment of having made it through a pregnancy and, somehow, gotten a baby out.   And that’s unfair.

     And I hate the way “natural” is, sometimes, a dis.  “I don’t feel the need to do it all-natural,” some folks say, as though “natural” means “martyr.”  It’s not being a martyr to rely on non-medical tools for pain.  It’s not selfish.  It’s not a birth fetish.  It’s not crunchy/granola.  People have different ways to deal with pain, period.  

     In the end, though, it’s all meaningless – “natural” doesn’t mean any more in the birth world than it does in food labelling.  All valleys are natural, but that doesn’t mean you’re in the mood for a granola bar today, right?  Childbirth is natural too.  

      Here’s what’s unnatural:

•  Being pregnant and not having any curiosity about what is going to happen at the end. 

• A healthcare system that treats women like they can’t comprehend labor unless they are doctors, or probably aren’t smart enough to make good choices for themselves. 

• Maternity care that is routinely managed in a way that leaves many women thinking their bodies don’t work properly. 

Instead of talking about “natural childbirth,” lets do this:

      When you’re pregnant, become educated about the physiology of labor, about medical tools available to address problem situations, and about all manner of ways to deal with pain.  You do not need an advanced degree; a high-quality prenatal class will suffice.  As you approach the birth, make sure you have access to at least one gentle, loving support person besides your caregiver, to be with you in labor and help you navigate your birth.  

      Afterwards, if you don’t feel like talking about the birth, don’t.  But if you do, I suggest that you say “I gave birth,” to mean a vaginal birth, or “I had a c-section,” if you did.  If you used pain medication and would like to talk about it, say, “I had an epidural,” (or fentanyl, or whatever), and if you didn’t use medication and would like to talk about it, you can say, “I didn’t use pain medication,” or “I had an unmedicated birth.”  If you’d like to add other info, you can do so specifically.  

      Does this sound wordy?  It is.  Childbirth is intimate and private and a big deal.  Your experience of bringing a child into the world and becoming a mother is more than can be captured in any two-word phrase.  You don’t need to tell anyone your personal business.  But if you want to, it’s OK to tell the story.