Consumer Reports: What To Reject When You're Expecting

This article from Consumer Reports is a great piece on the ten most “overused” procedures in childbirth:

1. C Section in low risk first birth

2. Automatic repeat C Section

3. Elective early delivery

4. Induction without medical reason

5. Ultrasound after 24 weeks

6. Early epidural

7. Continuous electronic fetal monitoring during labor

8. Routine artificial rupture of membranes (“breaking the bag of waters”)

9. Routine episiotomy

10. Sending baby to the nursery

The article, of course, goes into greater detail about how each of these is overused and what the alternatives are.  I like this piece because it’s a great reminder to everyone of a few really crucial points

1. When you’re there, in the hospital in labor?  You’re still a consumer, and entitled to excellent customer service.

2.  Health care is a product we pay for and it is important to think about whether each thing you do is necessary/worthwhile.

3.  You, as an adult, are competent to evaluate whether you need an induction/episiotomy/c-section/ultrasound, just like you evaluate whether you need the other things you pay for.  You don’t need to be a medical expert to do this.  You do need a medical expert *with you* to talk you through the benefits/risks/alternatives, but after that the decision is yours. 

4.  Not all of the things that doctors do routinely are helpful or necessary.

Ask questions.  Get to know your caregiver.  Be the customer.  Get good care.

Ina May: "I wasn't raised to think I was inferior to an animal"

Last night I went to a great event hosted by CEA/MNY — a discussion of modern maternity care between the awesome Jennifer Block and Ina May Gaskin.  

I can’t do justice to the whole event, which was so interesting, but I was particularly struck by the way Ina May described getting interested in birth in the first place.  She reported that when she was pregnant with her first child in the mid-1960s, she went to a doctor and was told she would have medication to knock her out, and a “forceps birth.”  When she asked why it was then-standard practice to extract all babies by forceps, the doctor told her that it was because “all” first-time moms had an “iron-hard” pelvic floor, which the baby would destroy like a “battering ram” unless a doctor cut her perineum and pulled the baby out.

A doctor who talks that way, whether it’s 1966 or 2012 is clearly trying to scare his patient out of further discussion, not provide guidance and counseling and safe, compassionate health care.  

Here was Ina May’s reaction at the time:

"I didn’t know about that.  But I did know I didn’t have any parts that were iron hard.  But I didn’t know that you could fire — should fire — a doctor who says something crazy."

Ina May was inspired by her own common sense — not at first (she did, apparently have the knocked-out-forceps birth that time), but later, after she became a mother, she became inspired to reevaluate the care she and others were receiving, and make dramatic changes.  

She began to think about medical advice and “what people said” about birth not only at face value, but in terms of whether it made sense to her.  She knew that “iron hard” does not sound like a description of any part of a woman’s body, and instead of concluding “I must be wrong about my body!” she began to explore the other possibility — maybe the person saying this is wrong, even though he is a doctor.  

And if so, then what?

The answer is, then I owe it to myself to to find (and ultimately, for Ina May, to provide) care that does make sense.

It’s inspiring.  At one point, Ina May added that another point of inspiration for her was that she had been “an English Major in college.”  Everyone laughed.  

She described how reading Tristram Shandy got her thinking about midwifery care.  Her point was not that reading 18th century literature is all you need to be a caregiver. Her point was that you don’t have to be a doctor to have a thinking cap.  Ina May felt confident that the intellectual gifts that served her in the rest of her life would help her understand enough about maternity care to make competent decisions for her own body’s care.  

You don’t have to become Ina May and start a Farm and catch 3000 babies in 40 years and become a birth guru.  But we can all take action in our own lives by insisting, with ourselves, that when it comes to the care of our bodies, that we use the common sense and intelligence we bring to everything else.  Birth (and breastfeeding, and motherhood) is not so haunted and mystical and weird and shameful that common sense and intelligence don’t apply. 

And when it feels too daunting to do that yourself, let that be a sign to you that you’re not supposed to figure all this out alone.  Childbirth classes, mother’s groups, breastfeeding support — all of these things exist to help you find the kind of care that will help you feel cared for while you do the transformative hard work of becoming a parent (or becoming a parent again!)

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.