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Friday, February 16, 2007

Childbirth Nazis?

So, the Oregonian recently had an article about how Oregon has rates of natural childbirth that are double the national average (about 20% attended by midwives, vs. about 10% nationally, and about 2% in birthing centers vs. about 1% nationally), and that many women here feel judged for their childbirth choices if they are not able to live up to the ideal of a completely natural birth. It probably won't surprise you that I had a pretty strong reaction to this article.

First, I don't think it's very good journalism. Like the "opt out" series of articles from a couple of years ago (about Ivy-League-educated mothers who chose to stay at home with their children), it seems overly colored by the author's own experience. Just as the "opt out" group of women were overwhelmingly white and wealthy, and a tiny minority of all mothers, the women who have angst over their birthing choices are also overwhelmingly white and educated, and urban. The article mentions the national rates of delivery by Caesarian section (up to almost 30% of all deliveries, with almost a 50% increase in the last 10 years), but doesn't reveal the rates in Oregon. Even if it is significantly lower than the national rate, I feel fairly certain that it is still greater than the rate of natural childbirth. The vast majority of birthing women are perfectly happy to go along with whatever their doctor suggests, and generally don't have misgivings about those choices unless something goes wrong.

The author also doesn't look at the underlying statistics. She mentions the increasing national rate of Caesarian sections, but doesn't compare it to the rate in Oregon or in other developed countries (Canada's rates of Caesarian sections and infant mortality are both lower than in the US), nor does she look into the possible reasons for the increase (higher malpractice insurance rates, larger numbers of multiples, women seeking to avoid pain and exercise greater control over the process, I think all play a role), or whether it is a good or bad thing. There are also statistics (somewhere . . . ) about the effects of various childbirth interventions (epidural or other anesthesia, episiotomy, hormonal induction or augmentation of labor, etc.) on fetal and maternal outcomes, but she doesn't mention these at all. It seems she's so concerned about women passing judgment on each other that she's unwilling to entertain the possibility that they might be right.

So, here is where I tell you about my own experience on the matter. Both my boys were born in a hospital, attended by a midwife, and both arrived vaginally, full-term, and healthy. That's about the extent of the similarities. Number One was conceived in the course of regular marital relations, but when it came time to be born, he stubbornly had his face turned to the side (the baby's head has to be turned the right way in the mother's pelvis to be able to come out). So, progress was slow, and, desperate, exhausted and nauseated, I opted for epidural anesthesia. It offered relief from the pain, but lessened the strength and effectiveness of my contractions. So right away, one intervention led to another, as I was put on a Pitocin drip. Progress continued, albeit slowly, and my midwife eventually decided she should break my bag of waters to help things move along (yet another intervention). Of course, his head was still turned sideways, so he couldn't come out in any case. I pushed and pushed and pushed, to very little effect (other than to wear me out), until after 2.5 hours I threw up, he turned, and emerged with his arm wrapped around his neck (as if to give himself a pat on the back).

Good final outcome, but I felt like I had been not so much in control of the process. I resolved right away that for my next child, I would a) get a doula (I thought that with the right kind of support, I could have gone without the epidural, and the resultant other interventions), b) let myself throw up instead of fighting it so hard (since so much progress happened when I did). I later learned about Hypnobirthing®, and resolved to use its techniques in my next labor experience.

So, Number Two was a lot harder to come by. After trying lots of different, lesser interventions, we ended up conceiving him through in vitro fertilization. As his due date approached, I practiced with the Hypnobirthing materials I had borrowed from my sister-in-law. One evening a week before my due date, my water broke as we were moving Number One towards bed. I called my midwife, and she told me to call her back if I decided to go to the hospital. Water broke at 8, contractions started at 10, went to the hospital at 11:30. Called my sister-in-law (veteran of 4 natural childbirths, at the last two of which I served as labor support) to come to the hospital to support me in labor. Walked the halls for a while, sat on a birthing ball with my upper body resting on the bed, listening to the Hypnobirthing relaxation CD for a while (actually falling asleep between contractions once or twice), sat in the Jacuzzi tub for a while, as my contractions grew more intense. At about 4:30, my body started doing a weird pushing thing, completely out of my control. At my sil's suggestion, my midwife came into the bathroom, saw what was happening, and said, "Time to get out!" I got out, made my way to the bed, and Number Two was born at 4:47 after just a few minutes of pushing.

The birth experience with Number Two was better than with Number One, and not just because it was shorter. I felt calmer and more in control of the whole process, and fewer interventions meant a shorter recovery (as well as a more alert baby, who latched on right away, yada yada yada).

So, my own personal experience tells me that natural childbirth is better than childbirth with even relatively few medical interventions. I believe the statistics for maternal and fetal outcomes are also better. Given this, what can I do to encourage women to make this choice without coming across as being judgmental? What can I do to help them have confidence in their ability to do it on their own? How can I convince them that they shouldn't be afraid of the pain (which, after all, can't kill them) or of not being in (conscious) control of what is happening with their bodies? Am I limited to saying, "Try it, you'll like it"?

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Blogger MWR said...

It's good to recalibrate sometimes what we mean by "anecdotal evidence." ;)

I was under the impression that, all other things being equal, the first delivery is usually the toughest.

I would be interested to see a long-term study of "outcomes" that took full account of why some mothers were having c-sections in the first place, and others not. I would expect to see some correlation between "natural" childbirth and an overall trouble-free pregnancy, and if that were the case then it would be silly (and a post hoc, ergo propter hoc fallacy) to think the better outcome was due to the natural childbirth.

There seems to be a strange need in some segments of our bourgeoisie for indicia of "authenticity", and this need seems especially strong in maternal contexts. And there seems to be an idea that it's not virtuous to intervene and spare the mother a great deal of pain, if that might mean that the little baby is groggy for a while or whatever. I can't imagine it makes the slightest difference later on whether a baby was groggy or not.

I don't think the transition from laying eggs to live birth left many great anatomical options for getting the baby out of mamamalian mothers. There's no special virtue attached to vaginal birth just because that's the best Mother Nature could come up with given what little she had to work with. We're not self-vaccinating, our teeth don't fill themselves, and sometimes we might need a little help in the birth department (well, not me, of course . . . I just get to sit at my keyboard and hold forth while others attend to the messy business of giving birth . . . but you take the point).

I also note that the doctrine I call "fear of irony" dictates that the more you plan to have a "natural" childbirth, the greater the chance that you will require a significant intervention in the event. For example, if you research different hospitals and find the one with the only in-suite special water tub, and you hold forth at length about the horrors of c-sections, and you say things like "18 hours of labor isn't really that long"—if you do all these things, what will end up happening is that you will have 25 hours of labor followed by a c-section.

The answer to your question is twofold. First, don't bring the subject up gratuitously, for example, if the person does not seem to be troubled or in conflict about birthing choices. If you decide to weigh in, just tell your story as you have here. This works in many contexts when even a slight appearance of being judgmental could be counterproductive. You're just telling a story, and it either resonates with the other person or it doesn't. Of course, you would want the story you tell to begin with you being in roughly the same position as the the hearer ("You know, I was about your age when I first got beaten up on the playground . . . .")

By the way, I can't stand any of the articles I've ever read about women "opting out" (and not just because it's only women who have that as a societally-sanctioned option, as if men don't just as often hate their high-pressure, high-skill jobs and wish they could stay home and raise the kids). As you note, it's often extremely privileged women, often with family money and husbands making in the mid six figures. The women interviewed invariably evidence no understanding of how fortunate they are to be able to more or less chuck their expensive educations and not work, when far more mothers couldn't even conceive of having that kind of education, much less being able to leave the workforce if fancy strikes. There is something troubling, conceptually, about the waste of societal resources that "opting-out" represents. Clearly, if women were opting out of neurosurgical residencies to raise kids, the medical establishment would have to reexamine how those positions were being filled, and if it turned out that some women, even without much conscious thought, ended up using med school and their neurosurgical residencies as a glorified matchmaking service, something would have to be done about that. This is an extreme example. A few brilliant lawyers opting out probably doesn't exact the same toll on society's resources, because there are many other lawyers. But Yale Law School was never meant to be an enrichment program for stay-at-home parents.

February 16, 2007 at 7:31 PM  
Blogger Lane said...

I was totally sold on natural childbirth but, due to my own set of circumstances, had the pitocin drip and epidural. Both actually made my delivery easier. I was lucky to react to the epidural the way I did since I was able to feel the contractions and push effectively.

I don't think it's a matter of "convincing" anyone of the "best" way to deliver. I think it's a matter of 1) doing more in-depth study of HOW women deliver and why, listening to a lot of stories and really thinking about what's going on and then 2) providing the support women need in order to make the decisions they feel best about.

But it's kind of a pipe dream. There was an article in the New Yorker about the economics of the birthing industry, such as it is. It's just too difficult and expensive to train ObGyns in traditional birthing methods. That's one of the biggest reasons why the support for natural childbirth just isn't there. It's becoming a lost art.

February 16, 2007 at 8:09 PM  
Blogger Swizzies said...

I don't get it. I really don't. I've never seen *any* article about childbirth or breastfeeding that didn't turn otherwise nice, normal humans into raving maniacs of the convinced-there-is-only-one-true-way variety. (And I'm not saying you're a maniac of any variety!! :-)

So, here's my question: WHY do you feel the need to say anything (unless someone asks you)? I have never seen anything like childbirth and child raising to elicit more unsolicited advice - it's tres bizarre. Have you ever seen the rabid breast-feeders or co-sleepers go after the non's?? Brutal.

Also, hear hear to what MWR said about the opting-out thing.

February 17, 2007 at 2:49 AM  
Blogger Adriana Velez said...

My previous comment was accidently posted under Lane.

Yeah, the evangelism behind certain parenting practices -- it is weird. Nursing evangelists and the like often end up alienating the very people they're trying to convert.

And its almost always the crunchy side of things. I'm totally pro nursing, co-sleeping, you name it. But I find the stridency of some of my fellow "natural" mothers embarassing. Why do "alternative" parenting methods seem to attract evangelicals? Is it because they attract politically-minded people?

Back to "natural" childbirth (a friend of mine says ALL childbirth is natural if it results in a human child) -- the other problem with this is the larger issue of pain. In these modern times most of us do not embrace or work through pain. We medicate it. Got a headache? Take an asprin. Got labor pains? Get an epidural. That's what we do. Any other approach to pain is going to be a hard sell, period.

February 17, 2007 at 2:06 PM  
Anonymous Anonymous said...


Aren't statistics tricky little buggers? Wish they were easier to pin down. And gosh, I love it when you speak Latin--takes me right back to the Toaster.

Authenticity, hmm. Yes, I suppose the search for it might be seen as somehow bourgeois, but I think it could also be seen as a backlash from the last century's "better living through science" that in some cases has come back to bite us in the ass. Sometimes the way we used to do things actually was better (see, e.g., the food industry). Yes, the medicalization of childbirth has saved many babies' and mothers' lives (though at the beginning I think the casualty rate increased because midwives had better hygiene than doctors), but in cases of uncomplicated deliveries it's just overkill. I don't think it's entirely apt, either, to compare childbirth (which would happen anyway) to vaccinations or dental care.

Am I bourgeoise because, were I to get a tattoo, I wouldn't get a design from someone else's ethnic heritage?

So I usually do do what you've suggested: tell my story. And actually, I usually bite my tongue when women tell me they "tried and tried" to breastfeed, but just couldn't figure it out (when I want to tell them that they obviously didn't try hard enough; it's hard for everyone (it is), etc.). But I have heard women say things like, "I just couldn't get the epidural soon enough" or "I'm afraid of feeling any pain," and watched as an acquaintance (hardly a friend) of my sister's disobeyed her doctor's recommendations in order to keep her baby small and deliver her prematurely so that she wouldn't have to gain too much wait, get too many stretch marks, or have to deliver a large baby.

And you know, Adriana, I think we all have our lines between what we think is good and healthy and what just goes one "natural" step too far. My most recent prenatal yoga class was in SE Portland (hotbed of the organic lifestyle), and I was a little on the conservative side because I didn't buy into naturopathic/homeopathic medicine, craniosacral manipulation, no vaccines, etc., although I did use acupuncture in conjunction with IVF, see a chiropractor every so often, and buy organic food.

As for the whole "opt out" phenomenon, well, the articles describe me and my friends pretty accurately--Ivy League graduate degree, husband with a nice income (of the five of us who lived in Hogan Hall together as 1Ls, all have two children apiece, two of us are at home full-time, one does non-law stuff part-time, one is a part-time AUSA, and one is full-time inhouse). The thing they never seem to mention in the articles (maybe in passing, or in a followup) is that pretty much none of us see "opting out" as a permanent choice, a giving up of our careers altogether. We pretty much all know that we'll be going back if we have any hope of sending our children to college. Where this new "opt out" generation differs from our mothers' generation is that we had better careers before we quit and therefore better ones to go back to, and we'll go back sooner than our mothers did (my mom went back to work when my youngest sister started school, after about 18 years out of the paid workforce).

I don't at all feel like my staying home at the moment is a waste of societal resources, just a reallocation of same.

February 19, 2007 at 9:55 PM  
Blogger MWR said...

ARMA virumque cano, Troiae qui primus ab oris
Italiam, fato profugus, Laviniaque venit
litora, multum ille et terris iactatus et alto
vi superum saevae memorem Iunonis ob iram;
multa quoque et bello passus, dum conderet urbem,
inferretque deos Latio, genus unde Latinum,
Albanique patres, atque altae moenia Romae.

February 24, 2007 at 2:54 AM  

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