Saturday, February 28, 2009

Reflections on Self-Education in Healthcare

As I finish up my first trimester of pregnancy, I wanted to reflect on something important that I've learned over these past 13 weeks, that being the following: Self-education in healthcare is critical, because healthcare professionals don't know everything (and some of what they "know" is false).

Now don't go thinking this is an anti-doctor entry, because it's not. Doctors and nurses (and other healthcare professionals) are great, and we need them. But they don't have time to keep current on every facet of healthcare, and some things that they were taught in med school are outdated and/or incorrect. That's why it's so important to do one's own research rather than relying blindly on medical help.

I knew this before this pregnancy, but it came home to me especially as I watched several doctors give me false information and/or advice. Thankfully I knew the most current data and wasn't misled, but there could have been bad consequences if I had not.

I'll give you some examples of what I experienced in only a few doctors' visits:

- One doctor told me that the dosage for Unisom for treating hyperemesis is 1/2 tab per day, up to an ultimate max of 1 tab per day. The current safe max dose is 3 tabs per day, and sometimes even more depending on circumstances. Motherisk recommends STARTING with a dose of 2 tabs per day and increasing from there. A dose of 1/2-1 tab per day will usually be less than useless in a case of HG.

- One nurse told me that she and the other office girls had had to Google "hyperemesis" to find out what it was. That's not a comforting thought coming from a trained obstetrical nurse.

- Another nurse obviously had no idea what I was talking about when I called to see if her OB could help me with hyperemesis, as evidenced by the fact that she carefully constructed the rest of the conversation around not having to say the word "hyperemesis." Again, not a comforting feeling from a nurse.

- One PA told me that she prescribed mostly lemons and ginger to help with hyperemesis. If you know about hyperemesis, you know that lemons and ginger are about as effective as snake oil in treating it.

- I could not get one nurse to take me seriously about the fact that my due date was really a week later than the divinely-inspired pregnancy wheel told them, due to the fact that I do basal body temping and knew my conception date. This is the kind of thing that leads to unnecessary inductions for "overdue" babies. In the end, I actually ended up "moving" my last menstrual period date up a week to avoid the arguments.

If I had not been prepared, I would have ended up with out-of-control hyperemesis being treated in vain with lemons and ginger and futilely-low under-dosages of Unisom, with a false due date more than a week off my true due date.

Anyhow, those are just a few reflections. So.... Do your homework! Love your doctors and nurses, but don't think that they are all-knowing. Even if they tried, it would be impossible. Know your own health issues so that you can come to the table prepared rather than naive.

Sermon ended!

Thursday, February 26, 2009

Book Review: "Playing Catch: A Midwife's Memoirs" by Sally Urang

"Playing Catch: A Midwife's Memoirs"
Sally Urang
2005, 407 pages

I was actually three quarters of the way through this book before I realized, quite accidentally, that it was a novel rather than an autobiographical work - which is a compliment to the author, as it was written realistically in autobiographical style - like Peggy Vincent's "Babycatcher." I did lose a lot of interest when I learned it was a novel, though - I'm just not interested in reading novels about midwives. I love reading midwives' autobiographies. However, I'm glad that this was a novel because I'm hoping there aren't too many midwives out there like this. God help us all if there are.

I finished reading this book in less than 24 hours. I'd like to say that it was because the book was riveting (and it was well-written), but the truth is that I read like the wind because I was in a battle with my conscience, which was nudging me constantly and saying, "Should you really be reading this?" I won out over my conscience in that I finished the book (an accomplishment definitely not worth bragging about).

I ended up having a love-hate relationship with this work, or rather, a like-disgust relationship. The reason for all of the above is simply that this book, as well as being a novel about hospital midwifery, is also a personal tale that involves a highly detailed saga of the heroine's trashy sex life, in extremely crude and vulgar detail, which an abundance of extremely foul language. I was really put off by this, and it is one of the reasons that this book will not be making my "highly recommended" list. I know that other people would not have the least problem with this, so I wanted to mention my bias so that it was known.

Aside from the detailed sexual exploits of this novel, it is the story of a hospital-based CNM and the midwifery work she does as a hospital midwife. It is, as I said, pretty well-written and interesting to read. I love the fact that when she uses clinical midwifery terms, she will immediately include a paragraph in parenthesis explaining the terminology in layman's terms so the reader can both follow the story and learn. I picked up a few that I didn't know myself! That was really great. However, I have read from other reviewers that there are a lot of inaccuracies in her midwifery knowledge as stated. I was reading so quickly that I didn't notice too much of that, although I did question the midwife's methods in a lot of the scenarios portrayed.

The author is herself an experienced CNM (certified nurse-midwife), so one suspects that much of the work is autobiographical - not in the specific details, but in the overall experience. Urang is obviously an experienced and knowledgable midwife, and it was great to have her knowledge so well-displayed in this work.

For me this was an interesting work in that it spoke of a different type of midwifery than the midwifery community with which I am familiar, that is, the homebirth midwifery community. The main character is a university-trained, hospital-practicing midwife, who I suspect would be termed by the natural birth community as a "med-wife." There's a lot of hospital protocol, pitocin, epidurals, and c-sections, and while the main character does advocate on the part of her patients, it is a much more medicalized atmosphere than the midwifery community I know. In fact, if a few sentences had been changed around and the book called "Memoirs of an OB/GYN," I never would have batted an eye, because in a lot of circumstances she seems to be more of an OB than a midwife. From what I have heard of hospital midwifery and nurse-midwifery, it is a common scenario for nurse-midwives to be caught in the middle in these working environments, both philosphically and practically. It's hard to practice the midwives' model of care in-hospital.

Don't get me wrong. We need hospital midwives - need them badly. They care for women who want midwifery care but aren't ready for (or desirous at all of) homebirth. They work to humanize the hospital maternity system and do amazing work. Here in Phoenix we have some great hospital midwives who do great work at some of our local hospitals. But oftentimes, hospital protocol succeeds in chipping away at true midwifery care, and midwifery in its purest form is often (though not always) only found in the homebirth community.

In a lot of ways, this book is an attack on true midwifery. The author, through the heroine, speaks scornfully and disdainfully of doulas, of self-educated patients, and of patients who don't want to accept her interventions or who question her advice in any way. There is one entire chapter which she spends attacking the author of a natural childbirth book, which seems (to me) to be a thinly veiled attack on Henci Goer (the fictitious author's name is "Harriet Ganci").

Do I recommend this book? Mmmmm.... No. For the crudeness, vulgarity and explicit sexuality, I could never recommend it. Other than that, it's a good book - I guess. I wish she had kept her heroine's sex life to herself (or just stopped outside the bedroom door) and focussed on midwifery. But this book is not a glimpse into "real" midwifery - that is, the holistic, woman-centered, evidence-based midwifery model of maternity care. Anyone reading this book without good background knowledge of true midwifery would come out with a really warped view of midwifery. I won't be reading the book again, and I definitely won't be recommending it personally. As one reviewer on Amazon said, "The good, decent, informative parts of the book were so surrounded by the sewage that I could never recommend this book to anyone." Too bad. Try "Baby Catcher" by Vincent instead.

Sunday, February 22, 2009

ICAN Publishes Groundbreaking Survey Results

I think I am possibly the very last birth blogger to write about this (though not the last to think of it!), but it is so monumental that I can't possibly neglect to mention it.

Some initial information for anyone new to the birth world:

The current U.S. c-section rate is something like 31.1% (and is reportedly under-reported). The phenomenon of VBAC, or Vaginal Birth After Cesarean, is thus a common topic among birthing women, as many women wish to have a normal, vaginal delivery with subsequent births. However, the current political situation among the mainstream birth-world is extremely anti-VBAC, despite the overwhelming evidence that it is safe (and indeed, safer than repeat c-section), and many women are being funnelled, voluntarily or no, into the "once a c-section, always a c-section" pathway, due to doctors who refuse to attend VBACs and hospitals who refuse to "allow" them. ICAN, the International Cesarean Awareness Network, is an international organization dedicated to c-section awareness and to helping women achieve the goal of VBAC.

ICAN has just released the astounding results of a survey undertaken through their volunteers, in which all (or nearly all) U.S. hospitals were questioned about their VBAC policy and whether or not they "allow" VBAC. (I'm using "allow" in quotes because technically, no hospital can force a woman into unwanted surgery - although it's happened - though they can make it devilishly hard to avoid.) The amazing result of the study showed that 49% of U.S. hospitals now do not allow VBAC!! This was broken down as follows:

28% of U.S. hospitals have currently banned VBAC (this is an increase of 174% since 2004)
21% of U.S. hospitals have a "de facto ban" - i.e. the hospital technically "allows" VBACs, but no doctor at that hospital will attend a VBAC
51% of U.S. hospitals still allow VBAC

I am so floored by this data that I have a hard time processing it. This is an outrageous insult against the rights of birthing women, and one which will hopefully not stand the test of time. To be told that one cesarean birth has doomed a mother to a lifetime of c-sections which are statistically riskier than VBAC births, both for mom and baby, is the absurdest of absurdities.

To make things worse, just because a hospital "allows" VBAC births does not translate into a hospital that is "VBAC-supportive" or "VBAC-friendly". Many (or rather, most) hospitals have such strict limitations for VBAC births that a VBAC can be almost as impossible to obtain as in a hospital with a VBAC-ban. Among some of the "VBAC rules" seen at various hospitals:

- A VBAC mum must go into labor before her due date, or she will have a repeat c-section
- A VBAC mum must have her baby during daylight hours, or she will have a repeat c-section
- A VBAC mum must have a textbook labor that does not exceed set time limits, or she will have a repeat c-section
- A VBAC mum must have already had one VBAC (that'll make you chase your tail for a while)
- A VBAC mum must have a "proven pelvis" - i.e. had one vaginal birth before her c-section

With doctors urgin grepeat c-sections and hospitals having ridiculous VBAC protocols, it's no wonder most VBAC-aspiring mothers cave and go for the repeat cesarean. Unless one has knowledge, massive will-power, a supportive family (hubbies in particular tend to get nervous) and a great support system, achieving a VBAC in today's maternity wards can be nearly impossible.

In many states HBAC (home birth after cesarean) is an option; unfortunately, here in Arizona homebirth midwives are banned from attending VBAC homebirths. Hopefully this ridiculous law will change in the future, but for now VBAC mums are stuck either facing a hostile hospital system or doing an unassisted birth. An acquaintance of mine was recently able to have a "legal" assisted home-VBA3C (vaginal birth after three cesareans) when a naturopathic-doctor friend of hers was willing to attend her at home. Another recent online acquaintance of mine who is seeking a VBA3C has decided, after much deliberation, to have an unassisted homebirth in her attempt to achieve a VBAC.

It is a sad, sad state of affairs when mothers who are seeking the safe and sensible option of normal birth following surgical birth are forced to decide between repeat surgery and unattended birth.

Here is the homepage of ICAN, which has an article detailing the study and the issue at hand:

ICAN homepage

I spent some time browsing the database of hospitals, which you can see here:

ICAN Hospital VBAC Ban/Allow Database

I noted in passing that the hospital where I was born, Riverside Community Hospital in Riverside, CA, has banned VBAC.

I then took some time going through Arizona hospitals and browsing the results. After counting up the results, I came up with the following:

33% of Arizona hospitals have banned VBAC (9 hospitals)
15% of Arizona hospitals have a de facto ban on VBAC (4 hospitals)
52% of Arizona hospitals allow VBAC (14 hospitals)

I did notice at least one hospital which was not listed in the results.

Out of interest, I looked at the hospitals that are closest to me here in Chandler. Here are some of the results, which may interest local readers:

CHW Chandler Regional - allowed
Tempe St. Luke's - banned
Banner Desert in Mesa - allowed
Banner Good Samaritan - allowed

I also (while we're on the subject) wanted to throw in this TIME article on "The Trouble With Repeat Cesareans", which was a very illuminating read. Check it out!

So what's the moral of the story?

#1 - We have a lot of work to do to clean up the maternity system in the U.S., both the hospital system and the homebirth system (which is often unnecessarily strict on midwife attendance at birth events such as VBAC).

#2 - If you are a mother or a prospective mother, you'd better work like a maniac to avoid a primary c-section (that is, if a vaginal birth is a goal for you), because it is extremely difficult to work back to normal birth after one cesarean in today's maternity culture. How to do this? Read, research, take classes, hire a doula, and stay out of the hospital as long as you can (if not permanently!). The World Health Organization has repeatedly stated that no maternal or fetal outcomes are improved by a cesarean rate higher than 10-15%, bringing us to the uncomfortable conclusion that a minimum of half, and up to two-thirds (or more) of today's cesareans are completely unnecessary.

(As a side note, I can completely corroborate this from personal experience.... Of the many women I know who have had c-sections, a huge majority of them were completely unnecessary - either due to maternal choice, doctor coersion, or iatrogenic complications - such as a botched unnecessary induction or "the doctor wants to leave on his vacation and you're not progressing fast enough" - seriously!)

We have a lot of work to do.

Saturday, February 21, 2009

Great News for Arizona Mamas: A New Birth Center!

I forgot to post this a few weeks ago when I was made aware of it, but I wanted to get this out there ASAP!! One of Phoenix's distinguished midwives, Shell Walker, has taken a great leap and started a birth center in Phoenix. This is an extremely exciting move, as the entire Phoenix valley has been birth-center-less for about two years, ever since Bethany Birth Center was forced to close down due to costs.

You can see pictures of the new facility here:

Pictures of House for Birth Center

It's gorgeous!

I am going to post Shell's letter of announcement here so that everyone can see what's going on. She's looking for help getting everything off the ground, and it should be open to clients soon!

"Dear friends and family,

"I have exciting news to share!

"The long long dream of a birth center has finally come true!

"I am partnering with one of my clients Julia H.- attorney, and her husband Steven H.- financial advisor on this project. They are bringing their passion and professional experience to the table and it looks like their little girl will be the first baby born at the center!

"The property that we have selected is absolutely gorgeous, sits on an acre of irrigated land in the heart of the city! It is located just a few blocks off of Interstate I-10 and is conveniently located between Good Samaritan and St. Josephs hospital.

"Imagine families birthing in a lovely B&B setting complete with spa services, personalized care, and easy hospital access if needed. Gift shop, Baby announcements, Postpartum baby nurse and doula care, Birth photography, Childbirth classes, Family friendly.

"From Tucson to Denver, there is not a facility like this!

"We are set to take over the property on March 1st. and have a 15 year with an open option to purchase. The property can be viewed at:

"As well as some minor investment in the facility we would like to generate enough capitol to cover the first year of expenses. We have reached 30% of our goal and are looking for investors or groups of investors who would be interested in investing in this project.

"I will be overseeing the clinical aspect of the project which will be separate from the from the business and financial aspect of the facility and center; which Steven will be overseeing. If you are at all interested and would like more information, please contact Steven at:

"I know these are not exactly the best of times to seek investment, but you never know what folks might be interested in or capable of so I am putting this out there to you all.

"In lieu of finances, well wishes, good thoughts and emotional support will be greatly appreciated and accepted.


"P.S I am including several doulas and childbirth educators on this contact list because we would really like to have as much community involvement and support as possible. If you are a childbirth or health care professional and would like to explore how we might make this a truly successful COMMUNITY project, please drop me a line!"

Saturday, February 7, 2009

Unassisted Childbirth Dissertation

Rixa Freeze of "Stand and Deliver" has posted her doctoral dissertation on Unassisted Childbirth, and it is really, really good. Go check it out! I'd post the link but this computer won't let me, but if you go to the site above, you'll see the link on your immediate right. I'm about two-thirds of the way through the document, and it is really fascinating. I'm learning a lot, and I think you will too!

Unassisted childbirth is not a current goal for me (I love my midwives!), but it's a fascinating topic, and one that's always a real possibility as an unintended accident that is quite common when parents (especially repeat parents who are expecting longer labors) call the midwife too late. So it could happen to anyone - including me! A fun possibility, but again, I love my midwives and would rather have them there.

For anyone who's interested, though, I have started a small sidebar on unassisted childbirth (UC), also called freebirth, and will be posting informational sites as I run across them.