I’m beginning the last segment of the website reconstruction – cleaning up the Natural Childbirth Directory. This is a big task. The directory has over 200 pages of information just about services available in the United States. Every page has to be reformatted to the new look. Every link has to be checked to ensure it still works. And that is what I find interesting today.
Having a list of useful links on a website is like shooting an arrow at a moving target. The internet is a dynamic information source, changing daily. A link that was helpful last week may be “broken” this week. A website with some interesting articles a year ago may be gone today.
When I began the directory, I wanted to be able to send readers to great sources of information. I wanted the unique articles that start discussions. I sought out web pages that complimented the information on Birthing Naturally, not pages that gave readers the exact same information. I wanted to be a link to resources families might not find otherwise – the hidden gems.
But the internet has changed. I think I first built the directory in 2005, and at that time it felt like a big deal to me to not send families to commercial sites they would find listed in any internet search (remember when search was basically looking through an edited list of websites?). I reasoned that if it took me a long time to find these resources, as plugged into the natural birth community as I was, it would be nearly impossible for families looking for information to find them.
I still think there may be hidden gems out there in the folds of the web, but I don’t spend time each week finding them. Many of the articles I considered great reads don’t exist anymore. But what is more interesting to me is that I don’t need to send families to an unknown webpage in the middle of a family’s personal website to provide research. There are great websites that do a fabulous job of educating women, integrating research and statistics with advice and basic information. Childbirth Connection, La Leche League, even the World Health Organization has pdfs that can be downloaded free to help women plan for birth – and usually in multiple languages.
So, just as in the other sections of the website, I find the needs of readers have changed and the directory must change to provide the best opportunities for the readers.
I’ve been trying to be diligent at getting the website updates completed. They must be completed before I begin classes again in the fall, or their importance will drop to the “don’t have time” category. Ugh.
It’s been an interesting journey to update the website.
Some days I surprise myself with how thorough I had been. I’ll make a list of things to “add” to the website, only to find in the midst of updating a section that I already added that five years ago!
Some days I’m surprised with how messy the navigation had gotten. The website “grew” organically from questions being received and interactions with mothers. Without an easy way to change the overall navigation scheme, pages were wrapped in an interestingly hard to navigate web. This time, I’m starting over with navigation because I’m updating the whole website. I hope this makes it easier for new readers to find what they are looking for.
Some days I struggle with how to balance evidence and information. My biggest example is the pregnancy concerns section – where I share things women sometimes try to get rid of backaches, stretch marks or nausea. It is in this section I have the most difficult time finding “evidence” that things work or don’t work. This is partly due to the difficulty in randomizing women to study the effects of an intervention. Do you randomize before they complain about something – before they get nausea? Because there may be differences in their diet that lead to nausea. If it is overall diet problems, then depending on the problem in their diet they may have different solutions to the problem. This gets really complicated really fast. Most studies tend to be observational, which might point in good directions but might also hide what is really working.
This is a struggle for me because I believe women have the right to the best information possible. I believe that information includes whether or not an intervention works – even if the intervention is eating fresh papaya. Why? Because if this is not something the woman ordinarily does, she has to take extra time and money to obtain and prepare the papaya – and she may not like the flavor. I have no right to decide for her if the extra time, money and eating something she doesn’t care for are worth the “relief” she gets, especially if I don’t know the papaya actually gives relief.
In preparing a talk on menopause, I came across an interesting study that looked at the effects of different types of treatments on hot flashes. Most women used hormone replacement or soy supplements, a few women used other things and some women used nothing. This was interesting because it didn’t matter what the woman used, if they followed her for about two years she reported improvement in the hot flashes – did you get that, they get better on their own. The only treatment that had any difference in the swiftness of improvement was the hormone replacement. But here is where I really paid attention – like a good research team they went back and shared what they had learned with their volunteer subjects. And they asked one more question – now that you know this, what will you do. Overwhelmingly the women who used soy said they would continue because even though most women didn’t have any benefit, it worked for them. But remember, the soy didn’t work any better than not doing anything – hot flashes improve on their own when given time.
There are many reasons the women in this study didn’t have improvement from soy, and other studies have found improvements – that isn’t the point. The point is the women in the study attributed the success of their relief to the soy when there was no added benefit of the soy to just waiting for menopause to progress. The soy cost the women money, took extra time I’m sure. But it wasn’t doing anything real for these women. Yet they couldn’t let go of the idea it was the soy, not the normal progression of menopause, that was making the difference for them. As an author on the internet and a midwife, I need to remember that what I say affects decisions women make. I don’t want to be the cause of someone believing they have to spend extra time and money on a solution that doesn’t really do anything.
This is one of the reasons the hair on the back of my neck starts to stand when women make comments about how there are many types of evidence, or that some trick always works for them even if evidence doesn’t support it. You cannot judge the value of a “trick” or treatment or intervention on it’s own. Just because I ate papaya and my nausea seemed to improve does not mean it was the papaya. It could have been something else I was doing — maybe getting more sleep or that I stopped eating something else. Or it could have been that I didn’t try the papaya until the time the nausea was going to be relieved on its own.
Considering a small sample without a control to be “evidence” is dangerous. It is what kept doctors believing some unnecessary things like episiotomy where helpful rather than harmful. And even if the biggest harm that comes to a woman is that she feels she must eat a food she doesn’t like, it still is not worth it to me.
So here I struggle with wondering how to let women know about the things most likely to help their symptoms, and about the things they are going to read that may waste their time and money because we just don’t know if they are helpful at all. And as I struggle through this, I am intensely aware that my natural birth friends may see this concern for quality information not as growth in me, not as a healthy concern for the women and families I serve, not even as responsible midwifery, but instead it may be seen as evidence that I am not really a midwife or not really interested in natural birth anymore.
The next piece of hypocrisy for me to tackle is the idea that my style of care is more evidence based than someone else’s idea of evidence based.
I love the natural birth community for many things, evidence based care is not one of them. Much of what my community supports for birth is good, best quality care based on evidence. But often, with the next breath, I hear suggestions not based on evidence but on faith in natural health care.
Some of this is not necessarily bad. The way we learn is to try new things – things not yet supported by evidence. Then if the things work we get more evidence and can make quality decisions based on that evidence. This is how a knowledge base grows, and I’m sure there is some percentage of disagreement that marks a healthy, growing knowledge base.
But at the same time, I need to accept that going natural rouge is as bad and potentially unhealthy as going medical rouge. Most everyone I know in the natural birth community believes it is not OK for a physician to decide that even though evidence doesn’t support use of cesarean for a particular problem, in this case she thinks it is the best way to go. Yet this same community accepts midwives recommending a particular herb, homeopathy or other complementary treatment, without anything more than the recommendation of another midwife.
I understand the concern that there is little research done on certain treatments, but I do not accept the idea that a midwife would begin using something without researching it. The problem lies in the fact that without adequate controls, you can draw the wrong conclusion. Think of all the physicians who used to believe an episiotomy was necessary, or that it was beneficial. The are still places in the world where episiotomy is taught from midwife to midwife and the belief that it works and is important is passed from midwife to midwife. Yet we know from research the place for episiotomy in best practice is very small.
The same thing can happen with any treatment because without the control you cannot tell the difference between how often the problem is resolved without the treatment and how often it is resolved with the treatment. The reality is, a treatment that is no better at resolving a problem than doing nothing is a waste of a family’s time and money.
So, in an effort to ensure the information I share is evidence based, I will be spending this summer updating the website to include evidence. Where evidence is lacking, I will be honest with my readers.
I’ve come to accept that I lie to myself, even though I could never successfully lie to anyone else. I’ve also come to accept this is a pretty normal human condition. It seems we lie to ourselves more often than anyone else. I lie about how much food I eat and how healthy it is. I lie about how much time I waste. I lie about my motivations for the things I recommend.
This week I want to spend little time identifying some of the lies I’ve recognized in myself, in the hopes it helps you identify the lies you tell yourself.
Why? Because even though I try so hard to believe these lies, other people see right through them. And when I am obviously being dishonest, my integrity will be questioned. It’s called hypocrisy, and it damages relationships and reputations. If the women I work with think they can’t believe me, I lose the opportunity to share the truth about healthy pregnancy with them.
The most obvious place I am dishonest is in my diet and exercise. I do try both – I try to exercise 5 or more days a week and I do try to maintain a healthy diet. But the truth is despite trying to balance diet and exercise for my entire adult life, I was only at a healthy BMI for about 6 months. The entire rest of my adult life I have been overweight, and for a sizable chunk I measured as obese. And even in the midst of those times I saw myself as a person who eats healthy and exercises.
I’m sure the women I work with wonder if I’m joking when I recommend good nutrition and exercise. If it was really so great, why don’t I do it. Because the truth is, if I was eating healthy and exercising my weight would be normal. My weight continues to measure as overweight because despite my dedication to healthy meals, I bake frequently enough that having one or two things from each baking episode keeps me overweight. My wight continues to measure as overweight because if I find myself with candy, I don’t stop eating it. My weight continues to measure as overweight because my “scoop” of ice cream is really more like two servings even though I estimate it as one.
These are deep habits, often difficult to even see myself doing. I am working on them, but I still make enough food choices based on desires other than health to keep me overweight. I tried an experiment once. When I talked about nutrition with women in childbirth classes I shared my struggles and asked the women to share theirs too. They shared, and it was much easier to help them meet nutritional goals when I understood what barriers were in their way. This works OK in a childbirth class, but I struggle to wonder if it is appropriate during a first prenatal. I have tried half, asking women to share their biggest food struggles. I’ve tried approaching it as areas many women struggle with, including me. It still isn’t the same as having the time to talk through it with a group of women.
My words will never speak louder than my body. If I look as if diet and exercise don’t matter to me, the families I work with will get the message loud and clear. They might even get angry if I suggest they make changes I obviously am not willing to make myself.
I have just over 24 hours to my midwife certification exam. In my midwifery path, certification by exam is a requirement for licensing. But when I get that certification, I will be able to be licensed to practice in any state and it will make my international work a little easier.
Certification and licensing are frequent topics of discussion among my midwifery friends. I have some on both sides of the licensing fence, and on both sides of the certification fence. Due to the crazy nature of this world, not all my friends who think licensing is good are licensed (some are in states without licensing opportunities). Similarly, not all my friends who think licensing is not a good idea are not licensed (some states require licensing to work as a direct entry midwife).
So what about me, where do I land in the debate?
I personally have no problem with certification for midwifery or any profession. Education alone would be nicer (and cheaper), but certification does provide a protection for the midwife consumer and me as the midwifery school consumer. Why? Because I believe knowing your graduates must pass an exam on the basic competencies of a midwife improves the didactic quality of the school. I can’t imagine spending thousands of dollars on a program only to find out it didn’t really give me the information I needed to work independently as a midwife.
I know there are some who feel the certification exam is no proof you are a good midwife, and I agree. Honestly, the only way to be a good midwife is to be a midwife for a few years. I will still be a new midwife, with or without the exam. But the certification exam shows I have a minimum competence with the tools and materials I will be using . It shows I understand the basics of evidence based practice — even if the process of test writing means it will be two to three years behind.
As for licensing, I am a fan. Again, I don’t think licensing makes you a good midwife. It is simply a way for the profession to be regulated — to ensure that all those who are practicing have met the minimum standards. But from the public health side, it does some amazing things. First and foremost, it gets midwives counted. Midwives, especially direct entry, tend to be invisible in research. As long as they are invisible, they will not be taken seriously and their practice will suffer from “evidence” problems. I want to change that.
I also have friends who are against licensing because they feel it restricts their practice. I disagree on two counts.
The first is that every state has a midwifery practice act, and if your practice doesn’t meet the definition your practice is already restricted. If your state’s laws don’t mention midwifery beyond nurse-midwifery it is too easy for your practice to be labeled as illegal. Licensing prevents that.
The second is that I believe midwifery practice (as with any health care practice) should have restrictions. A midwife should be expected to provide evidence based care, even if that means some mothers will be told home birth is not a safe option for them. I believe this as much as I believe physicians should be expected to provide evidence based care, even if that means some mothers will give birth vaginally in the middle of the night on a weekend. I don’t want midwives making their own estimations about which woman is or is not safe birthing at home any more than I want physicians making their own estimations about what is or is not an indication for cesarean. It is too easy to keep moving your own line in the sand.
The current problem is the lack of universally accepted evidence based guidelines – but this I see as a temporary problem. If the system is broken, you fix the system. When you ignore the system completely you lose opportunities to make change (like the problem I have with my research where direct entry midwives cannot really be counted and therefore their impact cannot be estimated).
Change is a slow process, and some of my friends have been waiting too many years (some whole lifetimes) for change. Some have been so burned by past “change” that they have learned to distrust the system. Some gave up fighting years ago, and now just want to do their midwifery without interference from governments or certification organizations. I know this. The sad truth is I don’t personally see a way to move midwifery forward — to extend the rights and protections for direct entry midwives — without causing their practices to be interfered with.
For me, the importance of licensing goes beyond my direct entry friends here in the US. For me, it is also an international thing. Midwives everywhere should have access to good quality training, good and useful tools to do their work, and be paid by the health system for the work they do. For this to happen, midwives need to be a real part of a countries health system rather than an invisible “problem” the health system sometimes ignores and sometimes attacks. Midwives need to be taken seriously. Licensing is one step to being taken seriously.
I was talking with another nurse practitioner (yes, I am actually a nurse practitioner now!!!) about what I would do with my midwifery training. I’ve decided to pursue a PhD, which means I am pretty sure I’ll never work as a baby catcher. I knew this, and accepted the possibility when I applied for the PhD program. But, as I explained to her, midwifery isn’t just about catching babies because women are more than a uterus.
But I also trained in family practice, which means I can help identify an illness or treat a chronic condition. In the real world, these two disciplines overlap. Pregnant women get sick, and women with chronic conditions get pregnant. Having the combined background puts me in a sweet spot to help women in these in between spaces.
I have an extensive knowledge of sexual health issues, and can help women as they make decisions regarding contraception or if they need treatment for a sexually transmitted infection or if they want a little help trying to conceive.
I am trained to support lactation, and all breast health issues which means I can as easily help a woman work through a plugged duct or thrush as I can assess a lump she found. I am comfortable enough with my skills to help a woman make evidence based decisions about breastfeeding while using a medication.
I understand the menstrual cycle and can help a women if she is moving through menopause, missing periods or bleeding heavier than she used to.
All of these are skills I have gained while training as a midwife. These are basic healthcare issues I may run into with any woman in primary care. No, I will not be a baby catcher, but I am a midwife and will still provide midwifery care for the other aspects of a woman’s life.
I am studying my least favorite subject tonight – TORCH infections. I have to admit to not learning much about these in class, not because we didn’t cover the information, but because I was not yet thinking about infections like a midwife.
As a childbirth educator, my training in pregnancy infections went something like this. ”Herpes is no big deal. They can cover any spots and prevent spread to the baby.” ”Toxoplasmosis is no big deal. Most women with a cat have already been exposed.” I was then assured that the medical community exaggerated these infections and used them to get women to do what they want.
It is scary to think this type of education felt adequate to me. I have to be honest, the provision of reassurance without adequate information on a subject was something I was told the medical community did to ensure people were compliant. I am not sure how I was oblivious to the same quality of “education” being provided to me.
I’m older and better educated as I pour over research on the subject today – actual research and not a paperback book for expectant mother’s about pregnancy. The reality is, these infections are serious and they do pose dangers to the baby. Fetal death, blindness, mental retardation and seizures are just a few of the possible outcomes. Maybe if I had understood that from the beginning I would have taken the time to really learn them instead of pushing them into my “not going to bother” pile.
Being on this end of it, I also have a better appreciation for how unnerving such a possibility must be for an expectant mother. If it were me, I wouldn’t want to be told not to worry about it. I would want information, real hard facts to help me understand how to reduce the risk to my baby. I can guess most women would react the same.
I may not see many women with these infections, just like I may not see many shoulder dystocias. This is why I now believe it is important for me to take these infections seriously. I need to be able to explain the risks to a woman, and help her understand how she can reduce those risks. I need to be able to tell the difference between being in contact with someone with an infection, and contracting the infection. I need to be able to identify a problem early, because quick identification of the infection may offer a chance for treatment, and that may be able to help a baby.
And as for herpes, I can accept that it isn’t usually going to be a problem. Not because the herpes virus is no big deal, but because I’ll help her prevent an outbreak and reduce the risk of transmission with suppression therapy. Having good information to share means the women I work with can make decisions based on solid research.
People like to say that statistics lie. Actually, the statistics tell the truth, people just are not always educated to understand what they mean. This happens alot in the birth world with the cesarean rate.
The CDC releases statistics about birth in the United States each year. In 2010, the CDC reported that 32.8% of all births in the United States were by cesarean surgery. This data has lead some childbirth professionals to assume a woman giving birth in the US has about a 33% chance of ending up with a cesarean. But this isn’t necessarily true. Why?
Because that number includes two different groups of women with two different rates of cesarean surgery.Childbirth Connection has a graph that may help visual learners get this concept, and statistics nerds may prefer this 2005 report from the CDC.
One group of women in that number is women who either never gave birth or only gave birth vaginally. The other group of women in the number is women who previously gave birth via cesarean. Women with a previous cesarean may give birth vaginally, or via cesarean. Currently the VBAC rate in the United States is pretty low, which means the cesarean rate for women who previously gave birth via cesarean is pretty high.
As you look at the graphic on the Childbirth Connection page, notice how in 1989, the cesarean rate was about 23%. Using this graphic we see that about 18% of women who had a cesarean previously gave birth vaginally, which means about 82% of those women gave birth via cesarean. In the same year about 16% of women who had never had a cesarean before gave birth via cesarean. Although the overall rate was 23%, a woman who had never had a cesarean before only had a 16% chance of having a cesarean.
Fast forward to 2004 on the Childbirth Connection graphic and you see the rate of cesarean increased to about 29%. Rate of VBAC declined to about 9%, meaning about 91% of women with a prior cesarean gave birth via cesarean. Primary cesarean rate also increased, but to about 19%. So although the overall rate of cesarean was 29%, only 19% of women without a prior cesarean gave birth via cesarean.
The graphic stops at 2005 because of implementation of a new birth certificate system which prevents accurate counting, but we can estimate as long as we accept the numbers we have are only estimates. In 2010, 33 states were using a birth certificate that allows us to count primary cesareans. So we have a count, but it will miss about 25% of the births in the country (because they happened in one of the 17 other states).
From the data we have, we can estimate that in 2010, 23.6% of women without a prior cesarean gave birth by cesarean while about 91% of women who previously gave birth via cesarean did so again. This means, that although the overall rate of cesarean in 2010 was 32.8%, a woman giving birth for the first time had a 23.6% chance of having a cesarean. Instead of 1 in 3, her chances are more like 1 in 4.5. On the flip side, 9 in 10 women with previous cesarean are likely to give birth via cesarean.
I heard it again today, “They won’t let me….” Whenever I hear someone talking about “they” or “them,” my ears begin to perk up because I know there is more to the story than I am being told. Here are the things that go through my mind.
1. Does this woman understand what she was told and why? I don’t ask that to be smug, but out of real concern about miscommunication. It can be easy to believe everything you hear, even if what you heard was not what was said. It is also easy to believe things you hear from individuals who are not in a position to be decision makers. If a friend tells you the hospital doesn’t do water birth, you are much less likely to ask about the option on a tour. If you don’t ask, you won’t find out that they only have two water birth rooms so if you are interested in a water birth you need to tell someone on admission.
2. Is this woman making assumptions due to misinformation? If you were to believe everything you read, every doctor, nurse and midwife is out to make sure you have a terrible birth experience that hinders your breastfeeding and bonding. The good news is that most health care providers are NOT like the stories you hear. In fact, each health care provider is a unique individual, just like every mother. Individuals have strengths and weaknesses, good days and bad days, get tired and will even have opinions. Sometimes the opinions of other individuals will be different from yours. But you cannot know this unless you ask. Making sweeping generalizations about everyone within a profession is stereotyping. Not only is it unfair, accepting your assumptions based on stereotypes means you are less likely to ask the questions you need to ask to prepare for the kind of birth you want.
3. Is this woman feeling judged about choices she made and just trying to get out of the conversation? For those with a passion for helping mothers have natural births, it can sometimes be difficult to understand why a woman wouldn’t choose a natural birth – and this can come across as judgmental in conversation. Some women politely smile and nod as you continue explaining the perils of epidural, some will get angry and tell you it is none of your business, and some will blame the decision on someone else so you will leave them alone.
How do I handle these situations? First, I never assume the mother and I are “on the same side.” I don’t make assumptions about who she is or what she wanted from birth or how she feels about not having an option. I don’t argue against the medical establishment, medical techniques or individual caregivers. Instead, I listen. I let her talk, sharing what she feels is important. If she needs to know I am listening and not judging I might ask if she can “Tell me more about that?” Instead of deciding for myself how she is feeling, I ask her, “how do you feel about that decision?” Then, I listen. Because she might be angry the option is gone, but she might be relieved.
This week I have been sharing some of the harder lessons I had to learn to become a midwife. The value of humility is perhaps the hardest one I faced.
I thought I did approach birth with humility. I believed I understood the process and knew that the best course of action was to let the labor take it’s course. Yet, at the same time I failed to see how I approached birth with arrogance.
- When I would hear labor stories, I would decide for myself what doctors, midwives, doulas and mothers had done wrong despite not being present for the labor.
- I had answers for every problem a woman might face because natural birth was always possible.
- I assumed what I knew about birth was not only all there really was to know about birth, but also the most important things to know about birth.
I now approach birth with a different type of humility.
- I accept that there are things about the human body I do not know or understand. I accept the ability of others to know and understand those things even if I currently do not.
- I accept that problems can arise in labor without anyone being at fault. Babies and placentas can have problems despite the best health of the mother and care of the midwife.
- I accept that the hands and knees position and a doula cannot possibly be the answer to every problem.
- I accept that there are multiple ways to respond to a problem and most of them will give a good outcome most of the time.