Controversies in Childbirth

The process of blogging this conference has been a little more time consuming than expected, but here’s the quick retrospective…

First impressions, and I think that these things have a bearing in determining what exactly the interests in this conference are.  This show is being run by Alan Huber, with whom I was not familiar, but it turns out that he is Robbie Davis-Floyd’s partner. Although he is connected to the Grand Dame of anthropological midwifery studies, I am not reassured that his conceptualization of the issues is as nuanced as I would prefer.

For example, the session titles area all clearly contrived to be very sensational; like the idea was just to set people of opposing viewpoints in the same room and let them duke it out. I guess it was meant to be the American Gladiator school of debate. Turns out that many of these people are not only not as sensationalistic as they were cracked up to be, but the speakers themselves seemed a little unhappy at the titles of the events.

For openers, Alan got up and talked about the “elephant in the room.” I had come to this thinking that the elephant in the room might be the rift between the obstetrical and midwifery models of care, or about the AMA and ACOG’s persistent persecution of midwives since, like, the dawn of time. But no. Unsurprisingly since Alan is a finance guy, the elephant in the room was “who is going to pay for this.” Actually, it was “who wants to improve childbirth,” [all hands raised], and “who wants to pay for it?” [my commie hand raised].  I had to gnash my teeth in fury for a moment, because I feel like we’re finally having a nuanced conversation about healthcare in the United States, and was really excited about having a real conversation about controversies in childbirth, and it all comes back down to crass economics. Not that I don’t think that economics are something VERY VERY serious and need to be thought about very carefully by bigger brains than mine as we hopefully move to a single-payer system some time in my lifetime, but really, how long will it take us to see that a rising tide raises all ships and it’s totally in our best interest to pay more for healthcare for everyone (and not just any healthcare or the most tricked out gadgetry we can afford, but effective client-focused healthcare proven by evidence). Shouldn’t we ALL want to pay more to improve birth, even if only to perpetuate the species? I was thinking that maybe, just maybe it’s hurting just enough to get us to change (like remember last summer when gas was $4 a gallon and everyone started selling their Escalades?)

Anyway, there was a lot of other stuff that squicked me out a little. Like the fact that I hauled my ass out a day early for some Birth Lawyers meeting only to get an email while I was on the tarmac that it had been canceled. Because it’s not like I have a family or a clinic workgroup or clients or anything that I’m putting out by jet setting (and Fort Worth, well, the locals call it Fort Worthless. That’s all.). Not only that, we paid quite a pretty hunk of cash, and there wasn’t even a soda machine in the room.  Luckily one of the vendors at the Super Baby Crap Bonanza downstairs was Luna Bars, and so they slipped a couple of “fun sized” protein bars into the bag of pamphlets and whatnot. I know it’s sort of grouchy of me, but I’ve been to conferences and whatnot that charged far less money and somehow managed to keep me fed and in free internet connection (that was another annoyance – they was a “pay for service” internet connection, and they acted very “it’s out of our hands” about the whole thing. Surely, surely there must be a way for them to buy a password and then give it out to the attendees?) I can’t help but think that the money wasn’t going to honoraria or to the facility itself, but rather to underwrite the cost of the Expo downstairs. Well played, Huber, well played.  Sadly, however, even as a just-barely-pregnant lady there was nothing useful to me there except the Luna bars. I even tried to get a Bible from the Gideons because at the moment I was having a “threatened abortion” and wondered if maybe their healthcare edition had something highlighted that I might find soothing, and they wouldn’t give it to me because it was just for healthcare practitioners. I left in a tiny bit of a huff, like “OH. This is the word of god to the NURSES, not to the rest of us, I see…” And how do you know I’m not a nurse? It made me wonder if the Gideon’s Bible that was no doubt in my hotel room was the “travelers and sinners” edition.

But enough of the raincloud—I appreciate the sentiment of wanting to get various people with an interest in birth to talk to one another over their fundamental differences of perspective (although I less appreciate the comparison to the abortion “debate,” particularly when the “birth is not ipso facto an emergency” folks are cast in the role of the crazy screaming radicals.) Alan is right, though… once a woman agrees to have a baby—you know, to the extent that it’s an agreement, but I’ll try not to get all Repro Justice on them—we all want to make it the best birth possible.

One of my very favorite presenters came early on, Laureen Hudson, who did a presentation about midwives and birth people retaining relevance now that we’re all Web 2.0 and shit. Anyway, I thought it was pretty neat: the ultimate message is that midwives need to brand better, because women of childbearing age are going to google for everything, and you can’t let the “Dr. What’s-Her-Names” of the world win just by sheer force of webclicks. I could not agree more; don’t get me wrong, crunchy moms are one of the most breathtakingly well connected groups of people out there, but so, so, so much information is so much crap passed on through word of mouth on MDC. You can usually read at least SOMETHING about any given Ob/Gyn by googling them (find their articles, sometimes even their caesarean and VBAC rates, whatever), whereas you’re lucky if a midwife has a website at all, it’s strictly Web 1.0, and she hardly ever answers email, etc. And it’s unsurprising since I have seen a little bit of subtle and not-so-subtle hostility toward the so-called “Millenials” or “18-35s” or whatever you want to call us, sort of like we’re the Pygmies of Bora Bora or something.

Frankly, if it weren’t for online communities, I would not be here. I mean, I’d be blogging (I am blogging elsewhere), but it was being able to connect with ICAN Online, other Yahoo groups, Freebirthers, Cloth Diaperers, and all orders of birth junkies that got me to the conference and where I “AM” in birth world. Although I have to say that there is a discernible divide between the blinkies and siggys and “DHs” and “TTC, so we’re going to BD”  of the message boards/babycenter and the semi-slick ease of use of Wikipedia and other sites my generation uses. So mayhaps we’re like Web 1.5 or something in birth world; but believe me, the geeks are starting to procreate, so I foresee a brave new world.

I’d like to think that the fact that I can multitask three different social networking services at the same time (which I am doing right now) doesn’t mean that my ability to interact in person with other human beings is somehow compromised. I see a lot of this taken with a sort of doomsday, dystopian feeling (in fact the people behind me are grumbling).  Wake up and smell the toobz! These internets are a great thing for birth. We worry that as society becomes more mobile, women are disconnected from the birth wisdom of their ancestors and sisters and all that, and now we finally have an opportunity to find our tribe.

Okay, the rest of this is a little disjointed because my notes are crazy.

One of the panels in particular stood out. Well, it could have stood out. It was Stuart Fishbein, a pro-VBAC doctor; Pam Udy, President of ICAN; Marra Francis, doctor who supports elective cesarean; and Pauline McDonagh who runs a pro-elective cesarean website.

The topic was  whether there is any independent value in a low cesarean section rate. I have to say that this conversation was a little like listening to people argue about the semantics of “pro-choice” and “pro-life.” (You’ve heard this conversation: “I’m pro-life, but I don’t want to make abortion illegal.” “Oh, so you mean you’re pro-choice. I’m pro-choice but I would never have an abortion.” “Oh, so you’re pro-life. We all agree on everything!”) Even though the panel was constructed in such a way that the speakers were supposed to be tearing each other apart, the only tearing I could hear was the upholstery on the chairs as everybody nodded their heads in violent agreement: nobody should be forced to give birth in a way that she doesn’t want to.

Great! Pop the champagne, let’s all go home!

What’s that you say? Women are still being railroaded into procedures that they don’t want? Child protective services are still threatening to take babies out of the arms of mothers that refuse to be injected, transfused, or cut open? Hmm… maybe it will take a little bit more than this.

Just as a side note, Dr. Francis doesn’t believe that women are forced to undergo procedures against their will, “because that would be 2nd degree assault with a deadly weapon, guize!” I’m sorry if anyone there heard me guffaw. First of all, yes, indeed it is a civil battery, but women who bring these cases are laughed out of the courtrooms. Second, criminal charges are never brought! The state would have to prosecute, and I’d love to hear about a prosecutor who gives a rat’s ass about a woman being coerced into surgery or having an episiotomy against her will, even when she’s screaming “DON’T CUT ME!”

This was the remarkable thing about this conference: they really did manage to swing it so that, at least with the speakers, there was a diversity of perspectives. I was particularly impressed (well, terrified) by Ms. Udy’s story of her own VBAC, and how when she requested her medical records to transfer to midwifery care, there were newspaper clippings about her being affiliated with ICAN, like they were building a case against her to order a cesarean before she even made it to term. SCARY. (and perhaps a good reason I remain a spook and not a real woman with a face or a name or whatever else makes you real and not virtual). However, because the panels were relatively unmoderated, there was not an opportunity to actually tease out the differences in what people are saying. Yes, common ground and all that, but when you have 4 people on the stage who should probably be vehemently disagreeing, but they’re all pretty much nodding and saying “yes, nobody should be coerced into a cesarean section.” Well… that’s not what I tend to think of as controversial.

There were a couple of moments where some sparks were going to fly: Ms. Udy said something to the effect of “we have to remember that this is how nature intended for babies to be born,” which of course opens to the door to “and nature intended for a certain percentage of women and babies not to survive labor,” a catch Dr. Francis was quick to make (“the natural consequence of cancer is death, but we intervene there” amirite?). I was telepathically trying to get Ms. Udy to say: “yes, but you are talking about a pathology, and birth is not inherently pathological. Your response reflects the prevailing obstetrical perspective of birth as an inherently emergent situation, whereas in reality only a certain number of births become pathological. We’re advocating for a model wherein interventions are reserved for the times when things go wrong. You don’t immediately give chemotherapy to everyone who comes in with any lump or lesion, nor should you give a cesarean to everyone who comes in with a labor that, say, lasts longer than 12 hours, is a breech, is a multiple, etc. etc.”

She didn’t. But you can’t blame her — when you’re sitting on a panel with people in lab coats, and you’re “just” a mom, albeit president of a large grassroots organization, well, let’s just say the power structures don’t just disappear when it’s convenient for us.

I was, of course, appalled to find out that the number of hospitals that officially ban VBAC has increased exponentially since the last ICAN phone survey. Now it’s something like 800, with 1,200 having a de facto ban? Insanity. And why? Dr. Fishbein, whom I admire, chalks it up to a fear of maloccurance (on whose part, I failed to note. Insurance carriers? Patients? Doctors? Whose ass is REALLY on the line here, hmmm?).

What I found most fascinating was the talk by Ms. McDonagh. First of all, you could tell that she felt like she was under the gun. And probably rightly so, because what I could understand of what she was saying made practically no sense from a logical perspective. Like, there is no independent value in a low cesarean rate because our maternal mortality rate is lower than it was when we had a much lower cesarean rate. Or because our maternal mortality rate is much lower than, say, Pakistan, which has a much lower cesarean rate.

Um? Ok. Stat 101: say it together, kids, correlation does not prove causation. Let’s not forget that the increase in cesareans coincided with other advancements both generally and in medical technology. Like, say, better sanitation, better diagnosing of both maternal and fetal problems, better nutrition, the list goes on. And then she cites something about how the chances of a person getting the birth they wanted are much higher in a planned cesarean, and the rates of maternal satisfaction are higher or something like that. Again, let’s not lose the forest for the trees here: if you want a cesarean birth, and you get a cesarean birth, you got what you wanted and can be pretty happy about that. If you want a vaginal birth and get a major abdominal surgery, you might feel pissed off about it. But since when has the possibility of not getting what you actually want ever justified just changing what it is that you want? And is anybody studying the women who think they want a cesarean, only to be floored by how hard recovery can be?

And then she brought out the perennial bugaboo of the pelvic floor damage. Reality check: yes, many women will suffer pelvic floor damage (especially if you cut a big honkin’ episiotomy!). And many women will be PISSED when it happens because they had no idea that it might. But I don’t understand the logic by which you choose to have the big, nasty surgery to avoid the much smaller surgery down the line. So why don’t we just educate all women about the possibility of pelvic floor damage from childbirth, indeed from lots of stuff like running to being overweight and just aging! Add to that training on how to prevent the damage. And then they can decide whether they prefer the childbirth+surgery with all its inherent risks or possible pelvic floor repair later in life. Not that I think that surgery to repair the pelvic floor is a picnic or anything, but it just seems preferable to a surgery with a large external incision that implicates internal organs and impacts future fertility.

Moving on, there was a really hilarious talk by some people who run a women’s hospital in Amarillo or something. It’s hardly worth commenting on, if only because they cited the idiotic statistic that women spend 80% of the money in the US (which is cited in AdWorld as the reason for pushing the whole photoshopped standard of beauty, and by Men’s Rights Advocates for BAWWWing that “the wimminz have all teh power”). “So we need to find out what women want in a hospital.” Is it support and autonomy? No, it’s HAIR DRYERS! Of course!

Granted, I like the idea of women’s hospitals, and it seems like they have a nice one-stop-shop set up for gynecological care, mammography, etc. But I was really put off by the “Pretty Pretty Princess” aspect of it.

There was some other stuff… Dr. Lucky Jain talked about the problem of iatrogenic prematurity (just whoa), Alan Huber basically said that most birth centers were doomed to fail economically, etc. etc.

There was a presentation on models of prenatal care that really stuck out to me. One of the models shown was “Centering,” where it seems like the mothers do their own prenatal care in a small cohort. It seemed really interesting to let women have control of their prenatal care, and I really like the idea of connecting pregnant women since overall we’re pretty disconnected from birth, but I have to take a moment and say a little wtf:  she mentioned that most of her clients were “Hispanics” and talked about how they play such silly games (the pygmies of Bora Bora again.) Because pregnant Caucasian women don’t play silly games related to pregnancy? Or is tasting baby food and wrapping yourself in toilet paper a normal behavior? The speaker admitted that nobody there spoke fluent Spanish, but apparently she taught a woman to “give a hand massage that changed her marriage.” Well I hope that they taught the husband how to give a foot massage that changed the pregnant mama’s day, at the very least!

Then my favorite person of all times, Jennie Joseph, CNM spoke about her model of care, The JJ Way. I had to laugh thinking about the “Hispanics” thing when she said “it’s the culture of having a healthy baby – what culture doesn’t understand that?!” Every single time I have seen Jennie Joseph speak, it has been breathtaking and inspirational. She has a method, apparently patented, that has literally closed the racial disparity in her practice.

The one thing that seems semi-controversial, and yet entirely commonsensical is the fact that she has “let go” of the need to have her patients deliver out of hospital. She aptly recognizes the fact that for many women, and in particular women of color, a hospital birth is actually a desirable thing. I know that this is an issue among Latina women that I have talked to, that there is a perception that if you have the means, there is no reason to “go back” to the traditional ways of birthing. Whether or not I agree, and whether or not I feel that obstetrics has anything particularly beneficial to offer a low-risk pregnancy, that’s the woman prerogative. I feel like her practice truly respects mothers and understands issues affecting women of color, and has done phenomenally in terms of removing the barriers to care created by the bureaucracy of poverty.

Someone asked a question that seemed a little bit “those people”: How do you get them to show up when there are transportational issues? Ms. J basically said “we can’t judge; they’ll be there if they want to be there, and they know that we’ll see them and not shame them if they’re late.” My god, if my medicaid clinic care had been like that…

I was also deeply impressed by a panel on legal issues with Lynn Paltrow and Susan Jenkins. I’m getting sort of tired, so I’ll probably talk about it at length some other time, but the bottom line is that they really hit the nail on the head with the legal issues of medical decisionmaking. At what point does a pregnant woman lose her right to make choices about her own body? Never!

So, yeah. Overall, I think I give this conference a B. There seems to be talk about there being another one of these, but I’m not entirely sure I want to shell out the bucks for something that, on some level, seems to be lining someone’s pockets. I guess I’m a curmudgeon, but at least I’m a populist, egalitarian curmudgeon.

Tagged as: birth centers, Centering Pregnancy, Cesarean Surgery, Controversies in Childbirth, Dr. Stuart Fishbein, ICAN, International Cesarean Awareness Network, Laureen Hudson, Lynn Paltrow, Malpractice, millennials, NAPW, National Advocates for Pregnant Women, Pam Udy, pro-cesarean, Susan Jenkins, The JJ Way