Wednesday, May 8, 2013

Baby Cutting

"It's just a little cut. Baby won't feel it." Does that sounds familiar? 

I sit in friendly silence so many times when midwives from various cultural places and bases are discussing male circumcision. I've learned over the years that when religion and emotions meet, its better to keep silent. 

But I am surprised and - yes - shocked to see the epidemic of frenotomies and the over-diagnosing of ankylglossia - commonly known as "tongue-tie".

In researching this subject, I found some sites and articles that suggested that the incidence of ankylglossia was about 10%. The suggestion is made that if this condition is not cured when the infant is very young, it could lead to speech and digestive problems when the child is older. But that can't mean that 10% of the population needed to be cut! We do have a pretty sophisticated system of communication, called language, that most of us can manage with quite effectively.

I found a critical summary of research done up to 2004 in a nice online journal that focuses on evidence-based medecine. The studies they looked at came up with an incidence of 1-4%, which is still hefty, but not unreasonable. It is suggested that frenotomy definitely helps reduce maternal pain during breastfeeding. The conclusion that is drawn, however, is that "...in the main this appears to be one of those areas where there is much opinion but little evidence. A much more thorough review [7] concludes that controversy is fuelled by lack of good information about intervention. It is surprising that there is not more good information. Ankyloglossia is not rare, affecting one to four babies in every 100. There is a congenital component, but we know little about other possible associations, except possibly with cocaine use in pregnancy. Clearly there is a need for more research, which need be neither expensive nor complicated. Less opinion, please, and more evidence. A great topic for postgraduate qualifications and the tongue-tied." (http://www.medicine.ox.ac.uk/bandolier/band124/b124-2.html)

A more recent study shows that indeed, nipple pain is significantly reduced and breastfeeding satisfaction is higher when frenotomy is performed on "...infants with signficant ankyloglossia". (http://jgh.ca/uploads/breastfeeding/aaptonguetie2004.pdf

On the other hand, " ...ankyloglossia is relatively uncommon in the newborn population, but inspection of the tongue and its function should be part of the routine neonatal examination. Most of the time, ankyloglossia is an anatomical finding without significant consequences for the newborn or infant affected by this condition. Current evidence seems to demonstrate that despite ankyloglossia, most newborns are able to breastfeed successfully". (http://www.cps.ca/en/documents/position/ankyloglossia-breastfeeding).

No one is arguing that severe ankylglossia will not lead to breastfeeding problems including nipple damage and pain; reduced intake, and a possible consequent failure to thrive. 

However, I am seeing the current approach as akin to the movement towards "routine" circumcision in the U.S. in the post-war years. I assume that the rationalization was based on an understanding of cleanliness and hygiene, and possibly to limit the spread of STDs (with the men just back from a series of battlefields, could that have been a concern?). 

Routine circumcision peaked in the U.S. during the sixties, when up to 90% of boys were circumcised, from around 30% in the thirties. (http://www.circs.org/index.php/Reviews/Rates/USA
In the U.K., the rate of circumcision due to diagnosed phimosis was under 5% in the 80's, and even this low rate has been criticized. It has since dropped appreciably, because of a better understanding of true phimosis and an improved diagnostic approach: "...The decline is attributed to the increased use of evidence-based medicine". (http://www.cirp.org/library/treatment/phimosis/rickwood2/ ) It has been dropping consistently in Canada, with most provincial health care plans delisting it. The average rate in Canada in 2006/7 was just over 30%. (http://en.wikipedia.org/wiki/Prevalence_of_circumcision#Canada)

Are we going to have another pendulum swing in thirty years, when we realize that we have been unnecessarily cutting the second most sensitive part of our babies' bodies for absolutely no reason?

When I was interning in Bali last year, at the Yayasan Bumi Sehat, I had an experience that taught me an important lesson about breastfeeding. I came in for my shift at 6am and the intern who was leaving let me know that there was a postpartum woman in one of the beds who was having serious difficulties breastfeeding. The intern was frustrated and worried, and asked me if I could find a way to let the mother know that she needed to be proactive about feeding her baby. 

The woman was twelve hours postpartum, and she was lying on her side on a low bed in the postpartum room. She was wrapped in a sarong but her breasts were bare, and the baby just had a cloth diaper covering his bum. Her breasts were not the best. They were large, with little tone, and her nipples were deeply inverted. I greeted her and asked how she was doing, she was doing well, she had eaten, everything was fine. I asked if I could sit with her. I sat next to the bed and kept my hands to myself. I wanted to get the baby's head, and stimulate her nipple, and put two and two together. But I didn't.

In Bali, you see a lot of people sitting around. People aren't frantically doing stuff like we do. They hang around and shoot the breeze.

I got her some water. Then I sat back down. Other people came in and out. I stayed. She put the baby on and took him off for about two hours, until finally he was well latched and sucking vigorously. 

This baby continued to thrive. I continue to sit on my hands and provide support. Certainly, we have mothers and babies who are not well: mothers get sick; babies have anomalies; breasts (very rarely) don't produce milk. 

If it ain't broke, don't fix it. Don't even try.





Baby Cutting

"It's just a little cut. Baby won't feel it." Does that sounds familiar? 

I sit in friendly silence so many times when midwives from various cultural places and bases are discussing male circumcision. I've learned over the years that when religion and emotions meet, its better to keep silent. 

But I am surprised and - yes - shocked to see the epidemic of frenotomies and the over-diagnosing of ankylglossia - commonly known as "tongue-tie".

In researching this subject, I found some sites and articles that suggested that the incidence of ankylglossia was about 10%. The suggestion is made that if this condition is not cured when the infant is very young, it could lead to speech and digestive problems when the child is older. But that can't mean that 10% of the population needed to be cut! We do have a pretty sophisticated system of communication, called language, that most of us can manage with quite effectively.

I found a critical summary of research done up to 2004 in a nice online journal that focuses on evidence-based medecine. The studies they looked at came up with an incidence of 1-4%, which is still hefty, but not unreasonable. It is suggested that frenotomy definitely helps reduce maternal pain during breastfeeding. The conclusion that is drawn, however, is that "...in the main this appears to be one of those areas where there is much opinion but little evidence. A much more thorough review [7] concludes that controversy is fuelled by lack of good information about intervention. It is surprising that there is not more good information. Ankyloglossia is not rare, affecting one to four babies in every 100. There is a congenital component, but we know little about other possible associations, except possibly with cocaine use in pregnancy. Clearly there is a need for more research, which need be neither expensive nor complicated. Less opinion, please, and more evidence. A great topic for postgraduate qualifications and the tongue-tied." (http://www.medicine.ox.ac.uk/bandolier/band124/b124-2.html)

A more recent study shows that indeed, nipple pain is significantly reduced and breastfeeding satisfaction is higher when frenotomy is performed on "...infants with signficant ankyloglossia". (http://jgh.ca/uploads/breastfeeding/aaptonguetie2004.pdf

On the other hand, " ...ankyloglossia is relatively uncommon in the newborn population, but inspection of the tongue and its function should be part of the routine neonatal examination. Most of the time, ankyloglossia is an anatomical finding without significant consequences for the newborn or infant affected by this condition. Current evidence seems to demonstrate that despite ankyloglossia, most newborns are able to breastfeed successfully". (http://www.cps.ca/en/documents/position/ankyloglossia-breastfeeding).

No one is arguing that severe ankylglossia will not lead to breastfeeding problems including nipple damage and pain; reduced intake, and a possible consequent failure to thrive. 

However, I am seeing the current approach as akin to the movement towards "routine" circumcision in the U.S. in the post-war years. I assume that the rationalization was based on an understanding of cleanliness and hygiene, and possibly to limit the spread of STDs (with the men just back from a series of battlefields, could that have been a concern?). 

Routine circumcision peaked in the U.S. during the sixties, when up to 90% of boys were circumcised, from around 30% in the thirties. (http://www.circs.org/index.php/Reviews/Rates/USA
In the U.K., the rate of circumcision due to diagnosed phimosis was under 5% in the 80's, and even this low rate has been criticized. It has since dropped appreciably, because of a better understanding of true phimosis and an improved diagnostic approach: "...The decline is attributed to the increased use of evidence-based medicine". (http://www.cirp.org/library/treatment/phimosis/rickwood2/ ) It has been dropping consistently in Canada, with most provincial health care plans delisting it. The average rate in Canada in 2006/7 was just over 30%. (http://en.wikipedia.org/wiki/Prevalence_of_circumcision#Canada)

Are we going to have another pendulum swing in thirty years, when we realize that we have been unnecessarily cutting the second most sensitive part of our babies' bodies for absolutely no reason?

When I was interning in Bali last year, at the Yayasan Bumi Sehat, I had an experience that taught me an important lesson about breastfeeding. I came in for my shift at 6am and the intern who was leaving let me know that there was a postpartum woman in one of the beds who was having serious difficulties breastfeeding. The intern was frustrated and worried, and asked me if I could find a way to let the mother know that she needed to be proactive about feeding her baby. 

The woman was twelve hours postpartum, and she was lying on her side on a low bed in the postpartum room. She was wrapped in a sarong but her breasts were bare, and the baby just had a cloth diaper covering his bum. Her breasts were not the best. They were large, with little tone, and her nipples were deeply inverted. I greeted her and asked how she was doing, she was doing well, she had eaten, everything was fine. I asked if I could sit with her. I sat next to the bed and kept my hands to myself. I wanted to get the baby's head, and stimulate her nipple, and put two and two together. But I didn't.

In Bali, you see a lot of people sitting around. People aren't frantically doing stuff like we do. They hang around and shoot the breeze.

I got her some water. Then I sat back down. Other people came in and out. I stayed. She put the baby on and took him off for about two hours, until finally he was well latched and sucking vigorously. 

This baby continued to thrive. I continue to sit on my hands and provide support. Certainly, we have mothers and babies who are not well: mothers get sick; babies have anomalies; breasts (very rarely) don't produce milk. 

If it ain't broke, don't fix it. Don't even try.





Monday, May 6, 2013

Birth and Political Theory?


One of my students has generously agreed to let me post her paper on classical feminism, patriarchy and birth. Read on!

Women as well as men have been discussing the various ramifications of patriarchy and sexism for quite awhile now. A lot of thought has gone into strategy on how to best fight it. However, the root cause often goes unquestioned by those discussing the effects. Some prominent thinkers have attempted to discover the root. Simone de Beauvoir, for example, states that the fundamental reason for women's oppression is her enslavement to the reproductive function. I agree. The female identity is formed not only in a reproductive body but in largely unexamined preconceived notions about that body. As Mary O’Brien, a political theorist and midwife, clearly puts it: the unexamined reproductive process  is the sturdiest plank in the platform of male supremacy.
So where did these preconceived notions come from? Both Beauvoir and O’Brien believe that there was a historical moment that catalyzed patriarchy.They explain that in realizing the reality of paternity and the male contribution to the reproductive process, men created systems in which they could control the process of reproduction. In patriarchy, female reproductive processes are defined by men.These processes, including menstruation, gestation and birth,  have been deemed not only scientifically uninteresting, but have also been mystified as the unknown, the strange, and even the grotesque.
This patriarchal view has clearly permeated the female view of her own body’s function. Even Simone de Beauvoir writes that the mother “is the prey of the species, which imposes its mysterious laws upon her, and as a rule this subjection to strange outer forces frightens her, her fright being manifested in morning sickness and nausea” .To Beauvoir, nursing is “the species gnawing at their vitals.”
Beauvoir, despite her great strides for feminism at her time, does not rethink the significance of the motherhood holistically and outside of male formed systems. Therefore, she, like the rest of patriarchal thinkers, denies the possibility of motherhood as a meaningful and authentic factor of a woman’s identity.  Once we acknowledge that commonly held views on motherhood are not universal truths, we can begin to accept the idea that the female reproductive process gives women a unique connection to the body, cyclic nature, and continuity.
The concept of being pregnant, and experiencing the evolution of having another identity within your body can be an enlightening experience, in which the concept of inner and outer, self and other, become blurred and questioned. In gestation and birth, women engage with the mind-body dualism in a way that is uniquely female.
The poet Adrienne Rich asserts that “patriarchal thought has limited female biology to its own narrow specifications.... in order to live a fully human life we require not only control of our bodies; we must touch the unity and resonance of our physicality, our bond with the natural order, the corporeal ground of our intelligence.” The intelligence and transcendence experienced by mothers that Beauvoir calls an illusion, Rich believes to be a consciousness outside of the narrow specifications of patriarchal thought.
Beauvoir along with other intellectual 20th century feminists are quick to acknowledge the disempowering, enslaving, and unpleasant elements of motherhood in contrast to the stereotypically male roles. Motherhood can be boring. It can be tedious and exhausting. Enslavement to any one role without choice or agency should be fought against, but motherhood is not intrinsically this, despite how patriarchal norms have defined it. There is the real possibility for a powerful female identity that has gone overlooked.
 If the process of reproduction from conception to gestation to birth  is understood, women can form for themselves an identity that experiences authentic creation in reproduction. The identity is formed by accepting the lack of control and the inevitability of repetition in life, by connecting to and understanding the body, and by engaging in the complex history of female subjugation by men, rooted in reproduction.
 It is time to open our eyes to the norms we accept in our hospitals regarding birth. We must open our ears to the patriarchal stories we tell each other that put fear and disgust in the birth process. Most importantly, all people, men and women, must open their arms to all the strong women who both struggle within and celebrate the experience of living in a menstruating, ovulating, pregnant, birthing, nursing, or menopausal female body. Whether it be ignored, mystified, worshipped, or objectified, it is woman’s to dwell within and create.

Hannah McCormick