Hope the Voyage is a Long One

Ithaka

As you set out for Ithaka
hope the voyage is a long one,
full of adventure, full of discovery.
Laistrygonians and Cyclops,
angry Poseidon—don’t be afraid of them:
you’ll never find things like that on your way
as long as you keep your thoughts raised high,
as long as a rare excitement
stirs your spirit and your body.
Laistrygonians and Cyclops,
wild Poseidon—you won’t encounter them
unless you bring them along inside your soul,
unless your soul sets them up in front of you.

Hope the voyage is a long one.
May there be many a summer morning when,
with what pleasure, what joy,
you come into harbors seen for the first time;
may you stop at Phoenician trading stations
to buy fine things,
mother of pearl and coral, amber and ebony,
sensual perfume of every kind—
as many sensual perfumes as you can;
and may you visit many Egyptian cities
to gather stores of knowledge from their scholars.

Keep Ithaka always in your mind.
Arriving there is what you are destined for.
But do not hurry the journey at all.
Better if it lasts for years,
so you are old by the time you reach the island,
wealthy with all you have gained on the way,
not expecting Ithaka to make you rich.

Ithaka gave you the marvelous journey.
Without her you would not have set out.
She has nothing left to give you now.

And if you find her poor, Ithaka won’t have fooled you.
Wise as you will have become, so full of experience,
you will have understood by then what these Ithakas mean.

©C.P. Cavafy, Collected Poems.Translated by Edmund Keeley and Philip Sherrard. Edited by George Savidis.Revised Edition. Princeton University Press, 1992

Fast and Furious

Honda Scoopy

I have to ride my scooter to the clinic from my house. The road is busy with scooters, cars and trucks and it is not a pleasant walk. I could make my way through the rice fields but I want to get to the clinic in the morning without muddy feet and a wet skirt, so I decided to rent a scooter.

I've been driving a car since I was sixteen and I am confident driving anything with four or more wheels. But this was a new experience! The balance is different - with a car you just sit there. On a scooter you are balanced on two wheels. You feel more vulnerable on the road too - even though the drivers in Bali are the most courteous I've seen.

But I get on my bike in the morning and I think about the women I will be caring for, some of whom travel for an hour or two on the back of a scooter to come to the clinic in labor. I think about the young mothers who are starting the journey towards motherhood for the first time, or the ones who had their first baby by cesarean section, or the ones who lost a child. I imagine the fears they are facing when they come to the clinic to give birth, and I think about the risks inherent in just being alive in a small village here.

And I think to myself - ride your bike...keep your head held high and don't be afraid, even when a large truck full of pigs or bamboo posts passes you too close on that narrow road. I know its a small hurdle compared to the daily hurdles that the women I attend jump over, but it has helped me to put things in perspective.

Can't you see me on a Harley???

Birth

Women all over the world give birth in exactly the same way. They make the same noise when they reach the pushing phase; they move the same way; they touch their newborns gently and hesitantly during the few minutes after birth.
Midwives are the same everywhere too. They catch sleep when they can, love attending births, like the smells and sounds of the birthing room. We are happy when we see poo!
Gratitude and respect to all the women who are birthing today, and to all of their attendants. May it be a day of peace and joy.

Induction Epidemic

"Unless conception occurred via in vitro fertilization, techniques used for obstetric dating are accurate to 3 to 5 days if applied in the first trimester, and only to 1 to 2 weeks subsequently. Estimates of fetal weight are accurate only to 15% to 20%. Even small discrepancies of 1 or 2 weeks between estimated and actual gestational age or 100 to 200g difference in birth weight may have implications for survival and long-term morbidity. Also, fetal weight can be misleading if there has been intrauterine growth restriction, and outcomes may be less predictable. These uncertainties underscore the importance of not making firm commitments about withholding or providing resuscitation until you have the opportunity to examine the baby after birth."
Textbook of Neonatal Resuscitation, 6th Edition, Ed J. Kattwinkel, American Academy of Pediatrics and American Heart Association (2011), p. 288

We cannot know when a person is supposed to die; neither can we predict exactly when a baby is to be born.

We have some numbers to play with and we do our best under the circumstances. Everyone knows that babies take nine months to grow in their mothers’ wombs. In the Jewish Talmud, it is stated that pregnancy should last 270 days from conception to birth. Modern Western medicine counts 40 weeks from the date of the last normal menstrual period, which gives a baby 38 weeks to mature, if his mother conceived fourteen days after her period. Many midwives will look carefully at a woman’s menstrual cycle, and will try to calculate together with the woman when she may have conceived. Based on these dates, she will give an estimate of a two or three week period during which the woman is likely to give birth. Some women give birth before their due dates, a few exactly on the day, and many give birth up to two or even three weeks after the date has passed. The tendency to carry a baby for over 41 weeks appears to run in families and can sometimes be predicted if a woman has carried her first child “post dates”.

One thing is for sure, babies do come out eventually. However, it is possible that certain risks increase the longer a baby stays in the womb. The placenta may diminish in optimal function after about 42 weeks, putting the fetus at risk for hypoxia. Babies born after 41 weeks often have a higher incidence of meconium in the amniotic fluid, which puts them at higher risk of meconium aspiration. Babies keep growing, so a 42-week baby may have a slightly larger head than she did at 38 weeks, thus making it a little harder for her mother to push her out.  Modern medicine tries to diminish these risks by making sure a baby is born on or around the estimated date of delivery, or the due date. There is a lot of controversy about this reasoning, and rightly so. The due date is rather arbitrary. No one really knows when the baby was conceived, and even if they do analyze various ultrasounds, we can still never predict which babies will want to stay in the womb for longer. Occasionally there is a real problem with a baby which prevents the labor from starting spontaneously. This is very rare and does not justify the high induction rates we are seeing.

On

Why are we concerned about chemical inductions? Our main concern is that because chemical labor induction creates very strong, painful and frequent contractions whose character is different from the contractions produced by the woman’s own body, there is an increase in epidural requests. Once she has requested an epidural, the risk of an instrumental or surgical birth increases. Our next concern is whether the woman’s body is ready for a chemical induction. If it is not, then all the chemical and natural assistance in the world will not convince her cervix to open and she may labor for days and end up in surgery. 

 

Let us first have a look at some statistics, remembering that these numbers can be stretched and manipulated just like the perineum during birth. A recent study examined the correlation between labor induction and cesarean section. It looked at a reasonably small group of women (just over 1200) who were at 41 weeks of pregnancy. About half of these women went into labor spontaneously, and the other half was induced. The half who went into labor on their own had a 14% c-section rate, while the rate for the other half was 19%. The increased rate was due to an increase in c-sections performed for “failure to progress”, which was “diagnosed and cesarean delivery performed when cervical dilatation or fetal descent ceased for 2 to 4 hours despite adequate uterine activity”. However, the researchers concluded that the increase was not due to the labor induction “per se”, but rather due to “nulliparity, advanced gestational age, undilated cervix prior to labor, and epidural analgesia”.[i]

It seems to me that if we look at these figures with open eyes we can see that, in fact, induction is definitely an important player in the rise in c-section rates, even if we split hairs and suggest that it is not the main cause. Nulliparity certainly has an effect, and every doula knows that a first-time mother is going to be more of a challenge than a mother who has already gone through the experience. When a first-time mother experiences the contractions produced by synthetic oxytocin, she is much more likely to request an epidural than an experienced mother who knows that labor will, in fact, end and her child will be in her arms soon enough.

A woman with a closed, hard and posterior cervix is not an acceptable candidate for chemical induction. The rates of surgical delivery increase with a lower Bishop’s score. The following chart shows how we calculate this important score.

       

Score	Dilatation	Effacement	Station	Position	Consistency
0	0	<40%	-3	posterior	firm
1	1-2 cm	40-50%	-2	mid	moderately firm
2	3-4 cm	60-70%	-1,0	anterior	soft
3	5+ cm	80%+	+1,+2	anterior	soft

A point is added to the score for each of the following:
   1. Preeclampsia
   2. Each prior vaginal delivery

A point is subtracted from the score for:
   1. Postdates pregnancy
   2. Nulliparity
   3. Premature or prolonged rupture of membranes

The scoring is done according to the physician’s or midwife’s estimation of the cervix, and extra points are added or subtracted. Any score under 6 usually means that the cervix is not ready for induction and cervical “ripening” is initiated using prostaglandins. A score above 6 is encouraging and often means that a woman will be successfully induced and has more chance of a vaginal delivery. Induction leads to a higher epidural rate; epidurals lead to higher c-section rates: it is undeniable that labor induction can increase the risk of a c-section.

How can the doula help? We do not want to alienate the women we are working with. If she is happy with an induction and understands the possible implications, then it is the doula’s job to support her. We do not want to turn a woman against her doctor. If a woman has chosen a doctor and is convinced she has made the right choice, then the doula must not interfere with that relationship. It is a woman’s right to ask questions of her doctor, and she can say no to the doctor’s suggestions, but it is not the doula’s responsibility to do so. We do not want a woman to feel guilty about listening to her doctor. We often find ourselves in the following situation: the client is reasonably happy with her doctor, who has said that she almost never induces before 41 weeks. The woman has just passed forty-one weeks and the doctor is not working on the upcoming weekend. She has offered an induction on the Thursday, so that she can be at the birth. Both the baby and the mother are fine on the one hand, but on the other hand, the mother is getting very tired of being pregnant and her in-laws are calling every five minutes. The client calls her doula in tears. What can happen during this call is what we call a “learning moment”. That is, the doula and her client discuss all the issues and go over all the options and implications: The doctor has confirmed that the baby is doing well. This is an opportunity for the woman to take the process into her own hands and refuse a medically unnecessary induction. She can wait until after the weekend, when she and her doctor can make a decision. Often, in this type of situation, a woman will spontaneously go into labor.

More serious is the situation where there is a perceived risk to the baby. In this situation, it is up to the doula to support her client and refrain from bringing doubts, research and opinions into the equation. If a doctor is convinced that, for example, the fluid is dangerously low, it is not the right time for a doula to suggest that perhaps this is physiologically normal or that the ultrasound technician could not see behind the fetus. This is the time for the doula to support her client wholeheartedly.

This is an example of the fine art of being a doula. We are not midwives, working from a rooted trust in the healthy efficiency of the female body. We are not physicians, sensitive to flaws and malfunctions in the labor process. We are there to support a woman through the labor process, as she sees fit, without judging, without voicing our opinion. Here is a story about an induction where the doula was very active in the whole process. This woman’s first labor had been chemically induced and she was hoping to avoid it the second time around.

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[i] Obstet Gynecol 2001;97:911-915

 

What to Expect from Nestle

We all have our prejudices and opinions about breastfeeding and natural birth. At a certain point, however, it is important to try to discover the facts buried deep beneath everyone's political agendas. I was struggling with this for a few days before I decided to write this blog, and a lady jumped out from the past and told me very clearly that I have to speak out.

I was in my early twenties, traveling through Africa on my own. I was walking to get on a ferry, which was basically a very large raft kept afloat by prayers and habit, to cross a river. A woman about my age approached me. She had a baby on her back, and she swung him around and presented him to me. Because of the color of my skin, she expected me to have some knowledge, medication, or connections that would assist me to bring her baby back. He was almost dead. His eyes were glazed and dry. He had diarrhea, she explained. I had no idea what to say to her. I didn't know anything back then. I had never seen a dying baby before, and I hope you never will.

I don't think people fully understand the significance of the use of baby formula in countries where poverty is rampant, and clean water is impossible to find. Here in Canada, those women who bottle feed their infants may be at risk for being sneered at, and their babies may be at higher risk for allergies or obesity. But in Africa and all over the world, babies who are fed formula are at a higher risk of  infection, from the moment they are born until they are at least two years old.

Unicef recommendations on breastfeeding are here, and they are worth looking at. The authors suggest that "The major problems are the societal and commercial pressure to stop breastfeeding, including aggressive marketing and promotion by formula producers. These pressures are too often worsened by inaccurate medical advice from health workers who lack proper skills and training in breastfeeding support."

Nestle is one of the major formula producers in the world and has just bought Pfizer Nutrition which markets four brands of artificial formula. Nestle actively promotes its breastmilk substitutes in Africa and elsewhere, claiming that HIV positive mothers' babies should not be breastfed. This is a subject that has seen much research and discussion over the past few years and it is by no means a conclusive claim. Infection rates can go up by over 60% after six months, so perhaps a better suggestion would be (see WHO recommendations) that babies everywhere and in every situation should be exclusively breastfed for the first six months of life.

The problem with formula feeding in poverty-stricken areas are twofold: one is the lack of clean water, refrigeration, sterilizing equipment and so on. Bottles are washed in less-than-sterile water; the powdered formula is mixed with infected water; and the remaining formula is left out and breeds bacteria. WHO guidelines on the preparation of powdered formula are very strict concerning cleanliness and refrigeration. This level of cleanliness is simply not possible in many households around the world.

Nestle has been boycotted for over forty years because of its aggressive marketing of breast milk substitutes  all over the world.

This is why I was shocked to see that it is sponsoring the What to Expect When You're Expecting movie premiere, and to see that these two organizations are partnering to sponsor a contest for pregnant women. The prize is a trip to Hollywood to see the WTE movie. Visit the link: Nestle Baby.  If you try to enter the contest, you are told that only "Nestle Baby Program" members are allowed to enter. So you go to the Nestle Baby link. A tiny popup opens to let you know that breast is best for up to six months. Then you are met with a $100 coupon for free samples, including formula and bottles.

This is directly in contravention of the World Health Organization's International Code of Marketing of Breastmilk Substitues, which states that: "there should be no advertising or other form of promotion to the general public" and that "manufacturers and distributors should not provide … to pregnant women, mothers or members of their families, samples of products…" Promotion through any type of sales device, including special displays, discount coupons and special sales, is prohibited. Furthermore, no company personnel should seek direct or indirect contact with, or provide advice to, pregnant women or mothers.



I expect and encourage What to Expect to immediately sever ties with Nestle, for the sake of their own reputation, and for the sake of the health of millions of mothers and babies around the world.

Unassisted Childbirth

Back in the good old days, when I was a subsistence farmer in paradise, I had a friend who told me her birth story. This was before I started working with birth, but not before I had already started studying and learning, and listening to women's stories.

Friends Sharing Birth Stories

 My friend's first baby had been a breech who did not want to get her head down. The policy at that time in Italy, as in many places, was to deliver breech babies by cesarean section, especially if the woman was a primipara.

So, my friend had a c-section, and she did not feel good about that birth at all. She thought that it was probably possible to give birth to a breech baby vaginally, and she felt pushed into making a decision that did not feel right to her. She decided she didn't want to go back to the hospital again to give birth.

She became pregnant again, and decided to stay at home this time and give birth on her own terms. She looked for a homebirth midwife but at that time in Italy they were a rare breed, especially if you were living in the hills as all us organic subsistence farmers did. She prepared by reading about natural birth, and she made sure she had methergine in the house - they always had it on hand for the goats.

Labor started and she sent her husband and child out for the day. She didn't want her daughter present for what she knew was going to be an intense and possibly scary event.
This was before cell phones, and they didn't have a phone, so he planned to come back around suppertime. She labored on her own and late in the afternoon, gave birth to a healthy baby.
"Were you scared?"
"Yes, I really wanted to have someone else around. I remember when I started pushing, and I felt a cervical lip, and I gently pushed it out of the way - I really wanted someone to be there with me. But I knew everything would be okay - I had a feeling. And if it wasn't ok, then it wasn't. I did it my way."

There is a growing movement that promotes unassisted childbirth as a way to regain control over your own birth, and there are many valid reasons for not wanting anyone at all from outside your circle of family and loved ones to be present at the birth of your child. It is, after all, a natural event, more like lovemaking than like a medical procedure. The presence of a stranger, even a well-liked one, can change and disturb the process. Midwives can be regulated by laws that perhaps don't agree with a woman's perception of how she wants her birth to proceed. This site provides some interesting information about unassisted childbirth:UC

I often get calls from women who are planning to give birth without attendants. They want information, or they want to find someone to be a "fly on the wall" - who can be there "just in case". Most of these women are women who have not been able to find a registered midwife - either they didn't call early enough, or they live in the wrong area, or they are considered too high risk for a homebirth. They don't really want an unassisted birth, but they are committed to not wanting to go to the hospital unless they really have to, so they are left with unassisted birth as their only option. Because we Canadians are used to free health care, cost is also a consideration. Unregistered midwives charge around $2000 for prenatal, birth, and postpartum care (that works out to about $10.73 an hour, in case you're wondering). Many women do not feel that this amount is an option, and, again, make the choice to give birth "unassisted".

I firmly believe in a woman's right to choose what's best for her body, and for her life. If a woman chooses to give birth on her own, or just with her partner, or her sister, in her own home, then power to her! She is making an adult choice, and she is accepting responsibility. But I do feel sad when women want to have the care of a midwife and cannot.

No woman should have to give birth on her own if she doesn't want to. Midwifery care should be available, really available, to any woman. Homebirth should be an option for us all. Unassisted homebirth is only one option, but it should be an option that is actively chosen and not decided on for lack of other plans. Equally, hospital birth is only one option. Health women carrying healthy babies should not have to go to the hospital to give birth unless they actively want to. Informed choice should be a reality - it should be informed, that is, women should educate themselves and each other, and they should ask for informtaion from their care providers. And choice should be a real choice with real options - unassisted, home birth, midwifery care, hospital birth.

Let's work together to bring the woman and child back to the center of maternity care!

Ask the Doula: Evidence-Based Care

It's Ask the Doula time again!

Please keep sending in your questions. You can add them as comments below, or send your questions to our Facebook page, or twitter @montrealdoula.

Today I will be looking at the concept of "Evidence-Based Care". What does it mean? How does it work?

Question Number Four

"What is evidenced based maternity care?"

What is the meaning of life? may be an easier question to answer.

First, I will offer you a collection of attempts to define evidence-based maternity care:

"EBM is about tools, not about rules. Good evidence is likely to come from good systematic reviews of good clinical trials. For many reasons too much of the medical literature can be misleading, or is just plain wrong. We must be able to distinguish good evidence from bad, and to have accurate, reliable knowledge readily available and readily accessible for all. The contrast between the individual and the population as a whole - unique biology, choice and circumstance, often dictates what happens, and evidence is but one part of a complex question."
Bandolier


"Evidence-based care is a type of care in which the medical studies are consulted to help you and your caregiver decide the safety and usefulness of all procedures used. With evidence-based care, only procedures that are proven by research to be safe and beneficial are done routinely. Other procedures which are not supported by the medical evidence are weighed carefully, taking your personal circumstances into account. This is called "informed consent". This may seem obvious, but, for example, routine use of epidurals is not supported by the evidence. 
Birth Matters Virginia


"Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information." 
Dr Nicholas Hicks

There is a never-never land that people believe we are heading towards, where our huge glut of information and meta-analyses, and  systematic reviews, and technological advances, will somehow be tamed so that we can quickly pick from any number of studies, the answer to a clinical question that is presenting itself. What is wrong with the picture is that we have become wrapped up in the science, or rather, in the scientific methods (or methods), and we have completely misplaced the person at the center: in our case, the pregnant, laboring, or breastfeeding woman.

I have in front of me an example of the type of study that is being used to support and  maintain evidence-based care. It is an "overview". This means that the researchers looked at reviews of trials. The trials are the actual clinical experiments, which are done on real people in real situations. The reviews are done when researchers look at, for example, ten different trials involving 10,000 women, and compare the results and draw conclusions.


This overview examines at several reviews that looked at pain management in labor. The conclusion is that:

"Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.
There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.
It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.
A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management." Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

So, what have we here? We have a "world where information is replacing the knowledge that displaced wisdom". (Birth Volume 36, Issue 1). We have a huge amount of man- and woman-hours being spent to gather and examine information.This information is considered to be the evidence, upon which we base our standards of care. The authors of this overview have come up with conclusions about the gathering and about the information. Let's look at the conclusions:
1. That the quality of the evidence-gathering was low, for various reasons.
2. Non-pharmacological methods of pain relief appear to be safe but may not work.
3. The effects of pharmacological pain relief on the baby has not been assessed.

From these conclusions, we can see that the researchers seem to have the best interest of mother and baby at heart. They want more studies on non-pharmacological methods of pain relief, and we get the feeling that they would like those studies to prove that these methods work. They want more studies to be done on the effects of maternal pain medications on the newborn, on breastfeeding and beyond, and we get the feeling that they would like these studies to lead to a decrease in use of pain medication,.

But it seems to me that here we are running into the late Phil Hall's suggestion that  "after initial gains in evidence-based medicine, we have moved from evidence-based decision-making to decision-based
evidence-making." (Birth Volume 36, Issue 1)
Make the decision that you would like to promote a more humane type of maternity care in your practice. Look at the studies that may support your hunches about how this can be facilitated. Draw your conclusions, make some protocol changes, and bingo!

The problem is thought, that studies can be deeply flawed and they can still be taken seriously. Let's go further with our overview:

It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.

What is this supposed to mean? I would say it is absolutely important to place the woman at the center of the whole event, where she belongs. Go as far as you can to fulfill her wishes. Cater to every one of her needs. But as soon as we start tailoring methods to a woman's circumstances, we get into trouble. Anticipated duration of labor, we all know, can often be wrong (is there a study?). The infant's condition of course is paramount, but are we then getting into continuous fetal monitoring? And are the authors suggesting that a woman should take an epidural before an oxytocin induction? (I'm not being facetious, it is offered frequently).

What's the biggest problem with this picture?  The whole overview completely missed out on one very important part of the equation. They mentioned massage, aromatherapy, sterile waters injections, TENS, and other methods as non-pharmacological, but nowhere in the overview does anyone mention the benefits of having one continuous presence - a companion, not the partner, but a companion who is trained to accompany women throughout labor and birth.

Let's take a look at the reality. Even during a traumatic, painful labor and an unexpected outcome, women feel better about their birth experience if they have been lucky enough to have had the presence of a doula. And isn't a positive experience for the new family what we are all trying to achieve?

The evidence is right there. You don't need to study or review. Just open your eyes, and then take the giant leap of trying to change practices and protocols.