Scrambled

What is happening? Birth is as always, good. Death is coming up in strange corners. Yesterday we started Levels One and Two (places still available, by the way) of the Birth Companions doula course, and not just one but two students burst into tears, at different points in the class. I'm not that mean to my students!

Life is turning faster and faster.

I have been through a car accident, a death in the family, a dear friend's death, disturbing news about another colleague, and all in the past month?

I am okay though, sending gratitude and thanks - thanks for my family, my husband and all the goodness that is continually bestowed upon me.

But every so often, I break down, and yesterday when my innocent husband decided to tear down the ivy that was plugging the gutters, I couldn't take it. Those poor vines! I couldn't stand the noise of them coming off the walls. Now they sit, in sad piles on the driveway.

We do not know how connected we are, either to each other or to the world around us. Let's carry our baskets gently, and be kind to each other.

Birth Companions Doula Course: One, Two, Three

Level One of our Birth Companions Doula Course spring 2012 session was a wonderful success! The students are already attending births, either with partners or with mentor doulas. They are now part of Montreal Birth Companions, and it has been a busy and productive summer.

Level Two will be starting on September 9, 2012, at Studio Vie. It will run for eight weeks, with three hour classes every Sunday. In Level Two, we will explore the challenges that can occur during pregnancy, birth and the postpartum period, and discover the ways a doula can facilitate healing. This level is open to anyone who has completed a doula training.


Level Three will be comprised of a select group who will travel together to Cuba, to explore in depth an aspect of maternity care and will tour the facilities at a Cuban hospital and meet the midwives.


Level One will be starting in the fall of 2012, as soon as we have full registration. We have registrants already, so please register as soon as you can. See below for registration details.

Hoping to see you all in the fall!!

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.

---

[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.