The Shaming Has to Stop

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Get ready for a major soapbox post.

I get it. Those of us who choose to birth outside the box are different. We make choices that don’t necessarily follow mainstream society norms. Our choices may not be in alignment with what is embraced by the obstetrical model of care. Our choices may make medical professionals feel uncomfortable, challenged, exposed. I get it, really I do.

But…

That doesn’t give a healthcare professional the right to deny care in order to shame women and midwives, to bully us, or to punish us into submission because a laboring woman didn’t choose what the medical professional thinks we should do for ourselves, for our children, or for our clients.

Yes, this really happens. All. The. Time.

And, it never should. Ever.

For the most part, people who choose to give birth outside of the hospital feel that giving birth in a hospital is like using a sledgehammer push a thumbtack into a cork board—way too much fuss for something that most people can do on their own—and that a healthy woman having a normal birth in a hospital is asking for trouble. It isn’t that doctors have bad intentions. Most of the time, doctors and nurses have the very best of intentions. But, once a woman walks into a hospital, she will need to be “treated.” And, once a normal labor is “treated” (read, “interfere with”), risk is introduced.

People who choose to give birth outside of the hospital view the medical community as a necessary resource if the normal process doesn’t go normally. Most of us don’t hesitate to seek medical care if there is a need. Yet, why would a woman hesitate? Why do so many of home birthers/birth center birthers distrust the medical community? The lack of trust in the medical community exists because women have been burned many times, and women share their stories with each other.

As a midwife, I’ve personally seen patients yelled at, forced to have vaginal exams despite an explicit refusal, and verbally abused (put down, shamed, coerced, threatened). Doctors have yelled at me, attempted to discredit me in front of my clients, and threatened me with complaints. Why? Is it because something was done wrong? No, quite the contrary. All of these things happened because of a hospital transfer when a mom needed non-emergency help. Yes, these examples occurred during non-emergency transfer situations.

You might think, “Well, during a birth, the hospital staff acts this way because they worry about liability.” OK, let’s assume a medical professional was upset about that. Does that warrant abusive treatment of women and midwives? Quite honestly, does their bias or fear of liability even matter? Their job is to treat whoever comes through the doors of the hospital. Federal EMTALA laws protect a woman’s right to be treated in labor. ACOG supports patient autonomy even if the provider feels the woman’s choices are in conflict with the provider’s belief that her choices are unwise. A practitioner’s unprofessional behavior actually increases the provider’s liability by failing to respect patient autonomy and by refusing to provide the same level of care they would give to any other patient they serve.

This lack of professionalism experienced in the hospital sometimes extends beyond the birth. This is where I feel like the treatment is almost entirely punitive. While I can understand the frustration and stress of a provider who receives an in-labor hospital transfer, this type of post-birth discrimination seems like coercion and punishment for a family making choices that a provider does not personally support.

After a normal, healthy birth, the midwife’s scope of practice is normal newborn care throughout the first 6 weeks. The midwife conducts all of the usual assessments and then recommends the family see a pediatrician for a normal well baby visit at the end of the six-week period. The family calls to make an appointment.

Hold the phone! Wait a second, they won’t see the baby? Why not? Some practices won’t see the baby because the baby was born at home. Say what? They won’t see the baby for 6 months because they didn’t get the vitamin K shot? You’ve got to be kidding me!

Do physicians have the right to deny those people care because they disagree with their choices? For instance, is it OK for a pediatrician to refuse to accept a patient into care because the mother doesn’t breastfeed her baby? Would it be OK if a pediatrician refused care for families who homeschool? No, of course not. Yet, in many cases, with the population of families we serve, if a family has refused for their newborn anything from the mainstream model (such as a Vitamin K shot or erythromycin eye ointment or hepatitis B vaccine), they encounter judgment, fear, or a refusal of service.

It is unethical to refuse care in an attempt to coerce or bully a patient into consenting to care they have refused. It is unethical to refuse care as a way to punish families for their choice to give birth in a way that you do not agree with. It’s morally wrong.

The shame that is heaped on families who’ve chosen a path outside of the mainstream standards has created a culture of resistance and distrust, and that’s not good for anyone. Women and their families should be able to count on a multi-tiered model of care. If a woman plans to give birth at home and the labor takes a turn, she should be given a high quality of care during her transfer, and when she becomes a patient at a hospital. What if instead of shaming, a medical professional chose compassion? Understanding? And what if the medical professional were trained to see themselves as an important part of the picture for women who choose to birth at a birth center or at home?

The shaming has to stop. The punishment has to stop. Is it any wonder we don’t trust you? The distrust has been built on years of mistreatment. It rests on the shoulders of those in the medical community who lack professionalism, who don’t separate their own personal choices and/or training from the choices of the women and midwives who come to them in good faith and in order to see a labor to a successful and safe conclusion.

This dynamic needs to change. Show women that you can treat them with the same respect their midwives show them. Help women to make informed choices, and then respect their right to informed refusal (without trying to make them feel bad about the final decisions). Welcome us—the birth team and the laboring women—so we feel we can come to you for help when it’s needed. Welcome us, so we don’t feel like we want to wait a little longer to see if things get better because we’re scared of how we’ll be received when we arrive at the hospital. Welcome us, so we know we can share our stories fully and honestly with you, without fear of mocking or teasing—or retaliation against our clients.

If the goal is truly to provide good care and not to punish people whose views differ from your own, it’s time to do something to make a change for the good. Every time we interact with you, you have a golden opportunity to let the medical profession shine. Don’t blow it. Help us walk towards you instead of away from you.

If you’re a doctor or a nurse and you support families who make choices that aren’t in alignment with your protocols, this post is not about you. Or, maybe it is. Maybe this is a love story about you. You are the people who give me that glimmer of hope that change is possible and that midwives, consumers, and the medical community can work together to make outcomes better for mothers and babies, and make the experience better for all of us.

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Good Cheer and The Pregnancy Diet

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It’s that time of year. The time when we bake cookies and fudge and tasty pies. The time when the workplace break room is littered with holiday candy and plenty of chocolate. It’s a time when it feels almost obligatory to feed the sweet tooth. But what if you’re pregnant? Does pregnancy give you an eat-all-you-want pass with the holiday sweets? The short answer is no. But then again, as with most anything, it’s all about balance.

We as midwives make nutrition an important part of the care we offer pregnant clients. It’s the hallmark of good prenatal care. To help pregnant women navigate this holiday season, we asked a seasoned midwife/educator/author to share her tried and true pregnancy diet, a diet based on a modified American Diabetes Association (ADA) diet, with specific portion sizes and an accompanying chart. The best part? Desserts are not off-limit, although one piece of pie could blow a lot of the small, allowed portions.

Juliana Van Olphen-Fehr, CNM, PdD, retired director of the Shenandoah University nurse-midwifery program and author of Diary of a Midwife, spent an entire prenatal visit on nutrition when she had a combination home/hospital practice. Clients often joked that subsequent prenatal visits were diet confessionals; some tried to hide ice cream cones from her view when running into her outside of appointments. The nutrition prenatal session left its indelible mark on the pregnant women she served and the Fehr pregnancy diet was a hallmark of her successful practice.

Recently, we asked her if her opinion on the optimal pregnancy diet had changed all these years later: “No. Not one bit…. You are what you eat, so when you’re pregnant, so is the baby [what you eat]. What your job is, when you’re pregnant, is to nourish that body and really make sure that the body inside you will grow up to be an incredible and productive human being.”

Dr. Fehr frames the pregnancy diet in both biological and historical perspectives. Our brain requires glucose. “It doesn’t use protein and vitamins. Glucose is it. And now the pregnant woman has two brains and one is really changing fast. It’s growing and it’s interested in getting all the nutrition it needs.” Yet, historically, humans’ access to sugar was seasonal and typically fruit, or at the very least, lactose, another sugar, from a cow’s milk.

“Humans were designed to survive despite the lack of access to sugar. That’s what we were meant to do, because [historically] we didn’t have it. The problem is that evolution takes thousands of years to develop. We now have so much access to sugar; we are inundated with it. We need it. We crave it.”

But at some point the pancreas won’t keep up with a contemporary intake of sugar. And that creates problems for both the baby and the mother.

Every day a pregnant woman needs grains and carbohydrates to offer the brain the sugar it needs. But the trick is to keep track of serving sizes and amounts. A pregnant woman and her growing baby needs:

  • 9 servings of carbohydrates
  • 9 servings of protein
  • 3 servings of milk
  • 3 servings of vegetables
  • 6 servings of fruit
  • 5 servings of fat

And the serving sizes are small: 1 ounce of meet or cheese, 1 egg, or 2 tablespoons of nut butter meet the protein serving requirement. And nut butters also count for 2 of the fat exchanges. Vegetable serving sizes are ½ cup cooked or 1 cup raw. One half of a bagel, 1/3 cup cooked lentils, 1 small potato, or 2 cups cooked pasta meet the carbohydrate serving size requirement.

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So where does that leave a pregnant woman during the holidays? A little bit of good math, planning, and awareness go a long way. Enjoy that pie, but be mindful of the carb, dairy, fruit, and fat exchanges. Enjoy that piece of fudge, but pull back on your dairy and fat servings for the remainder of the day. And be sure to fill the rest of your day with all of the nutrients that are most important for you and your growing baby. You’re eating for two. Two brains, two pancreases, one of each that are still growing and developing. A good diet is an investment in your own health and in the long-term health of your baby. Cheers!

When a Home Birth Becomes a Hospital Birth

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You did everything “right.” You took Bradley Method childbirth classes. You hired a doula. You hired a midwife to attend your birth. Your diet has been perfect. You rented the birth pool. You took all of the right supplements, attended prenatal yoga classes, had regular chiropractic care, and gained a good amount of weight — not too much, not too little, just right for you.

But birth isn’t just a series of checklists.

It’s good to pay attention to what contributes to a healthy pregnancy and birth, but it’s not a guarantee that the actual birth will perform like an item on a checklist.

Birth is complicated, often messy and surprising, and it’s best to remain flexible as you approach the due date.

Despite doing everything “right,” for some reason, things might not go as planned, and the blissful, ecstatic, empowering, or even orgasmic home birth you planned becomes the birth you didn’t plan. Your home birth becomes a hospital birth.

Is this such a bad thing? It doesn’t have to be. It can be a very good experience, even if it deviates from the original plan. As a midwife, I’ve seen the good, the bad, and the downright ugly hospital transfers. Fortunately, the ugly transfer experiences have been rare.

The Different Paradigms of Care

Midwives and obstetricians approach birth from different paradigms. So what is a different paradigm of birth and why does it complicate things? For one, midwives are trained to attend the 95% of births that occur without complication. The approach to labor is grounded in this very real statistic, but also has to do with the midwife’s training, which focused on continuous labor support and limited intervention.

A physician and/or surgeon is trained to handle the 5% of complicated births. In contrast to midwifery training, obstetrical training is grounded in staying ready for that rarer complication.

It’s important to note that midwives are trained to recognize when a complication arises and vigilantly keep an eye on a woman’s labor to ascertain if there is ever a need to transfer care to a hospital, where a physician/surgeon can take over the birth.

Sometimes the two types of training can clash. Most often obstetricians have never attended a home birth or observed a birth with a midwife in the primary care role, whether at home or at a birth center. Thus, their only experience with home birth moms is likely the mom who has transferred with a complication. They don’t see the other, larger population of women who have had healthy births at home or in a birth center with the midwife.

In their training, obstetricians see the more complicated side of childbirth. One physician I know spent her obstetrical rotation at a hospital serving a poor community that had limited access to prenatal care. Some of the mothers were addicts. The deliveries were complicated and the outcomes not always optimal. While this training and awareness is necessary and important, especially in emergency situations, it can color their responses to home birth transfers. They have seen what poor prenatal care and poor lifestyle choices can mean for a birth. The part of midwifery care that they may not understand is that midwives have already carefully screened their clients to be sure that the pregnancies are healthy and that home birth or birth center birth is a viable option for the mom. It’s also not uncommon for a midwife to transfer care during the pregnancy if the mother becomes high risk.

In my case, as a member of my local healthcare community, I do my best to educate the hospital staff, nurses and physicians alike, as to how a midwife practices. It can be hard to cast aside a person’s training experiences to learn about a different model of care, but with hard work and respectful dialogue, between the moms and midwives and the hospital staff, care providers in the obstetrical care setting can gain greater understanding of just “who these midwives really are.”

So what will a transfer birth look like?

The ability to transfer a mother is an important tool in the midwife’s toolbox. And a transfer hospital birth can turn out just as positive as the home birth might have been.

Depending on the hospital and staff, a midwife may shift into more of a doula role during the birth, helping the laboring mom make the best decisions and making sense of the medical events that often happen quickly with a transfer. The midwife can provide support to the family members who might be there as well. Sometimes the hospital will require the midwife to leave, but that is becoming a rarer exception. If that happens, the midwife will still provide some sort of postpartum care and support. During the transfer, the nurses and doctors are doing their job when they take over the birth – they know complicated birth best – and it’s important to remain grateful for both models of care.

The goal of every birth is a healthy mom and baby. Stay focused on navigating the transition with a positive attitude; it will help you feel better after the birth, whether your birth is a home birth, or a transfer hospital birth. Assert your needs, but don’t be confrontational. Be respectful. A combative attitude helps nobody and serves as an obstacle to good care. Your midwife will be there to help you process the unexpected transfer and transition in care. Midwifery care does not stop with the transfer; it simply follows the needs of the mother, no matter the birth setting or interventions.

Disappointment is Natural

You know you did everything right: you followed the latest nutritional guidelines, you exercised, you took a childbirth class, you prepared. But your birth didn’t happen at home like you planned; it happened at the hospital. The important thing is to remain grateful that you could rely upon a two-tiered system of care. The right provider used his/her skills to bring the birth to the final stretch. Yet, you have an overwhelming sense of disappointment.

Birth is an emotional event. It’s physical, it’s spiritual, and it’s a hormonal journey that sometimes bring tears, elation, sadness, joy, or a combination of all. If you’re feeling disappointed about the birth, find ways to express that disappointment. Write about it. Talk about it. Cry about it. Practice radical acceptance.

Your birth is just one step in the path into motherhood. Celebrate that you’ve become a mother and focus on the positive. Your birth happened just as it needed to happen.