Friday, August 21, 2009

Commencement: Copyright 2009

I just finished a very enjoyable book, called Commencement, about the experience of four young women at Smith College and their "commencement" of life outside of Smith. I especially enjoyed it, I think, because I lived in Western Massachusetts at the time the novel was set in, and it was interesting to read about a place I passed on a regular basis.

There were a few things I didn't like about this book though. First, there was what felt to me like a big plot stretch to include lots of information about girls and very young women being forced into prostitution. It's not that this issue wasn't related to other issues explored in the book, around freedom and feminism and the choices women make, or aren't able to make and why... it's more that the plot felt driven by it in a way that didn't feel realistic.

What really annoyed me, though, was this scene, when one of the four central characters, Sally, is in the hospital giving birth:
"'Sally, we're having a little trouble getting the baby's shoulders out,' the doctor said. 'We're going to have to do a small episiotomy.'

'How small?' she said.

'Small,' the doctor said. 'I promise. Seven stitches, max.'

Stitches? Celia reminded herself to get on the waiting list for a couple of Romanian orphans as soon as she got home.

'No,' Sally said, shaking her head. 'I don't want it done.'

Celia was about to speak up, about to say that these damn people needed to listen to Sally, and really, hadn't the poor girl been through enough without slicing her open?

'Babe,' Jake said gently [Jake's her husband & the baby's father]. 'I know you didn't want one, but it will heal so much better than a jagged tear.'

Bree's eyes nearly popped out of her head.

The doctor grinned. 'I see Daddy here has been reading What to Expect When You're Expecting. He's right, I'm afraid.'

'Oh okay,' Sally said. 'Just get this thing out of me.' She put her head back, resigned.
Okay, maybe this scene infuriated me. I'll admit it.

I don't know where to start. The fact that the doctor promises the number of stitches it will take to close the episiotomy? How would he know?? Especially since from all the research I've seen many of the worst kinds of tears happen more frequently after an episiotomy.

In case you're wondering, this is what the very mainstream Babycenter.com says about perineal tears:
"A third-degree laceration is a tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the anal sphincter (the muscle that surrounds your anus). A fourth-degree tear goes through the anal sphincter and the tissue underneath it." . . . and that "It's possible to tear even if you have an episiotomy. In fact, an episiotomy may raise your risk of getting more severe tears."
And here's a bit of what Henci Goer writes in Obstetric Myths Versus Research Realities about episiotomies, "The major argument for episiotomy is that it protects the perineum from injury, a protection accomplished by slicing through perineal skin, connective tissue, and muscle. Obstetricians presume spontaneous tears do worse damage, but now that researchers have finally done some studies, every one has found that deep tears are almost exclusively extensions of episiotomies. This makes sense, because as anyone who has tried to tear cloth [or paper] knows, intact material is extremely resistant until you snip it. Then it rips easily" (276).

I do that demo in class, with paper. When we talk about circumcision, almost always the dads turn a bit green. The episiotomy demo has the same effect on the moms.

This is an excerpt from Chapter 32 of A Guide to Effective Care in Pregnancy and Childbirth:
Although episiotomy has become one of the most commonly performed surgical procedures in the world, it was introduced without strong scientific procedures of its effectiveness. The suggested beneficial effects of episiotomy are: a reduction in the likelihood of third-degree tears; preservation of the pelvic floor and perineal muscle leading to improved sexual function and a reduced risk of fecal and/or urinary incontinence; reduced risk of shoulder dystocia; easier repair and better healing of a straight, clean incision rather than a laceration . . . On the other hand, a number of adverse effects of episiotomy have been suggested. These include: the cutting of, or extension into, the anal sphincter or rectum; unsatisfactory anatomic results such as skin tags, asymmetry, or excessive narrowing of the introitus; vaginal prolapse; rectovaginal or anal fistulas; increased blood loss and hematoma; pain and edema; infection and dehiscence; and sexual dysfunction.

Liberal use of an operation with the risks described above could only be justified by evidence that such use confers worthwhile benefits. There is no evidence to support the postulated benefits of liberal use of episiotomy. Controlled trials show that restricted use of episiotomy results in less risk of posterior perineal trauma, less need for suturing perineal trauma, fewer healing complications, and no differences in the risk of severe vaginal or perineal trauma..." (295)
Then, the fact that, in a book with a 2009 copyright date, full of thoughtful examination of women's independence and women's choices the author writes, with no evidence of criticism the passage quoted above... this passage that feels like the baby's dad and the doctor pull a paternalistic act of "reassuring" the "ignorant", "hysterical" laboring woman, with LIES, makes me feel a little crazed!

Where is the critique? Where is the "speak truth to power"?? Where is the sense of outrage???

Instead we get "She put her head back, resigned." We get one observer whose eyes nearly pop out of her head and another who is so traumatized and horrified that she wants to adopt children instead of give birth. We get What to Expect When You're Expecting.

There are 29 holds on this book from the Maine library system. People, probably mostly women, are reading it. And on the whole, it's a good book. Which makes the above passage all the more insulting, in my opinion. And all the more damaging.

What would possess an otherwise well-informed, sensitive, thoughtful author to write it? Any ideas?

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine
Mamas & Muffins: New Moms Group

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Sunday, February 22, 2009

The Blue Cotton Gown: A Midwife's Memoir

I just finished The Blue Cotton Gown: A Midwife's Memoir, by Patrician Harman this weekend. It was an excellent memoir - very well-written and full of moving stories, both the author's story and the stories of the women she saw in her practice as a midwife.

Because this is a "midwife's memoir", I think some readers may be expecting lots of birth stories. There aren't many, in fact, just a handful, which emphasizes two important issues.

First, midwives can provide care during the entire spectrum of a woman's life - from her first gynecological check-up to discussions about menopause. Midwives do a lot more than attend births!

Second, not all midwives (or obstetricians, or family practice doctors) can afford to provide obstetrical care. Harman writes, "when the cost of medical-liability insurance almost doubled, we looked at what it would cost to continue obstetrics, and we couldn't break even. Bringing new life into the world in a gentle way was our calling, but a calling we could no longer afford" (206). For a more in-depth review of the book, and discussion of the issues in it, read Jo's review at The Modernity Ward.

When I was discussing the fact that the gender part of my recent post on Dell received more attention than the midwife part, she said - "oh! you could rewrite that part to show how a real midwife would handle the situation!"

Coincidentally, one of the few birth stories in The Blue Cotton Gown does just that:
"So we push... And we push... For two hours, we push. It's a group effort.

We try every position the nurse and I can think of. 'Can't we just do a C-section?' Nathan [the dad] asks, eyeing the tracing as the fetal heart rate dips into the nineties, then bounces back to 150 again, a nice normal baseline. 'Maybe he's too big.' That thought has crossed my mind too, but it's not time to give up yet.

'Come on, let's get back to work. We're missing some of these contractions. Here, Jeannie, pull on my hands. Pull!' An hour later, when Tom [OB, Harman's husband] returns from the OR, he enters the birthing room as if he means business, and I'm glad to see him.

'How you doin?' he asks Jeannie and shakes hands with Nathan. 'Getting tired?' I catch his eye and glace toward the monitor. The decelerations are steeper now but always returning quickly to baseline.

Another big contraction and Jeannie grabs her butt then flops back in bed, trembling. 'I don't think i can do this!' After two days of labor and three hours of pushing, the young woman is spent.

'Ready for some help?' Tom asks, slipping into a long green sterile gown. Terry, the RN, uncovers the delivery table and places the vacuum extractor, a modern alternative to forceps, near the corner. Clearly, she thinks it's time.

'You bet I'm ready!' says Jeannie. 'Is this finally gonna happen?'

Though the extractor, which comes with a soft plastic suction cup, is less risky than metal forceps, it's not without danger. It can cause bruising, laceration, a hematoma, or worse, a shoulder dystocia . . .

Dr. Harman parts the labia. 'This may hurt a little,' he warns as he applies the vacuum cup to the fetal head.

I center my attention. 'Okay, Jeannie. Tom can't pull the baby out by himself. That would be too much strain on the little neck. You've got to push as hard as you can and soon you'll be holding your little one.'

But I'm wrong. Each time Dr. Harman pulls, the head moves only a quarter inch. Once, the vacuum slips off. Then again it slips off. And again. The head is crowning now, and by protocol, the provider gets only three tries with the extractor; any more may cause damage. Tom lays the mechanical device aside, then sits on the stool between Jeannie's legs, checking the vagina for stretch. Neither of us routinely does episiotomies - in fact, rarely, if ever - but I can tell he's thinking about it. Nathan stares numbly at the top of his baby's bruised head.

I reach over and pour a little oil, which the nurse has placed on the delivery table, over Tom's fingers as he massages the vaginal opening; our gloved hands touch and he smiles. Our last delivery together. Shoulder to shoulder.

When the monitor shows a good contraction, I lean over the bed and whisper to Jeannie, 'This is it, babe! One more push. You're on your own now, no vacuum extractor. The head's almost out.' With valor, the worn-out woman pulls back her legs once again. Nathan gets into position, holding her head, and I bend over, showing more optimism than I feel, to help Tom support the perineum.

Imperceptibly, there's a shift, and the fetal head dips below the pubic bone. There's no stopping Jeannie now. All at once, the baby rotates a quarter turn and hurtles into Tom's waiting hands. I place the wet squirming bundle in Jeannie's outstretched hands, cord still attached. 'Thank you,' she cries, 'Thank you, everyone. My baby! My baby girl.' Nathan is sobbing. There are tears in Tom's eyes. Our last delivery together" (209-11).
This is obviously a much different scenario than the vacuum-assisted birth on Private Practice. Mom works for hours to push her baby out: they try lots of different positions, lots of encouragement and support, tolerance of variations of normal in the fetal heart tones. I do wish the author had included more of the informed consent conversation that I'm assuming happened. And I'm assuming that lots of the positions they worked through earlier were more upright ones, but that these last pushes happened with mom on her back because they were using the vacuum extractor as a last resort.

I'll be back on a regular schedule again now that we've recovered our power. This has been a record for how long it's taken me to write a post - I started this one over the weekend, but since we lost power when it snowed 18" on Sunday, I haven't been able to get back to it!

I keep repeating to myself: Spring is coming! Spring is coming!!

More posts coming soon!

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine
New Mothers Support Circle

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Wednesday, January 28, 2009

Same Old, Same Old??

Adbusters published a provocative essay on childbirth last fall, "Industrial Childbirth," and while the piece was written about a birth that took place in Dublin, Ireland, there are many similarities between the management of this birth and how birth is routinely managed throughout the United States. The author, Shonagh Strachan, begins her essay, explaining that
"My experience of childbirth was not an unusually traumatic one. In medical parlance I had an NVD: a Normal Vaginal Delivery. The midwives were pleasant. I was given an epidural. I was admitted to hospital at 2pm and delivered a healthy baby boy ( 8lb 7oz ) eleven hours later. This is the essential information, is it not? This is the only kind of information that we ever really hear about other women’s experiences with childbirth.

But there is more to it than that. It took me a while to sort out my feelings after the birth – the elation you feel at the presence of a new life combined with your physical exhaustion leave room for little else. And I never really experienced the hopeless grief of the flippantly named “baby blues” in the weeks or months that followed. What I felt – when I was finally able to identify the reasons for my confusion – was anger.

Is anger only blame and self-pity? Or can it be illuminating? For me it can – anger has traveled beyond blame, beyond the individuals involved and my personal experience, and shocked me into changing my whole outlook on life."
She goes on to describe her birth experience: artificial rupture of membrane; contractions that did not progress dilation quickly enough, which led to Pitocin; an epidural. This birth story is what is typically offered in United States hospitals as well. The 2006 Listening to Mothers Survey II reports that, "Despite the primarily healthy population and the fact that birth is not intrinsically pathologic, technology-intensive childbirth care was the norm. Each of the following interventions was experienced by most mothers: continuous electronic fetal monitoring, one or more vaginal exams, intravenous drip, epidural or spinal analgesia, and urinary catheter."

Okay, so this is where I admit: already, I'm shocked. But remember, the author of the essay is explaining how, so far, she is not angry. Yet.
"The point at which I started to feel a twinge of anger was when, after the delivery, I wasn’t allowed to feed my baby. It was only then that my instinct was strong enough to say, “No. This is really wrong.” There is a period of about an hour after the birth where the newborn is alert and breastfeeding can be established. However, after a brief hold, he was taken away as I was given a Syntometrine injection and his placenta was delivered (by tugging on the cord). He remained away as I was stitched and examined and had to wait for a doctor to examine me.

By the time I was given the all clear (in tears at this point asking, “Can I feed him now?”), I had to be moved from the delivery ward and down to the post-natal ward. It was now 2 am, so friends and family in the waiting room were told to go home without ever having seen the baby or me. The baby’s dad had been present at the birth but was also sent home. Yet again I asked, “Please, can I try to feed my baby?” but he had to be taken away again – this time for a Vitamin K injection and for the nurse to bathe him and put his first vest and Baby Gro on."
But the whole separation of mother/baby: that's old-school, right? Now the baby's first examination (weighing, measuring, etc. & etc.) can be done by the mother, and he never leaves mother's side, right? Well, that may or may not be the reality. Listening to Mothers II reports that "Despite the importance of early contact for attachment and breastfeeding, most babies were not in their mothers' arms during the first hour after birth, with a troubling proportion with staff for routine, nonurgent care (39%)." Add that to babies who needed urgent care, and that's a significant number of babies who are away from their mothers during that first hour. Of course, as the Adbusters' essay shows, even one baby separated from mama for nonurgent reasons is significant, at the very least to that baby and mama.

[And as a public service announcement, here is a link to a blog entry that discusses and shows one newborn's bathing experience, "How NOT to Bathe the Baby". I couldn't get through the video myself: it's horrifying. But I do believe it's incredibly important, if at all possible, to have someone who cares about baby accompany him or her at all times as an advocate.]

Shonagh Strachan explains another source of anger:
"In theory, a woman has the right to refuse any of the interventions offered to her. In practice, the normality of intervention and the culture of risk minimization (read: liability minimization) mean that women do not feel empowered to say “no.” I certainly never thought about saying “no” or asking what the alternatives were. I blame myself for this – that I was not more informed and proactive. But I am also angry at the bullying system in place. It is hurried and overwhelming so there is never time or space to question the “professional” medical opinion as to what is really right for you and your baby. So we become numbers, subject to routine interventions."
And ends her essay with these paragraphs:
"It is my belief that at some deep level, we all feel that we have been robbed. We pass through our childbirth initiation to become disempowered, disconnected, long-suffering, patriarchal mothers. We tell our horror stories as just that, or we say nothing at all. But it doesn’t have to be this way. If I ever have another child, it will not be in the same way. And it doesn’t stop there. I will never again blindly place my trust in authoritarian professionals and institutions. I will recognize all capitalist patriarchy for what it is and I will do my best to speak out against it.

Every day, in every way, my son is a wonderful gift. I would go through ten more hospital births just to keep him. I am sorry for his shabby entrance into this world but I am thankful to this little person for helping me to see something: the bald, blatant, oppressive, damaging, misogynistic forces at play in the most vital aspects of women’s lives. Revisiting his birth has made me angry, but that has made so much else clear: how blinded we can be by the guise of protection, how crippled we can be made by fear.

I wish that we talked about it. That we could stop reveling in horror stories and better place our fingers on the reason for our traumatic births – not the curse of Eve medicated to by our benevolent system – but the systematic violence that delivers our babies for fear that we might give birth to them ourselves. For in the process we might begin to understand our own strength and find words for our anger. We might begin to disobey."
Very, very powerful.

Here's another thing that shocks me: it seems like we're fighting for the same things, over and over again. In her excellent memoir, Lady's Hands, Lion's Heart: A Midwife's Saga, Carol Leonard tells how she tries to institute changes in a local New Hampshire hospital - back in the late seventies. She creates a list of changes that she thinks would result in more family-centered maternity care, and offers them to the Chief of Obstetrics, "First on this list, obviously, is discarding the wrist restraints. No more being tied down like a deranged animal. Also, deep-six the standard prep of high enema and shaving" (116). These routines have thankfully ceased to be standard, as they were for my birth, in 1974.

However, most of the rest of Leonard's list looks appallingly familiar: "No more routine, continuous electronic fetal monitoring for normal, uncomplicated births. No arbitrary, elective Pitocin inductions without some clear medical indication . . . no more routine drugs, episiotomies, or mandated supine - flat on one's back - positions. No more withholding fluids and nourishment, 'just in case anesthesia is needed,' and no more routine, artificial, early rupture of membranes, which has never been proven advantageous by any evidence-based data. And babies are allowed to remain with their mothers at all times" (117).

How are we going to change this system? I think it goes back to basics: being informed, asking questions, networking, and insisting on a different experience, whether in a hospital, birth center, or at home. Excellent hospital births are possible - I know, because I had two: go check out Madelyn & Owen's birth stories here, if you'd like. Or go read this terrific article in the Los Angeles Times, "Midwives Deliver".

I have more ideas in old posts, "Mother-Friendly Childbirth", and "Questioning Safety" and "Choosing a Care Provider and Birth Place" and "Pregnancy and Birth: What Are My Choices?".

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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Wednesday, November 12, 2008

Folic Acid (Folate)

The importance of folic acid is becoming fairly well known because of an advertising campaign sponsored by the CDC (Center for Disease Control), the March of Dimes, and the National Council on Folic Acid. I think many women are aware of the link between adequate folic acid and reduced risk of neural tube defects, like spina bifda.

Folic acid is critical very early in pregnancy. By the time many women realize they are pregnant, their baby's spinal column and brain are already fully formed (around week four). Many women plan pregnancies, but just about as many are surprised by an unplanned pregnancy. For these reasons, all the books I read recommend that women of childbearing age take a daily multivitamin that contains at least 400 mcg of folic acid, whether they are planning a pregnancy or not.

During pregnancy, most of the books recommend 600-800mcg of folic acid, daily. All the prenatal vitamins I reviewed contained 800mcg of folic acid. While getting some folic acid through diet is certainly do-able, this particular vitamin is another one, like calcium and iron, where supplementing with a vitamin can make a lot of sense.


What does Folic Acid do?
Folic acid is best known for what it prevents: say folic acid and many of us think "prevent spinal bifida", even if we're not sure what spina bifida is. Inadequate folic acid has been linked to neural tube disorders, which are malformations of the central nervous system. Spina bifida is the most common of these neural tube disorders. Many studies have shown that adequate folic acid during the first weeks of pregnancy dramatically reduce these very serious disorders.

In Nutrition for a Healthy Pregnancy, Elizabeth Somer explains just how important folic acid is: "Neural tube defects are the second leading cause of death among infants who die from birth defects in this country (Downs syndrome is the leading cause). One nutrient known to prevent NTDs is folic acid. Numersous studies since they early 1990s have consistently found that folic acid supplementation in women around the time of conception and during pregnancy reuces the risk of NTD, especially spina bifida and anencephaly. Women who supplement with folic acid also deliver babies at low risk for urinary tract, cardiovascular, and limb defects. You also tend to improve your fertility, are less likely to miscarry, and should suffer less from nausea" (6).

It is important to continue to get adequate folic acid because low levels may increase the risk of complications during pregnancy. Some studies show that a deficiency of folic acid during pregnancy can also increase the chance of preterm birth.

Having a Baby, Naturally also mentions folate's importance in DNA synthesis and the formation of red blood cells.


What are good food sources for Folic Acid?
Because folic acid is so important, many foods are now fortified with it, including cereal, pasta and rice.

Good natural food sources of folic acid include: beans and peas, leafy green vegetables, asparagus, sunflower seeds, whole grains, papaya, oranges, blueberries and strawberries.

According to Peggy O'Mara in Having a Baby Naturally, "you can get 400mcg of folate in your daily diet if you eat:
  • 1 glass of orange juice or 1/4C of wheat germ or a small handful of dried soybeans and
  • 1 egg or 2 slices of bread or 1/4 of a cantaloupe and
  • 1 cup of pinto, black or navy beans or two cups of cooked turnip greens, spinach or asparagus or 1 tablespoon brewer's yeast" (25).
  • Other excellent food sources include:
    1 cup of most breakfast cereals = 100mcg
    1/2 cup boiled lentils = 180mcg
    1/2 cup pinto beans = 147mcg
    1/2 cup boiled asparagus = 130mcg
    1/2 cup boiled spinach = 130mcg
    1/2 cup wheat germ = 100mcg
    1/2 cup orange juice, from concentrate = 109mcg
    1/2 cup chickpeas, canned = 80mcg
    1 cup spinach, fresh = 109mcg
    1 cup split peas, cooked = 123mcg

    How is Folic Acid absorbed?
    Folic acid is not stored in the body, according to The Pregnancy Book, by Dr. Sears, which is why it is so important for women of childbearing age to have a consistently adequate intake of folic acid. Dr. Sears also explains that the kidneys excrete more folic acid during pregnancy, which is one of the reasons why pregnant women need more folic acid than when they're not pregnant.


    Folic Acid supplements
    Nutrition for a Healthy Pregnancy explains that, unlike many other vitamins, folic acid supplements actually work better than food sources. "Supplements are better than food when it comes to raising blood levels of this B vitamin and reducing birth defects . . . Folic acid levels in the blood increased only in the women who supplemented or consumed fortified foods, while dietary intake of folic acid-rich foods produced no change in folate status . . . Your best bet is to include two or more servings of folic acid-rich foods in your daily diet AND take a supplement that includes at least 400mcg of folic acid" (8).

    Below are the books I used to write this post:
    The Pregnancy Book, by William Sears, MD and Martha Sears, RN
    The Harvard Medical School Guide to Healthy Eating During Pregnancy, by W. Allan Walker, MD
    Nutrition for a Healthy Pregnancy, by Elizabeth Somer, MA, RD
    Having a Baby Naturally, by Peggy O'Mara

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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    Wednesday, November 5, 2008

    Calcium

    During pregnancy, women need various vitamins and minerals to grow the baby - both the process and the baby's actual body. If a woman does not obtain enough of these vitamins and minerals to support her own body as well as the pregnancy, her body will always provide for the baby first, and her own nutrition will suffer.

    Women who do not get enough calcium through food or supplement are at risk for osteoporosis (a reduction in bone mass) because of this fundamental principle. A pregnant woman's body will use the calcium stores in her bones to build the baby's skeleton.

    Most sources recommend at least 1200mg of calcium each day for pregnant and breastfeeding women.

    Do you know how much calcium is in your prenatal vitamin? Here are a few common brands and how much calcium each contains:
    Rite Aid Brand Prenatal: 200mg
    Rainbow Light Prenatal: 200mg
    GNC Prenatal: 500mg
    One-a-Day Prenatal: 300mg
    Stuart Prenatal: 200mg
    Surprised?

    Clearly it's important for pregnant women to avoid counting on a prenatal vitamin to meet all of their calcium needs during pregnancy and breastfeeding.

    What does calcium do?
    As many of us know, calcium builds bones, so it is important prenatally for the baby's bones. Most us also know that calcium is in milk products - it's in breastmilk too! So, nursing mothers need calcium after baby is born too.

    Several studies suggest that optimal amounts of calcium decrease the risk of pregnancy-induced high blood pressure (PIH) and pre-eclampsia.

    In the Sears' Family Nutrition Book, Dr. Sears writes that "calcium is one of the most vital minerals for optimal functioning of your entire body" 955).


    What are good food sources for calcium?
    Good sources for calcium include dairy products like milk, yogurt, and cheese; fortified products like soy milk, orange juice, and cereal; fish; soy products; and greens. Here are some specific numbers:
  • Milk, low-fat: 1 cup = 300mg
  • Cottage Cheese: 1 cup = 155mg
  • Yogurt, low-fat, plain: 1 cup = 400mg
  • Parmesan cheese: 1 ounce = 336mg
  • Cheddar cheese: 1 ounce = 200mg
  • Sardines: 3 ounce = 371mg
  • Orange juice, calcium-fortified: 1 cup = 300mg
  • Tofu: 3 ounces = 190mg
  • Salmon: 3 ounces = 180mg
  • Broccoli, chopped (raw): 1/2 cup = 47mg
  • Almonds: 1 ounce = 80mg
  • Cereal, calcium-fortified: 1/2 cup = 100-200mg
  • Spinach, cooked: 1/2 cup = 136mg
  • Orange: 1 medium = 50mg
  • Soybean nuts: 1/4 cup = 116
  • Honestly, calcium was never a problem for me, because I love dairy. If I had one serving of cheese during the day (approximately 150mg), plus two glasses of milk for dinner (which equals 4 cups of milk, for a total of 1200mg), that was my calcium. People who don't tolerate dairy well, though, or who simply don't like it, need to be more mindful about including non-dairy calcium-rich foods in their daily diets.

    O'Mara offers these suggestions for obtaining 1,000mg of calcium through food sources:
  • 1 cup of milk or fortified soy or rice milk and
  • 1 cup of yogurt or fortified soy or rice yogurt or 1 cup of cooked collard or turnip greens and
  • 3 ounces of sardines or 1 stalk of broccoli and 1 cup of cooked turnip greens (26).

  • How is calcium absorbed?
    In Nutrition for a Healthy Pregnancy, Elizabeth Somer explains that "the total cost of pregnancy for a woman who has had two babies and has breast-fed them both for three months is approximately 100,000 mg, the equivalent of more than 333 extra glasses of nonfat milk!" (77).

    Somer offers this explanation for how the body handles its need for calcium during pregnancy and breastfeeding:
    "During gestation, it helps compensate for higher calcium needs by increasing the average amount absorbed into your bones from food - from about 20 to 25 percent prior to pregnancy to as much as 50 percent during pregnancy. While nursing, your body compensates for the loss in breast milk by reducing calcium losses in the urine . . . Regardless of absorption, you need to make sure you get enough of this mineral prior to, during, and after pregnancy" (78).
    In Having a Baby, Naturally, Peggy O'Mara explains that calcium is aborbed better when taken with vitamin C and vitamin D (26).

    O'Mara adds that "new research on calcium is beginning to make some experts believe that getting the body to retain calcium stores is much more crucial in the prevention of osteoporosis than how much of it you consume. Consuming too much alcohol and caffeine and eating a high-protein diet seem to deplete the body of its calcium stores more quickly. Exercising helps the body to hold on to its calcium supply" (26). These habits - avoiding alcohol, limiting caffeine, and exercising regularly - have many health benefits for pregnant women and their babies beyond calcium retention, but that's certainly one more good reason to make them a priority.

    Finally, calcium is aborbed best when smaller amounts of calcium-rich foods are eaten through the day and with meals.


    Calcium supplements
    For women who do not get enough calcium through their diet, a calcium supplement can make up the difference. Here is a list of recommendations to keep in mind if you decide to take a calcium supplement:
    Avoid "natural source" calcium pills like bone meal or oyster shell because they might contain lead, a very toxic metal.

    Take the calcium supplement at a different time - not at the same time as a prenatal or iron supplement, because calcium interferes with iron absorption, and iron interferes with calcium absorption.

    Take calcium with vitamin C and vitamin D (400IU) to increase absorption.

    Know how much of the calcium in your supplement is elemental - that's the amount that's actually usable by your body.

    Taking calcium before bed may help you sleep.

    Below are the books I used to write this post:
    The Pregnancy Book, by William Sears, MD and Martha Sears, RN
    The Harvard Medical School Guide to Healthy Eating During Pregnancy, by W. Allan Walker, MD
    Nutrition for a Healthy Pregnancy, by Elizabeth Somer, MA, RD
    Having a Baby Naturally, by Peggy O'Mara

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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    Thursday, October 16, 2008

    How to Choose a Prenatal Vitamin

    Many women take prenatal vitamins during their pregnancy. Some expectant moms take store brand vitamins, others get a prescription from their care provider for a specific brand. Since taking a prenatal vitamin is such a common aspect of pregnancy, I thought I'd spend the next few "Nutrition Wednesday" posts on it. This post will be an overview - and then each week I'll highlight a few common vitamins/minerals contained in the vitamin: what each does for mom and baby; common dosages; what foods contain this nutrient etc.

    Interestingly, as I checked in several pregnancy and prenatal nutrition books, I found that there was not a consensus on prenatal vitamins: several books went so far as to explain that if mother's diet is excellent, prenatal vitamins are unnecessary. Most of the my sources, however, did suggest using prenatal vitamins almost as insurance:

    The Harvard Medical Guide to Healthy Eating During Pregnancy has a helpful chapter called "Dietary Supplements - What's Good and What's Not". In this chapter, the author explains that
    "Most physicians recommend taking a prenatal vitamin to ensure that pregnant women are not deficient in nutrients. This is an important point, because the goal of taking a vitamin is not to 'boost' the levels of any one nutrient to excess but to bring abnormally low levels of nutrients to a normal level. A reputable supplement with the right amount of vitamins and minerals can serve as a safety net in case the foods you eat fail to supply a critical nutrient that your baby needs, or if nausea and vomiting are preventing you from eating a balanced diet" (92).
    and

    Peggy O'Mara writes in Having a Baby, Naturally :
    "Taking a prenatal vitamin can help ensure adequate vitamin levels, although it should not be used as a substitute for a good diet. Experiment with the best time of day to take your supplement, because taking it on an empty stomach may contribute to nausea. Taking it with a meal is usually best" (11).

    Okay, so that's why many doctors and midwives recommend taking prenatal vitamins... now, which one to take? Here are some guidelines:

    First, take a prenatal supplement, meant specifically for pregnant or breastfeeding (lactating) women. Prenatal vitamins have been modified to correspond with pregnant women's needs, and will work better than a traditional multivitamin.

    The Harvard Medical School Guide to Healthy Eating During Pregnancy offers these additional considerations:
    "It is safest to choose a supplement from a large, reputable manufacturer at a retail pharmacy, because these companies will be under higher scrutiny to provide a safe product than small companies that sell products over the Internet or in smaller stores. Choose a formula specifically designed for pregnant women, and check to see that it provides the level of vitamins and minerals that you need. You can ask your doctor to recommend an over-the-counter vitamin or to prescribe one through your pharmacy. Some people may also choose not to take a multivitamin, instead preferring individual supplements of the nutrients they need most. In this case, it's important to make sure you are getting the right dose, because individual-nutrient supplements are often sold as doses above the recommended daily dose" (93).

    According to this same book, here is a list of Dietary Reference Intakes During Pregnancy, for women 19 years old or older:

    Calcium: 1000mg
    Phosphorous: 700mg
    Magnesium: 350mg
    Vitamin A: 770mcg (2,560IU)
    Vitamin D: 5mcg (200IU)
    Flouride: 3mg
    Thiamin: 1.4mg
    Riboflavin: 1.4mg
    Niacin: 18mg
    Vitamin B6: 1.9mg
    Folate: 600mcg
    Vitamin B12: 2.6mcg
    Panthothenic acid: 6mg
    Biotin: 30 mcg
    Choline: 450mg
    Vitamin C: 85mg
    Vitamin E: 15IU
    Iron: 27mg
    Zinc: 11mg
    Copper: 1000mcg
    Selenium: 60mcg
    Iodine: 220mcg

    Elizabeth Somer writes in Nutrition for a Healthy Pregnancy that
    "the secret to supplementation is to do it sensibly. Choose a multiple vitamin and mineral that supplies at least 400mcg of folic acid and approximately 100-200 percent of the Daily Value for all other nutrients. If you don't consume daily at least two calcium-rich foods, such as nonfat milk and fortified soy milk, and lots of magnesium-rich whole grains, wheat germ, and legumes, then consider supplementing your multiple with extra calcium (500mg) and magnesium (250mg) since no one-pill multiple contains enough of these two minerals. In addition, you will need additional iron if blood or tissue iron levels are low" (10).

    Here is Mothering's response to "I'm looking for a really good prenatal vitamin and wondered what your suggestions would be."
    I have used DaVinci Laboratory's Ultimate Prenatal Vitamins for 20 years with excellent results. It is in a base of herbs so consult with your midwife or doctor about your own health needs in this area. Some vitamin shops carry this product although it was formerly for professional use only. Ask your doctor to order it for you if you cannot find it locally visit their website at www.davincilabs.com Wishing you a beautiful pregnancy and birth experience.

    So there are a few caveats about prenatal vitamins:

    1. Don't assume all prenatal supplements (or supplements in general) are safe.

    The author of the Harvard Medical School Guide to Healthy Eating During Pregnancy cautions that "dietary supplements are regulated differently from either food or medications. The responsibility for ensuring a supplement's safety lies with the manufacturer, not an overseeing agency such as the FDA . . . supplements that contain the same ingredient have been found to vary widely in quality and content. This doesn't mean that all supplements are dangerous; most reputable companies know that ensuring a safe, consistent product is in their best interest. But you can't assume that everything sold on your pharmacy's shelves [or online!!] has been tested for quality and safety" (92).

    For example, you might want to check out a vitamin on this list before you buy it: Survey Data on Lead in Women's and Children's Vitamins. I was shocked to notice a significant overlap between health food store vitamins and the vitamins on the list for the highest lead content.

    2. Prenatal vitamins sometimes cause nausea in pregnant women, especially in the first trimester. If your prenatal vitamins make you nauseous or add to your morning sickness, consider switching brands or - what I've found anecdotally to help the most women - take them at night after dinner rather than in the morning on an empty or nearly empty stomach. The Midwifery Today e-newsletter had an article about this common problem just recently: Nausea and Prenatal Vitamins

    3. While taking prenatal vitamins can be "insurance" against a nutritional deficit, it's critically important to eat a balanced, healthy diet during pregnancy. Our bodies absorb nutrients much better from food than from vitamins, and many times the combinations involved in foods or traditional recipes combine together to work better in our bodies. Also, there are lots of important phytochemicals in fruits, vegetables and whole grains that are not available (yet?) in prenatal supplements.

    Several of the books mention iron, calcium, and folic acid as three nutrients in prenatal vitamins that are particularly important, because many pre-pregnant and pregnant women do not get adequate amounts of these nutrients through the foods they eat. We'll start with those next week. In the meantime, these are the books I used to compile this information, and would recommend reading as additional resources:

    The Pregnancy Book, by William Sears, MD and Martha Sears, RN
    The Harvard Medical School Guide to Healthy Eating During Pregnancy, by W. Allan Walker, MD
    Nutrition for a Healthy Pregnancy, by Elizabeth Somer, MA, RD
    Having a Baby Naturally, by Peggy O'Mara

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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    Wednesday, September 24, 2008

    Local Eating during Pregnancy: Part One

    I'm finishing up the excellent book Animal, Vegetable, Miracle: A Year of Food Life, by Barbara Kingsolver, who is one of my favorite authors. And I'm finishing up my year of garden work: picking my winter squash and orange pumpkins, the last peppers and eggplant, and putting cold frames over the less-hardy greens. Three days of rainy weather approaching has made the task more urgent - I don't want my peppers and winter squash to get moldy! During the rain, I think we'll be inside peeling apples from our local orchard for applesauce and husking/blanching/freezing corn from a farm just up the road.

    There are many advantages to buying & eating more foods locally and seasonally. Some help others most directly, but certainly affect us in the long-term: economic benefits for the local area and local farmers; less dependence on gasoline to bring the food to you; small farms often farm more sustainably and/or organically (even if they don't go through the process to be certified organic). There are other benefits that are just for the local eater her/himself: eating food that was grown for taste, not portability/storage (YUM!) as well as the additional nutrition offered by eating locally and seasonally.

    For many women, pregnancy is a time when they are more motivated to learn about nutrition, and to make food choices based on what they learn. It's also a time when there is a more obvious link to other mothers - mothers past, animal mothers, our mothers, future mothers. One of my favorite books to read during pregnancy was a memoir-ish book called Having Faith: An Ecologist's Journey to Motherhood. The author, Sandra Steingraber, discusses her journey month-by-month through pregnancy, giving each chapter a moon name, from "Old Moon" to "Harvest Moon". She writes in the preface that "When I became pregnant at the age of thirty-eight, I realized, with amazement, that I myself had become a habitat. My womb was an inland ocean with a population of one" (ix).

    So, in honor of the coming harvest, and for all of you mamas growing your babies in the "inland ocean", here are a few recipes I'll be using to take advantage of this beautiful (and delicious!) season...

    KALE

    This recipe, Dino Kale Saute, is my favorite ways to use kale - everyone I've made it for as always loved it. Kale is an excellent source of Vitamin C, Vitamin A, and Vitamin K and has calcium and protein in it (!!).

    Dino Kale Saute

    12 ounces dinosaur kale or regular kale, cut or torn into 1- to 2-inch pieces (about 12 cups)
    2 tablespoons olive oil
    1/4 cup soft sourdough or French loaf bread crumbs
    1/8 teaspoon pepper
    1 teaspoon white wine Worcestershire sauce
    Lemon wedges (optional)

    1. Rinse kale leaves thoroughly under cold running water. Drain well; set aside.

    2. In a small skillet heat 2 teaspoons of the oil. Cook bread crumbs in the hot oil for 1 to 2 minutes or until browned. Season with pepper; set aside.

    3. In a large, nonstick skillet heat the remaining 4 teaspoons oil. Add kale. Cook the kale, covered, for 1 minute. Uncover. Cook and stir for 1 minute more or until just wilted. Transfer kale to serving dish. Drizzle with Worcestershire sauce. Sprinkle with the browned bread crumbs. Squeeze lemon wedges over all. Makes 4 servings.

    Nutrition Facts
    Servings Per Recipe 4 servings
    Calories 89, Total Fat (g) 5, Saturated Fat (g) 1, Cholesterol (mg) 0, Sodium (mg) 53, Carbohydrate (g) 9, Fiber (g) 4, Protein (g) 3, Vitamin C (DV%) 94, Calcium (DV%) 8, Iron (DV%) 8, Percent Daily Values are based on a 2,000 calorie diet


    APPLES

    Apples are delicious this time of year and there are so many kinds to choose from. Apples have some Vitamin C and are a good source of fiber.

    Rustic Apple Sauce

    Ingredients
    4 cups cubed peeled Braeburn or Pink Lady apple
    4 cups cubed peeled Granny Smith apple
    1/2 cup packed brown sugar
    2 teaspoons grated lemon rind
    3 tablespoons fresh lemon juice
    1 teaspoon ground cinnamon
    1 teaspoon vanilla extract
    Dash of salt
    2 tablespoons crème fraîche (or full-fat yogurt or sour cream)
    Preparation

    Combine first 8 ingredients in a Dutch oven over medium heat. Cook 25 minutes or until apples are tender, stirring occasionally.

    Remove from heat; mash to desired consistency with a fork or potato masher. Stir in crème fraîche. Serve warm or chilled.

    Nutritional Information
    Calories:140 (12% from fat)
    Fat:1.8g (sat 1g,mono 0.5g,poly 0.2g) Protein:0.3g Carbohydrate:32.5g Fiber:2.3g
    Cholesterol:3mg Iron:0.5mg Sodium:30mg Calcium:31mg

    One of my favorite recipes comes from the mother of my best friend growing up. It's not really a recipe, actually: chop up an apple and a small handful of walnuts; add a couple of spoonfuls of ricotta cheese and a sprinkle of cinnamon. Yum!


    PEARS

    Pears are also in season in the fall. They have some Vitamin C and are a very good source of fiber.

    Pear Clafouti

    Cooking spray
    1 teaspoon all-purpose flour
    2 cups cubed peeled pear
    3/4 cup all-purpose flour
    1/4 teaspoon salt
    1/8 teaspoon nutmeg
    2 cups 1% low-fat milk, divided
    3 large eggs, lightly beaten
    1/2 cup sugar
    1/2 teaspoon vanilla extract
    Preparation

    Preheat oven to 375°.

    Coat a 10-inch deep-dish pie plate with cooking spray, and dust plate with 1 teaspoon flour. Arrange the pear cubes in the bottom of prepared dish, and set aside.

    Combine 3/4 cup flour, salt, and nutmeg in a bowl. Gradually add 1 cup milk, stirring with a whisk until well-blended. Add 1 cup milk, eggs, sugar, and vanilla extract, stirring until smooth. Pour batter over pear cubes. Bake mixture at 375° for 35 minutes or until set.

    Nutritional Information
    Calories:230 (15% from fat)
    Fat:3.9g (sat 1.3g,mono 1g,poly 0.5g) Protein:7.7g Carbohydrate:41.1g Fiber:1.8g
    Cholesterol:113mg Iron:1.3mg Sodium:171mg Calcium:121mg


    PEARS & APPLES

    I think pears and apples are both excellent addition to spinach or lettuce salads. A salad with spinach or mixed greens, apples or pears, a sprinkle of sunflower seeds and some chopped cooked chicken or hard-boiled egg is an excellent lunch or dinner. Paul Newman's raspberry walnut salad dressing is a good one to try on this type of salad if you don't want to make your own balsamic vinaigrette. A sprinkle of (pastuerized!) blue cheese or goat cheese, or cheddar, can be nice too.

    Pears and apples are also good served with this dip:

    Cottage Cheese and Apple Snacks

    1 cup low-fat cottage cheese
    2 tablespoons peanut butter
    1/4 teaspoon ground cinnamon or apple pie spice
    1 to 2 teaspoons skim milk
    3 medium apples or pears, cored and sliced

    For dip, in blender container or food processor bowl place the cottage cheese, peanut butter, and cinnamon or apple pie spice. Cover and blend or process until smooth. If necessary, stir in enough milk to make dip of desired consistency.

    Serve the dip immediately or cover and chill it for up to 24 hours. Serve dip with the apple or pear slices. Makes 6 (2-tablespoon) servings.

    Nutrition Facts
    Calories 106, Total Fat (g) 4, Cholesterol (mg) 3, Sodium (mg) 178, Carbohydrate (g) 13, Protein (g) 7, Percent Daily Values are based on a 2,000 calorie diet

    Next week, I'll include more seasonal recipes for spinach, winter squash, pumpkin and more.

    In the meantime, to learn more about eating locally, I recommend Kingsolver's book (of course) - as well as the Animal, Vegetable, Miracle website, which offers tons of online resources to learn more about the benefits of eating locally/seasonally and how to incorporate more seasonal/local food into your diet. There is also information on how to find local foods, and the recipes from her book (which I can't wait to try!).

    For us Mainers, I also recommend the Get Real Get Maine website, which has searches for specific food items, listed by county; pick your own farms; farmers markets; CSAs (community sustained agriculture farms that sell "shares" of their produce) and more.

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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    Friday, September 19, 2008

    The Other Side of the Glass

    I watched a very, very powerful film trailer, called The Other Side of the Glass, the other day and I want to invite you to view it too. You can also view it directly from Janel's (the film's writer/producer) blog, along with information on how to purchase the extended trailer and her story of making the film so far. I just purchased the extended trailer myself & can't wait to view it - and offer it as a resource for my clients.

    This trailer is about dads and moms and babies: how babies are thinking, feeling creatures from the time of birth (and before), and as such, deserve dignity and respect during the birthing process; how dads can be guardians of the birth space, for mom and baby; how birth is now and how it could be.

    I've noticed that families who are expecting their first baby sometimes have a certain attitude about experiences they see or hear that challenge the decisions they're making for their baby's birth: this _____________ won't happen to me. It happens to other people, but it won't happen to me because ___________________.
    **I** won't be one of the women who have a cesarean for failure-to-progress (the reason for 40% of primary cesareans).

    **MY baby** will stay with me for skin-to-skin bonding after the birth (according to the Listening to Mothers II report, 39% left their mother's arms during the first hour for "routine, non-urgent care").

    **MY hospital/doctor/midwife** will treat me like an individual, offering care specific to my body, my baby and my birth.
    Turns out that many caregivers and hospitals have certain routines (routine IV, routine continuous electronic fetal monitoring, routine epidural), and they have varying degrees of willingness to deviate from that routine. According to the Listening to Mothers II report, "Each of the following interventions was experienced by most mothers: continuous electronic fetal monitoring, one or more vaginal exams, intravenous drip, epidural or spinal analgesia, and urinary catheter."

    There are certainly doctors, midwives, and hospitals who encourage women to participate in their care, and who treat women and their babies as individuals, with respect and dignity and patience. But, unfortunately, not all do. Even if you personally like your provider, or he/she is "terrific" accoring to your friends, or if he/she is the closest, or has rights at the newly remodeled hospital birth center: none of these things guarantee that dignity, respect, patience and/or treatment as an individual. According to the Listening to Mothers Survey II, 26% of women chose a care provider on family/friend recommendation; 26% for its nearby location; 47% because of their insurance plan. Only 18% chose a care provider because (s)he was a good match with the mother's philosophy.

    I encourage (implore?) moms and their partners to remove any blinders and truly investigate whether or not the provider/birth place that they've chosen truly fits their needs. Ask challenging questions! Ask yourself, each other, your care provider(s), your hospital/birth center. Assuming (hoping?) that it won't be you, or your partner, or your baby has nothing like the impact of asking questions, communicating preferences, doing the research, and making informed decisions. Nothing guarantees a perfect birth experience, but doing this kind of work ahead of time has obvious advantages for moms, dads, and babies!

    Wondering where to get started? I wrote two posts that directly address these issues, both full of book and website recommendations that might help: "Pregnancy and Birth: What Are My Choices" and "Choosing a Care Provider and Birth Place".

    Other resources to check out, especially for partners: book review on Don't Just Stand There, and one of the best books for moms & their partners: Penny Simkin's The Birth Partner. Pam England's book Birthing From Within also has some good suggestions specifically for dads and birth support people, as well as some thoughtful & practical information for dads on her website.

    Good luck on the journey!

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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    Friday, August 22, 2008

    Questioning Safety: Hospital, Birth Center, and Homebirth

    Where is it safe to birth your baby? Is the hospital the safest option? The only safe option? Are planned homebirths safe? Is it safer to have an OB/GYN (obstetrician, who is a doctor) as a care provider, or are CNMs (certified nurse midwife) and CPMs (certified professional midwife) safe options too?

    First, I want to share a quote by Harriette Hartigan (midwife/photographer) that is commonly heard in the birthing community, "Birth is as safe as life gets". I wonder what the context of this quote originally was... to me, it suggests several important ideas:
  • Birth is a part of life. This is easy to forget when, in our culture, birth is so removed from life - usually taking place in the hospital, with only the birthing mother, her partner and maybe a female friend or relative. Very, very few of the pregnant mamas who take my classes have ever seen a real birth - human or animal. Contrast that experience with the one pictured below, where you can see birth really is a part of life:



  • While birth is safe, there are no guarantees. And that, I think, is the hardest thing. We've all heard horror stories, and I feel no need to put additional details in people's heads. Thankfully, in our country, most births conclude with a healthy mother and healthy baby (not that there isn't room for improvement!). But there are times, so sadly, when despite careful attention to mother and baby, something goes wrong. Sometimes with a warning, sometimes not. Even sometimes when the mother has had excellent prenatal care, an uncomplicated pregnancy, and highly qualified, experienced birth attendants. As sad as that is - it's life. People die. The struggle is to avoid medicalizing the experience of so many motherbabies in the name of preventing one or two deaths. Because doing that - continuous fetal monitoring, or not laboring at all and giving birth via a cesarean at 39 weeks - actually carries many, many more risks for mothers and babies, as well as the health of their future children. The struggle is to avoid lawsuits where something bad happens despite excellent care. This tendency has had the unfortunate effect of justifying doctors who practice defensive medicine: monitoring continuously for the paper trail, and the many cesareans that happen "just in case", because doctors know they will be sued over the cesarean they didn't do, not the one they did.

  • Choices we make can make birth safer. I wear my seat belt, and buckle my kids into booster seats. We wear life jackets. We get consistent check-ups by experienced, well-trained care providers. We eat lots of fruits and vegetables and whole grains etc. & etc. & etc. My husband and I make choices for ourselves, and for our children, that - to the best of our knowledge - enhance and protect our healthy bodies. Women can make choices for their birth experience that enhance and protect their bodies and their babies.

    One last point - while I wear a seat belt, I do still drive a car. I know that accidents happen, but that doesn't change my decision to drive on a daily basis. While I try to minimize the chance that something catastrophic happens while we're in the car, I understand that driving safely, while I'm not too tired, in a safe vehicle that gets routine maintenance, doesn't completely protect me. There are things that happen where no blame can be assigned - they just happen.
  • I believe birth is very similar to driving a car. Safe most of the time, even when people don't make the best choices; safest, but not perfectly safe, when they do. So, back to the original questions: where, and with whom, is it safe to give birth?

    Book after book that I've read reassures that quality care in a well-prepared home or quality birth center is as safe if not safer than a hospital birth attended by a doctor. Here are some excerpts that I found particularly helpful:

    From the Sears' Birth Book on birth center births, "In 1989 the New England Journal of Medicine reported a study of nearly twelve thousand women admitted for labor and delivery to eight-four free-standing birth centers in the United States. The study concluded that birth centers offer a safe and acceptable alternative to hospital births for low-risk women. The cesarean-section rate for the women in the study was 4.4 percent, far below the national average. There were no maternal deaths, and the neonatal death rate was well below average" (Sears 42). To find a birth center near you (as well as lots of other great information), check out American Association of Birth Centers . For questions to ask and things to think about, visit Childbirth Connections "Tips and Tools for Choosing a Place of Birth" page.

    While discussing homebirth, the Sears' write: "In 1900 fewer than 5 percent of births took place in hospitals. This increased to 75 percent by 1936, and by 1970 approximately 99 percent of mothers delivered in hospitals. But is this progress? Illustrating the differing perceptions of home birthing are these two mothers discussing their birth choices: 'You are brave to have a home birth,' said a concerned mother. 'You are brave to have a hospital birth,' replied the other" (43). They go on to discuss the safety of home births this way, "both sides of statistics to support their view. The people in white coats boast that the chances of a mother dying in childbirth was much higher in 1935 than in 1980, and that this is the result of technology available only in the hospital. Home-birth supporters argue that there is no reason to believe that there is a cause-and-effect relationship between birth in the hospital and lower mortality rates. Today's women have better access to prenatal care and more is known about safe birthing. Antibiotics are available to treat infections, and most aspects of health are better now than they used to be. Hospitals actually have higher mortality rates than home births, in part because mothers with the highest risk of life-threatening medical problems deliver in hospitals. Statistics that show poor outcomes in home births are equally misleading since these studies lump all out-of-hospital births together, whether they're planned, properly attended home births or involve foolhardy couples with no prenatal care doing it on their own [or happen by accident, at home or en route, mom has the baby earlier than anticipated]" (46).

    The more recently published book, Having a Baby Naturally, comes to similar conclusions. O'Mara asks "Which birth environment is safest? Surprisingly, home births, birthing in birthing centers, and hospital births are equally safe. Recent studies show definitively that there is no improvement in outcome, for mother or baby, in hospital births as compared to those that happen at home or in a birthing center . . . in fact, there is an indication that outcome is actually slightly better in low-risk births out of the hospital" (34). She goes on to explain that "home births, and births in birthing centers, have enjoyed a recent renaissance in the United States. However, there is still a lingering societal question about the safety of such births, and most women continue to go to the maternity ward of the hospital where their caregiver practices. Choosing to do something different may take real courage, as friends and relatives may be particularly concerned about the safety of your choice" (35).

    There is a great website that offers answers to many of the "What if" questions friends and family might ask. It does have some loud music that accompanies it, but if it bothers you, just mute it.

    The Home Birth Reference Site has some terrific information too, on the safety of homebirth, as well as home birth stories, reasons why people homebirth, how to plan a homebirth, more answers to "what if?" questions and other useful information. The North Carolina Homebirth website provides additional information on why homebirth, how to plan and prepare, and more birth stories.

    A few additional links include:
  • Citizens for Midwifery document comparing WHO recommendations, CIMS suggestions, and the reality of birth in the US as of 2004.

  • An article by Pam England (Birthing From Within), "No Place Like Home".

  • Childbirth Connections offers excellent information about the different care provider options, as well as information on questions to ask yourself in making a choice, and questions to ask during the interview process.
  • Finally, I want to mention that the United States is not the standard-bearer for safety for mothers and babies. Using 2008 statistics, the United States (6.3/1000) currently ranks BEHIND the following countries for infant mortality rates: South Korea (5.94/1000), Cuba, Isle of Man, Italy, Taiwan, San Marino, Greece, Monaco, Ireland, Canada, Jersey, New Zealand, United Kingdom, Gibraltar, Portugal, Netherlands, Luxembourg, Guernsey, Liechtenstein, Australia, Belgium, Austria, Denmark, Slovenia, Macau, Isreal, Spain, Switzerland, Andorra, Germany, Czech Republic, Malta, Norway, Anguilla, Finland, France, Iceland, Hong Kong, Japan, Sweden, and Singapore (2.3/1000).

    There is something many (but not all) of these other countries have in common: universal access to prenatal care, and more support and use of midwives and out-of-hospital births.

    Marsden Wagner's book Born in the USA offers some interesting critiques and comparisons of care in the US vs. care in other developed countries. He writes, "Whenever I discuss home birth with obstetricians in the United Sates, I need only ask, 'What about the Netherlands?' to see their faces fall. The Netherlands has a long tradition of planned home birth. As recently as thirty years ago, half of all births in the Netherlands were planned home births. The percentage fell to one-third in the 1980s, but the rate has been climbing for the last ten years and is now more than one-third - 36 percent. The Dutch do not have significantly more women and babies dying around the time of birth than other Western European countries, and they have lower mortality rates than the United States does" (144).

    Later he also discuss birth in Denmark: "Denmark also guarantees a choice of place of birth to all Danish families. Like every other highly industrialized country except the United States, Denmark also has a national health care system. In Denmark, midwives attend all low-risk births either in the hospital or in the family's home . . . The home birth rate varies within Denmark (it is around 10 percent of all births in some districts), and Denmark's mortality rates for birthing women and newborn babies are among the lowest in the world" (193).

    Wagner also explains that "In some areas of Western Europe and Scandinavia, a low-risk pregnant woman can choose a small group of midwives who share a practice. The woman will usually get to know all of the midwives during prenatal visits over the course of her pregnancy, and when she goes into labor, one of them will come to the home or hospital and assist for the entire time, even if the labor is thirty-six hours long. This allows the woman to receive one-on-one continuous care with a known midwife - so this scientifically proven ideal scenario is not pie in the sky, but quite feasible. All those countries in Western Europe and Scandinavia where midwives handle prenatal and birth care for low-risk women exclusively have lower mortality rates for birthing women and their babies than the United States does" (198).

    He goes on to use a few more examples - "a resurgence of birth houses in Japan began [after the Americans left post-World War II], and more and more midwives are leaving hospital practice to work as community midwives in birth houses. This Japanese experience confirms what we have seen in the United States, that in the end, attempts to eradicate midwifery are not successful. In every society, there will always be midwives working to maintain women's freedom to control their own reproductive lives, and there will always be women who will avail themselves of midwifery services" (199).

    And, "In New Zealand, the maternity system is similar to Scandinavia's, but a woman having a low-risk pregnancy can choose either a midwife or a family physician to provide her prenatal and birth care" (Wagner 199).

    Each of these countries have significantly better outcomes for babies: New Zealand (4.99/1000), Netherlands (4.81/1000), Denmark (4.40/1000), Japan (ranked third, at 2.80/1000), and Sweden (ranked second, at 2.75/1000).

    Another famous champion of birth, Barbara Katz-Rothman, explains that "Birth is not only about making babies. Birth is about making mothers - strong, competent, capable mothers who trust themselves and know their inner strength." Safety concerns should not limit women's options for where they give birth, and with whom. Women should be able to choose the options that feel safest to them - hospital or birth center or homebirth, obstetrician, family physician, or midwife. All care providers should encourage women to trust themselves, to participate in decision-making, and treat each birthing motherbaby as individuals. Your baby has only one birth experience; you will probably only have one or a few birth experiences - and each one is an amazing opportunity for growth and joy.

    There's a quote in Our Bodies, Ourselves For the New Century that I share with my clients: “When women go to caregivers for checkups, they should walk out from every visit feeling ten feet tall. Every site of care and style of care, no matter who gives it, ought not only give surveillance but should educate and empower, should enhance every woman’s feeling of ability to do what she’s doing well” (451). That sums it up beautifully for me, and I hope this blog entry helps you explore the options for care that surround you so that you enjoy education and empowerment on your journey to motherhood.

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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    Thursday, August 14, 2008

    Choosing a Care Provider & Birth Place

    In many parts of the United States, women can choose between a hospital birth, a birth center birth, or a homebirth; they can choose an OB doctor (obstetrician), a FP doctor (family practice), a CNM (certified nurse midwife) or CPM (certified professional midwife). Different states have a variety of legal options, and even in the states where homebirth isn't explicitly legal (or is explicitly illegal) there are "underground" networks of midwives. To find out more about the status of midwifery in your state, visit the Midwives Alliance of North America (MANA) chart.

    In Maine, there is currently one birth center, The Birth House, located in Bridgton, and run by Birthwise Midwifery. To find a birth center outside of Maine, try searching the American Association of Birth Centers Find a Birthcenter page - though there may be a birth center in your area that is not accredited.

    There are also quite a few CPMs who attend homebirths in Maine. For more information on finding a midwife to attend your homebirth, you can visit the Birthing Your Baby Local Resources page or the Midwives of Maine site. To find a CNM for a hospital birth, visit the Find a Midwife section of the American College of Nurse-Midwives website.

    If you're interested in learning more about your options, there are lots of websites and books to help you explore.

    BOOKS

    The Birth Book(1994), by William Sears, M.D., and Martha Sears, R.N.
    The Sears' dedicate a whole chapter, "Choices in Childbirth" to discuss the many options that are available to birthing women. There is in-depth information about choosing a birth team (who your care providers will be), questions to ask during the interview process, choosing labor-support, choosing a birth place, and choosing childbirth education classes.

    I especially like their "Sample Prenatal Interview List":

    "While quizzing your prospective doctor [or any care provider], be sure you know where he or she stands on these important topics:
  • labor management
  • pain management
  • natural childbirth
  • walking during labor
  • improvising various labor and birth positions
  • electronic fetal monitoring: continuous, intermittent, telemetry, none
  • labor-support persons: professional assistant, baby's father
  • episiotomy: how often performed, alternatives
  • forceps and vacuum extractors
  • birth plans
  • criteria for cesarean birth
  • vaginal birth after cesarean
  • use of water during labor [or birth]
  • epidural anesthesia
  • childbirth classes
  • pregnancy health: exercise, nutrition, weight gain, etc.
  • hospital affiliations
  • routine prenatal screening tests
  • call schedule (group or solo practice; birth philosophy of covering [providers])
  • vacation schedule (in case it's during your due date)
  • fees, insurance plans (usually handled by office staff)
  • What would birth look like in this country if most women asked some questions about their care providers philosophy before or during the first visit. What would happen, I wonder, if women no longer accepted vague reassurances when they asked about cesarean birth rates? What would happen if women flocked to care providers who allowed eating and drinking, who encouraged women to give birth in a position that was comfortable for her, even if it was not on the bed, even if it was in a tub!

    The reality, though, is that, right now, most women do not ask questions about the routine care practices of their care providers. It's not that there are wrong answers (well, vague or misleading or dishonest answers are wrong) - the philosophies of the birthing woman/family and the care provider either match, or they don't. But if a woman doesn't find out until the birth that the hospital's routine care involves an IV, and the care provider will harass her if she doesn't submit to one, or that the care provider does not believe that a natural tear is better than an episiotomy and so routinely preps and performs them, even when a woman states that she does not want one - that's too late to make a change, obviously.

    Unfortunately, I'm not exaggerating. I had a client who was really afraid of needles, and was very concerned about a routine IV. She didn't want one unless absolutely necessary. I encouraged her to ask her care provider what her options were regarding an IV, given her personal fear of needles. My client had the conversation with her care provider, who said - "If you don't have an IV, your baby might DIE!!" and who went on to explain how important she believed a routine IV is to the care of mothers and babies. My client was horrified by the scare tactics used by the care provider, and since she found out in plenty of time (second trimester) that her philosophies didn't match her care provider's, she changed practices (yay for her!).

    Another key point in the Sears' list is knowing the call schedule of your provider. So many of my clients are surprised to hear that the providers in the office alternate - if there are four providers on a call schedule, a birthing woman has a 25% chance of being cared for by her primary care provider during her birth. There are ways to make this more palatable, by meeting all the care providers in the practice, and knowing that they have similar philosophies about routine care, for example. But here's another personal example - my sister in PA went to a well-known OB/CNM practice, who asked women to meet all the possible care providers who might attend the birth - there were something like ten. So much for continuity of care! Yes, she had a ten-minute appointment with each provider, but did she really get to know any of them? No. For her second baby, she went to a birth center - for that reason and many others.

    Another section in the Sears' chapter on choices that I really appreciated personally was their discussion of in-hospital vs. out-of-hospital classes. Here's part of it:
    "Ideally, schools should prepare students for the real world in a variety of circumstances. In-hospital classes prepare you for the birth policies of that hospital. On the other hand, out-of-hospital classes have the advantage of describing a variety of birth choices so that you can prepare for the birth you want - but one that the hospital may not be willing to deliver. Ideally, birth place, birth attendant, and childbirth educator should all share the same birth philosophy, but where this is not the case, a good childbirth class should help you understand your doctor better and enable you to work with him or her and the hospital staff to achieve a birth that is safe and satisfying. Look for an instructor who emphasizes flexibility and good communication between parents and professionals" (51-52).
    Sometimes people wonder why I don't teach for a hospital, or why anyone would need or want to take a class that wasn't provided by the hospital. I like the freedom to teach what I believe is most important; I like to teach about making informed choices, and encourage my clients to think of themselves as consumers, not as "patients". I think there is value to being outside of "the system", free from any influence other than my clients' best interest. My philosophy isn't that all women should give birth one way, or another - instead, I encourage mothers/partners to think about what they want in the birth experience, and to communicate with their care providers. Birth is a once in a lifetime experience - even if a woman has several babies - each birth is that baby's only birth. I do encourage flexibility; though we talk about birth plans, we also talk about living in the moment and doing "the next best thing" if the first best thing doesn't work out, which we all know sometimes happens. Birth is a part of life! Plus, I have small classes (one to four couples), I can work my schedule to accommodate people who call me a month before they're due, or who work at night, etc., and I offer unlimited telephone and email support. It's a good deal for everyone!

    Anyway, back to resources... Next up is Mothering Magazine's Having A Baby, Naturally (2003), by Peggy O'Mara. She also offers an entire chapter on "Making Birth Choices - Choosing Your Place of Birth and Your Birth Attendant". O'Mara lists "reasons to choose" and "reasons not to choose" to birth at home, a freestanding birth center, or at a teaching/large hospital; she also mentions a few other choices like smaller hospitals, alternative birth centers within hospitals, and water birth. There is an explanation of the typical care provided by midwives, obstetricians, and family physicians.

    O'Mara offers several considerations at the beginning of the chapter to help families assess which birth setting might work best for them, including information on safety and cost. She goes on to write:
    "A more important 'cost' to assess, however, has to do with the effects that birth trauma and general hospital-style treatment have on the bonding between a mother and her child. High levels of stress incurred in hospital settings can seriously affect a parent's ability to function well in the difficult weeks after birth. Many women agonize about their negative birthing experiences, including unnecessary interventions and unkind or patronizing treatment, for months or even years after birth. Since birth sets the stage for your early parenting experiences, it makes sense to avoid anything that increases stress for you or reduces your ability to bond with your child. Making a decision on where your baby's birth will take place is second in importance only in making the decision to become parents in the first place! Take time to explore all the options you have" (35).
    The "Which One is Best for Me?" list of considerations is also helpful:
    "There is no formula that can help a mother-to-be decide what type of care provider will be best for her. That is because every provider is different, even within such different categories as 'obstetrician' and 'midwife.' Some obstetricians are very open to the idea of a birth with minimal or no interventions [like my daughter's birth, born after minimal procedures while I squatted on a birth stool, the OB hovering to play catch on the floor - it was great!]. Some midwives may practice in hospitals and be much more likely to rely on technology than others [my sister, who had her membranes sweeped, water broken, Pitocin, Nubain etc. & etc. had a "medwife" - a medically-minded midwife].

    For this reason, it is necessary to interview several candidates before making a final decision. It also helps to know that no decision is absolutely final. While it may not be ideal to change birth attendants midstream, it is better than working with someone you find you are unhappy with. To decide who to interview, consider these points:

  • Check to see if this person is able or willing to attend a birth in the location you have chosen. Most doctors will not attend home births, so this will narrow your field automatically.
  • If you want an attendant who will be with you throughout most of your labor, you should consider using a midwife. Obstetricians will generally only be with you during the final stages of labor, checking on you intermittently beforehand. You will be attended to by labor nurses for the most part.
  • Know that midwives spend significantly longer on regular checkups than most doctors do, from twenty to forty minutes per visit. Again, there are always exceptions to this.
  • Cesarean section rates, on average, are much lower for midwives than for medical doctors. In addition, rates of successful VBACs (vaginal births after a cesarean) are better for midwives. Certified nurse-midwives, for example, have a rate of 11.6 percent for C-sections and 68.9percent for successful VBACs. The national average is, respectively, 23.3 percent and 24.9 percent [much higher national average C-section rate now, hovering around a third of all births].
  • Choosing a male ob/gyn, rather than a female increases your chance of ending up with a cesarean section by 40 percent.
  • Using a family practice physician can be advantageous if this is a person who is already very familiar with you and your family. Perhaps this will be the same person who is going to care for your newborn" (42-43).
  • Finally, O'Mara suggests questions to ask during the interview process, and some pointers on how to communicate effectively with your care provider.

    Another great book resource is Henci Goer's The Thinking Woman's Guide to a Better Birth (1999). She includes three separate chapters on choices for care during pregnancy and birth, "Professional Labor Support: Mothering the Mother", "Obstetricians, Midwives, and Family Practitioners: Someone to Watch Over You" and "The Place of Birth: Location, Location, Location". There is some very solid information in these chapters, including interview questions, lots of lists of pros/cons, some advice on what to do when provider choice is limited, either by insurance or by medical conditions or mother's location, a thorough comparison of birth sites that is really terrific, and more.

    There are some great "reality checks" throughout these chapters, including the following in the labor support chapter: "If you are a first-time mom planning a hospital birth, you're probably assuming that your nurse will shepherd you and your partner through labor. Ever-present, she will comfort and ten you. I suppose it happens occasionally, but not often. Studies show that the average labor and delivery nurse spends fifteen minutes of her eight-hour shift [italics mine] offering physical comfort measures, providing emotional support, or advocating for her patients. Another study showed that time with laboring women didn't increase even with a group of nurses who acknowledged the importance of labor support and when that was the study's intent. Meanwhile, with staff cutbacks the order of the day, even the best-intentioned nurse has not time to labor-sit" (177).

    Hopefully you have not heard responses like the ones listed below from your caregiver. If you have, Henci Goer suggests, “these behaviors will tell you that you have the wrong person, someone who wants to coerce rather than convince you” (196). Here are the “red flags” listed in The Thinking Woman’s Guide to a Better Birth:
    • Scare tactics. “We can do that – if you don’t care what happens to the baby.” “Which would you rather have: a nice experience or a healthy baby?” You can have both. In fact, the things that make a nice experience also make for a healthy baby.
    • Anger. “And where did you go to medical school?” “I can’t take care of you if you don’t trust me.” Of course you should trust your caregiver, but the trust must be earned.
    • Ridiculing your concerns, desires, opinions, or competency to participate in decisions about your care. “I see you’ve been reading those women’s magazines.” “You want natural childbirth? I think that makes about as much sense as natural dentistry.”
    • Patronizing you. “Don’t worry about a thing; just leave everything to me.”
    • Vagueness. It’s a bad sign when you can’t pin a caregiver down enough to get at least ballpark estimates of personal statistics such as cesarean rates . . . It’s also bad when the caregiver says you can do anything you want during labor and won’t specify what situations might preclude that" (196-197).
    Finally, there are some great suggestions regarding choices for provider and location in The Big Book of Birth (2007) by Erica Lyon, who was the education coordinator and administrative supervisor at the Elizabeth Seton Chilbearing Center in NYC. A few of suggestions in this chapter include:
  • "Check if your practitioner's belief system matches yours. There is a range of how practitioners 'manage' or 'care for' women, from authoritarian to nurturing, of how available and accessible they are. Most of us know whether we want someone more authoritarian who can tell us what will happen [debatable, I think, if anyone can tell us for sure what's going to happen, other than a baby is going to come out, some way or another!] and what to do when we're birthing our baby, or someone who is more nurturing and gives us more personal responsibility. Asking questions to gauge if this is a good match so that you are relaxed and feel you can trust your practitioner in labor is very important . . . If you think your practitioner is eroding your confidence, causing unnecessary concer, or looking for problems where they don't exist, then changing may be a good course of action" (269).
  • "Think outside the bassinet. By this I mean look at models of care around the world that get good (better than the U.S.) outcomes and try to model your care after that [planning to discuss this in my next post]" (270).
  • Stop reading What to Expect When You're Expecting, or any book that has headlines like "Warning" or "Danger". The anxiety such a book produces is not helpful . . . to normal pregnancy and produces a lot of unnecessary guilt and concern [time enough for that after the baby is born & you're parenting - hahah!]. No one can tell you what to expect, only the various paths and options and how all of these can be relative at times" (270).
  • "Take a moment and be honest about your concerns and fears. Understanding our emotions and psychology does not necessarily give us more control over a situation but it does help us cope and identify what we truly need" (271). This is so important! I ask all my moms to ask themselves "What is most important thing your care provider could do during the birth to help you?" and they think for a minute and come up with an answer. Then I ask - "Have you talked to him/her about this?" and as of yet, every single mother has said, why no, I haven't. So there it is: care providers cannot read minds. And sometimes, we ourselves aren't sure what is most important if we haven't taken some time to think about it; only after the fact can we identify something that could have been done differently to improve our experience. So, I encourage women to do a lot of reflecting themselves, and then have some honest conversations with their partners and their care providers about the kind of care and support they want for the birth!
  • And the last one I'll mention from this terrific section, "Give some thought about what might make this more manageable for you. In which areas do you need reassurance? . . . Labor and birth are challenging no matter how we do it, but what can you put in place for yourself that will give you confidence and help you go through it . . . When we take care of the mother, we take care of the baby. (The baby is still part of us at this point!) As I write this, I can hear the 'reactive' voice to this statement: 'How selfish! Labor is not about the woman, it's about a healthy baby!' Yes, at the end of the day absolutely true; however we women know that and we will make decision that help us cope and meet that objective. (To imply otherwise is a wee bit patronizing.) . . . with information and support, we move through labor knowing that we are doing what we have to, what we believe in, what we are capable of given all the variables - and that it is okay" (272).
  • Two other very interesting books about care during pregnancy and birth in the United States are Pushed: The Painful Truth about Childbirth and Modern Maternity Care by Jennifer Block and Born in the United States: How a Broken Maternity System Must be Fixed to Put Women and Children First, by Marsden Wagner. I'm sure there are other books that I'm not mentioning - if you're thinking of one that has helpful information on choosing a care provider or the birth place, please leave it in the comments!

    WEBSITES

    The excellent organization Childbirth Connection offers an entire section on Choosing a Caregiver, highlighting the importance of making an informed choice about, what the different care provider options are, and other insightful information. I appreciate that they also include reasons that are "insufficient" for choosing a caregiver:
    "It is not wise to select a caregiver solely because:
  • that person practices near your home or workplace — convenience is nice, but you may need to travel further to find the right person
  • you know someone who worked with that person — even if recommended by a friend or relative, you will want to be sure that a maternity caregiver's style will meet your needs and values and reflects the best available research
  • that person is a woman, or a man — if you have a preference for caregiver gender, you will want to be sure that that person's maternity philosophy and style of practice match well with your needs and values and with the best available research
  • that person has been your provider for well-woman or primary care — you will want to learn about that person's maternity philosophy and style of practice before making your decision."
  • The next pages offer information on midwives and obstetricians and family physicians, as well as "Best Evidence (a discussion of studies done about differences between midwifery and obtetric care)," "Tips & Tools" (interview questions, etc.), and "Resources" (links to helpful resources).

    Childbirth Connection offers a similar set of resources about Choosing a Place of Birth: a review of the options, best evidence, tips & tools, and resources.

    Childbirth Connection offers many more terrific resources, including an important free .pdf called The Rights of Childbearing Women, as well as a free .pdf download of the Listening to Mothers surveys (interesting to get a picture of what birth has been like in the United States for the past few years), and the amazing resource A Guide to Effective Care in Pregnancy and Childbirth - buy it on Amazon for a lot of money or read the sections that interest you here for free! A Guide to Effective Care "is an overview of results of the best available research about effects of specific maternity practices. The full text of the current edition (Oxford University Press, 2000) is available on this website [linked chapter by chapter] courtesy of the authors: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett and Justus Hofmeyr." I could keep highlighting useful information for their site like the pregnancy pictures and stages of pregnancy etc. & etc. but really, go check it out - amazing resources!

    Coalition for Improving Maternity Services (CIMS) has some useful downloads on its site, including information the Mother-Friendly Childbirth Initiative with links to "Evidence Basis for Mother-Friendly Care" and "Having a Baby? Ten Questions to Ask" and other helpful documents.

    UNICEF and WHO joined together to create the Baby Friendly Hospital Initiative, with an explanation of what a "Baby Friendly" label means, and a list of "Baby Friendly" hospitals and birth centers. In Maine, as of July 2008, we have Central Maine Medical Center in Lewiston, Maine General Medical Center in Augusta and Waterville, Miles Memorial Hospital in Damariscotta, and York Hospital, in York.

    Citizens for Midwifery offers a chart Ideals vs. Reality in U.S. Births, which compares the WHO recommendations, CIMS recommendations, and U.S. reality as of 2004.

    So that's my highlight of information that could help a mother (and her partner) choose the kind of care provider and birth setting that will work the best for them, as well as information on interviewing/choosing a specific provider and setting. The most important things to remember, in my opinion, are that you do have choices, and that the choices you make can have a very significant impact on your birth experience. If you're not happy with the care you're receiving or the setting you initially chose - please consider reviewing your options. One of the statements that is repeated over and over in all the books and sites I include in this entry is the importance of making choices about provider and setting that are right for you and your family as you get ready to meet the new little person growing inside of you.

    Happy exploring, and best wishes for making the best choice possible!

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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