Growing in professionalism

I’ve been a certified professional birth doula for over 3 years now, and my goal for this Fall is to increase the professionalism of the business side of my, well, business. Being a doula is such a privilege and honour that it has been easy for me to overlook the fact that actually I own a business! Step one in this process was applying for an LLC. Step two will be introducing new features like a logo and ability to pay for services through this website and by credit card. Watch this space!

Animal behaviour

I recently worked with a lovely lady who, at our postpartum visit, told me that she was embarrassed by how she had ‘behaved’ during the last few minutes of her (glorious, beautiful, moving) birth. She said that she had felt out of control, like an animal. Two things struck me from this comment and I wanted to share them here.

First, and this sounds like a bit of a no-brainer, we experience our own births differently from our support team. So many times my ladies have remembered screaming or shouting at particular points in their births – at transition, or at starting to push, or at crowning (especially at the notorious ‘ring of fire’). And yet, in my experience of their birth story (which, of course, is theirs to write and tell) there is no screaming or shouting – or very little. There is almost always vocalising of some sort: intense moaning, repetition of a mantra, or expression of a certain ardent desire to be done with the whole thing. But I have actually very rarely heard a mama scream in labour. And yet I have several mamas who remember screaming, even who apologise for it. The only way I can account for this disparity is that we experience birth distinctly inside our own heads, away in labour land, in a manner that trumps the outward physical expression of whatever is going on internally. It is such a powerful experience that it writes a physical memory of an emotional response. This is true of my own births too.

Second, I really believe that that out of control, ‘animal’ feeling, is almost essential to birthing, and certainly to an unmedicated vaginal birth. It’s what Ina May Gaskin refers to as the ‘inner ape’ as she calls on women to ‘Let your monkey do it’ (Birth Matters: a midwife’s manifesta, 2011, p37). It’s a primal, overwhelming negation of intellect and its replacement with instinct and pure physicality. It’s so important that labour can slow or stall if the intellectual brain kicks back in for some reason – for example, if someone turns on the lights in a dark room, or if an unfamiliar person comes in. Some women embrace this finding of a different inner self while some women fight against it, uncomfortable with the loss of inhibition that goes along with it. Some revel in its freedom; others recall it with mortification. In the modern western world, giving oneself over to being out of control, operating on instinct, surrendering to the process of birth – it is really hard. It is a reminder that we are mammals, and that just as cats and dogs seek a quiet, undisturbed place to birth, so too do we need a place where we feel safe, private, and cared for. A place where no one will tell us to be quiet or to stop moving. A place where a lover or doula or nurse or midwife or doctor will say quietly instead ‘yes that’s it, that’s perfect, listen to your body, you are so strong, you are so beautiful, yes yes yes.’ A place where one or all of those people help us float gently back to ourselves, newly anchored by the warm, wet, vital being who has arrived earthside. It’s a place where there is no shame in or judgment of instinctive, animal behaviour, but rather a celebration of the raw and beautiful power of it: what it takes to bring a baby in.

Thoughts on the CDC statement

In the land of instant information and where everyone has a blog (like me – ha!) it can be hard to know where to turn for reliable, trustworthy information. This fact is especially true for any hot-button or emotional topic, like circumcision. If you google the word, you get hundreds of thousands of hits, with tones varying across the whole spectrum from dry academic research to heated parental debate to the frankly weird. From my perspective, even the results that seem to be trustworthy can be tricky, because, as with everything involving statistics and medical research, numbers can be read many different ways, and research can be spun. The two key lines of distinction that need to be drawn in reading research and making decisions are first, the difference between relative and absolute risk, and second, the difference between causation and correlation. I’ll come back to this point below. I am rather reinventing the wheel here – all the links I posted last time contain this information. The absolute best thing to read is by an Oxford University ethicist named Brian Earp.

One response to my previous post on circumcision raised the current stance of the American Academy of Pediatrics (AAP), which reads as follows:
‘Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmision of some sexually transmitted diseases, including HIV.’ You can read the short statement here and the full technical report here. This week the CDC has come out with a very similar statement, claiming the same ‘benefits’.

As a dear friend once asked me, ‘What mother wouldn’t want to protect her son from UTIs and especially cancer and HIV?!’ The question to ask is, DOES male infant circumcision protect against these things, and if so, how much?

Let’s start with UTIs. Certainly some studies have shown that circumcision reduces the risk of UTIs (although other, more recent studies have not) – but let’s look at the numbers. According to one study from 1985, of every 1000 boys who remain intact, 7 will be admitted to hospital for a UTI before the age of 1 year old. Of every 1000 boys who are circumcised, 2 will be admitted to hospital for a UTI before the age of 1 year old. We could look at those numbers in various ways: circumcision reduces the risk of UTIs by more than two-thirds! Or we could look at the absolute risk: 7/1000 is 0.7%. Circumcising reduces the chance of a hospital-bound UTI from one very tiny number to another very tiny number. We can flip that number around and look at it from the other side: of every 1000 boys circumcised, 993 would never have needed hospitalisation for a UTI in any case. Or you could look at it another way, and say that for every hospital-bound UTI prevented by this choice, about 141 circumcisions were performed needlessly (this is the ‘number needed to treat’ to achieve the goal). This point also highlights what we mean when we say that the health benefits of circumcision are potential rather than actual – they prevent (possibly) things that might happen. Before moving on we can also note that girls under the age of 1 have approximately as many UTIs as boys. We treat them with antibiotics.

The second health benefit listed by the AAP is the prevention of penile cancer. Let’s look at the numbers. Of every hundred thousand men who are intact, 3 will develop penile cancer. Of every hundred thousand circumcised men, 1 will develop penile cancer. So, we could indeed say that circumcising a baby boy reduces his risk of penile cancer by two-thirds. Or we could flip the numbers and see that 99,997 circumcisions were performed needlessly. Penile cancer is so incredibly rare that, in fact, more men die of breast cancer in the United States every year than of penile cancer. About 1 in EIGHT women will get breast cancer at some point in their lives. We do not remove the breast buds at birth.  This argument for performing circumcision is so ridiculous that decades ago the American Cancer Society actually asked the AAP to stop using it  and today the American Cancer Society recommends good hygiene and not smoking as far more effective methods of risk reduction.

Finally, the AAP suggests that circumcision can reduce the transmission of STDs including HIV. The link with HIV came out of three main studies performed in Sub-Saharan Africa about ten years ago. Adult men who chose (please note it was a choice) circumcision were found to have about 60% protection against contracting HIV. However, many scholars have found problems with these studies, mostly around the difference between correlation and cause. The men who chose to be circumcised had more clinic visits and thus access to lectures on safe sex and condoms than the men who did remained intact, for example. The studies were stopped early. The ‘protective effect’, even if considered ‘real’, is still only 60% (and the absolute reduction was just 1.3%), meaning that even the circumcised men should wear condoms to avoid infection or infecting others. We can also draw two national comparisons. Most HIV transmission in Africa is by male-female sex. Most HIV transmission in the USA is by male-male sex and contaminated blood (like sharing drug needles) – circumcision does not protect against these means of transmission and the risk of female to male HIV transmission in the USA is incredibly low anyway. Finally, if this link is causal, we would expect the USA, with its relatively high levels of circumcision, to have low rates of HIV, and countries with low rates of circumcision to have higher rates of HIV. That is simply not the case: Norway, for example, has almost zero male circumcision and much lower rates of HIV than the US – 0.47 per 1000 in the adult population compared to 3.7 per 1000 in the US. Once again ask what is the number of men circumcised for this reason who never would have contracted HIV in the first place – what is the number needed to treat? Some studies have shown that males are less likely to contract other STDs like genital warts if circumcised, while others have shown that they are more likely to infect women if infected themselves. You can read an overview (from an admittedly anti-circumcision site) here. One fundamental point to consider is this: is your baby boy going to be sexually active? Is he going to be engaging in activity likely to land him an STD? Could you teach him how to have sex safely, that is, by using a condom or avoiding promiscuity? Could you let him choose circumcision as a preventative measure if he so desires, in the knowledge that he would STILL need to wear a condom to have sex safely?

To sum up, the health benefits of circumcision are not at all clear. They are disputed. They are potential rather than actual.They are all either treatable by other means or avoidable by methods far less drastic. If any scientist or government committee suggested introducing any new surgical procedure (rather than one entrenched in this country’s culture) on the basis of these kinds of number, they would be laughed at.

One final note: all of these perceived and potential benefits are predicated on the notion that the foreskin is pointless – that there is no advantage to having one and that it serves no function. This is certainly the stance of the committee that prepared the AAP and CDC statements referenced above. That stance could not be further from the truth, but you will have to wait for another blog post to read about the wonders of the male foreskin.

A hard decision, but the right one for me

I’ve been thinking about a question, sparked by a new doula friend. A huge part of my job is helping mamas to protect their bodily autonomy – that they make the decisions about what happens to their bodies with genuinely informed consent – and genital integrity – specifically, avoiding episiotomy unless medically indicated and minimising the chance of tearing during birth by following physical cues for positioning and pushing, ‘breathing the baby down’, or perineal support, for example. I hear things like ‘I don’t want to be cut unless it’s an emergency’ or ‘I want my vagina or vulva to be the same afterwards’ or ‘I’m afraid that I will tear and it will hurt’ or ‘I tore last time and it was very painful and took time to heal: how can I avoid that this time?’ Imagine helping a VBAC (vaginal birth after cesarean) mama birth a nearly ten pound baby over an intact perineum. Think of seeing a mama who had had a huge episiotomy (to which she had not consented) that extended to a fourth degree tear with complications, birth her second sweet baby with no tearing at all. It’s incredible. I say, ‘Trust your body. Your body is not broken. Your body was perfectly designed to birth this baby. You will open and stretch. Trust your body. Your body is perfect.’ These are some of the mantras of doula-assisted birth. Again: women want me to help them guard their own bodily autonomy and genital integrity. And I am very, very happy to do so.

How do I hold this role in my mind with some parents’ decision to circumcise baby boys, breaching their bodily autonomy and genital integrity? Recently I have come to the conclusion that I can’t hold both things in my mind at the same time. I hear in my head the same requests and questions above, this time in the voice of a baby boy: ‘Please don’t cut me unless it’s an emergency…Please let me decide…Please let my penis be the same as it is now…Please don’t hurt me.’ In a whisper, so that parents cannot hear, I have told brand new baby boys ‘You are perfect, and whole, and your body is not broken.’ And I have said ‘I’m so so sorry, I tried my best.’ Someone might tell me to mind my own business, that’s it’s not my decision or my place to apologise. To this I can only say: it is this one baby boy’s penis. He has the right to bodily autonomy and genital integrity. Just as his mama does.

Consequently I’ve decided not to offer doula services to mamas who are carrying boys and choose to circumcise. I understand that (male) infant circumcision is seen as a legal right* and a cultural norm in much of the United States. I know that there are a number of spurious health claims about circumcision, myths about cleanliness and frankly offensive ideas about the aesthetics of the intact penis. I believe, most of the time, that parents who choose to circumcise make their decisions out of love and with the best information they have at that time. I recognise that for at least two religions it is an important rite.** But for myself, for my own mental and spiritual well-being, I can no longer reconcile working so hard to help mamas have a gentle birth, a ‘gentle welcome’ into motherhood, and leave knowing that I have failed to secure a ‘gentle welcome’ for a baby into life just because he is a boy, born in a country where routine infant male circumcision is normal and often unquestioned. It is true that this decision may cost me clients: in fact, it already has. But I think that is an easier cost to live with.

If you want to learn more about circumcision, why it’s done and why it’s important to leave all babies, boy or girl, intact, these are some great resources:

http://www.psychologytoday.com/blog/moral-landscapes/201109/myths-about-circumcision-you-likely-believe

http://www.doctorsopposingcircumcision.org

http://www.wholenetwork.org

http://www.drmomma.org

http://www.savingsons.org

* Technically, the Fourteenth Amendment means that laws forbidding female circumcision apply to males too.

** For Jewish people, as part of the Covenant; for Muslims, as a cultural expression rather than a requirement of the Quran.

New certification!

Hello strangers. I’m delighted to announce that I am now a Certified Lactation Educator with CAPPA. Look out for a post about group and private classes and in-home support coming soon.

In the meantime I was asked in a recent class about resources for pumping and returning to work. As with many issues I really recommend the kellymom website and this huge and helpful list of links from La Leche League.

There is also a wonderful book, available on amazon, called Nursing Mother, Working Mother, with lots of useful tips. This one is on making more milk, a common concern for working mothers – and it’s by Martha Sears!

Do you work outside the home and nurse? How do you do it?

New class coming!

Having disappeared for a time, and had my third baby (another boy! at home!) I’m emerging from the blur and I’m teaching my first breastfeeding class tomorrow. I’m working on certification as a CAPPA Certified Lactation Educator, and as part of my course I have to film myself teaching an hour long class. My good friend Heather McLees-Frazier has given me a spot in her Lamaze Class and I’m excited to work with her. I’m going to show a couple of short films during the class, and I thought I would share them here too, since they are excellent resources. The first is an Indian film of a newborn breast crawl (you can see a really interesting cultural difference too – the mama’s face is blurred out as too personal to share, but her breasts and nipples are fully visible. Which is helpful in a breastfeeding film!). The second is a film made by Ameda about how to achieve a good latch. Enjoy!

Here are another couple of great resources on getting off to a good start with breastfeeding:

Size of a newborn’s stomach (from the excellent website www.babiesfirstlactation.com owned by the Canadian IBCLC Katie Wickham)

Is baby getting enough milk (from www.kellymom.com) – I include this because it is a number one concern of nursing mamas (and their families).

Update

I’m not very good at this regular blogging thing, am I? That’s not likely to change over the next few months, since I am due any day with #3. I’ve had a lovely year so far, with five births, including two in one night for the first time ever – you can read one of those birth stories over on the ‘Birth Stories and Testimonials’ page. I’m not attending any births over the summer, but look forward to working with new mamas in the new year. What will 2015 bring?

When plans go awry

I’ve had the honour now of attending twenty births as a doula – not many by the midwifery or OB scale, but far more than most people in the US. Six of those births – close to a third! – were cesarean births. Two were planned, and four unplanned (but not emergencies). I am grateful to have had the opportunity to support the mamas and papas through the cesarean experience, and at the same time, I’m sad to have seen so many, relatively speaking. That simultaneous happiness and sadness is a strange thing, and one shared by the families I have worked with.

I had a wonderful cesarean (unplanned but not an emergency) myself with my first son. We worked extremely hard to birth him vaginally (you can read his story on this site) and when it didn’t happen, had a gentle, ‘natural’ cesarean in which my son came straight to my chest under the drapes and I breastfed him there in the OR. I was ecstatic. I was also sad to have not birthed him in the way I had dreamed. No one ever made me feel bad about this dichotomy. Everyone respected my grief. No one said ‘at least you have a healthy baby – that should be all that matters.’ Of course it matters, but it isn’t ALL that matters. I asked myself all kinds of hard questions – what could I have done differently? Did I try hard enough? If I had pushed for another hour/tried a different position/done x, y or z, could it have been different? I made peace with D’s birth (ha – then lost it, and then found it again) and he loves to hear his birth story now.

Witnessing cesareans as a doula is very similar. I’m very fortunate not to have been at any births with what we might (quietly, to one another) call ‘scalpel happy’ care providers. I can honestly say that the cesareans I’ve witnessed were medically necessary. They did not come because of premature induction or at the end of a ‘cascade of interventions’ or at 4.30pm so someone could go home. No parents were pressured into the decision; there was no fear or panic. But there was huge sadness, later of course twinned with the joy of meeting a new baby. I second-guess myself every time. Did I try – or suggest trying – everything possible to avoid this outcome? Did I translate or interpret accurately and helpfully between the parents and the caregivers? Did I guard the parents’ space to give them the most thinking and decision-making time? Did I do enough? In the moment of decision and afterwards I do my very best to help the parents find peace – and I tell them what it helped me so much to hear: you did the right thing. You acted before there was a (likely or very likely) emergency. You will be able to bond. You will be able to breastfeed. You will recover. You will be able to try for a VBAC down the road. It’s okay to be sad and to grieve the birth you didn’t have. Whatever feelings you have, they are okay, they are yours. I will walk with you. You are a mother. You are still a warrior and a birth goddess.

If you are confronting a cesarean birth, there are some things you can do to make it feel less surgical and, well, more ‘birthy’ (all on the basis that it is not an emergency and you and baby are healthy). If you anticipate a scheduled cesarean, you can ask under certain circumstances to wait until you go into labour, so that your baby still gets to pick his or her birthday. Many OB-anesthesiologist teams will allow you to have both a partner AND a doula in the OR with you, or at least to let you have your doula trade in if your baby has to be taken out and your partner goes with the baby. Keeping your birth team with you makes a world of difference, and if your baby has to go to the warmer, then your partner can go with the baby while your doula stays with you (or vice versa). You can ask to play your own music in the OR, and even have your own scent. Ideally you can ask for a ‘natural’ or ‘family cesarean’, which more and more OBs are discovering. In these births, the drapes are lowered so that you see your baby being born (don’t worry, you don’t see any of your insides!). Delayed cord clamping may be available, and your partner may still be able to cut the cord. The baby can come straight to your chest under the drapes for skin to skin contact, with all procedures done with baby on you instead of the warmer, just as in a vaginal birth. You can nurse right there on the table. Your OB may offer to swab your vagina and wipe your baby’s mouth and face in order to populate him or her with your vaginal microbiome – an increasing number of studies are indicating how important this is for long term intestinal health (see this article). All being well, you and baby need not be separated at all.

A cesarean may not  be your first choice. But there are still steps you can take to shape your experience – and your baby’s first few moments earthside.

New beginnings

Well, it turns out that writing a blog is kind of like a job – you have to keep at it! Obviously I slipped rather at that over the autumn and winter so far. The first flush of enthusiasm ebbed, I had several births, I took a neonatal resuscitation class (and was certified, yay!), and I got pregnant again myself. We are expecting our third baby in the summer. All that meant that I dropped the ball on website maintenance.

I’m a little over 15 weeks pregnant now, so I’ll be attending births for another few months as a doula before I go on leave. Every doula has her own preference for working while pregnant. Some barrel on through (which I did last time). Some have debilitating morning sickness or fatigue or risky pregnancies (I make it sound so glamorous) and stop attending births as soon as they see two lines on a stick. With my last pregnancy I attended births until 2 weeks before H was born – we didn’t plan it that way, but she was at the late end and H was early. I’m not certain I gave that mama, papa and babe my absolute best, though I thought so at the time. So this time around, I’m working until mid-April and then going on leave. In the meantime I have several births booked, and it’s my goal to post here once a week or so. Here’s a lovely image for new beginnings.skeleton