"Pushed" to Iatrogenic Prematurity

I am currently reading Jennifer Block's expose on modern maternity care titled "Pushed." It's a nice wrap-up from the midwifery and obstetric literature I have been scouring for truths and perspective over the last two months. It's an eye-opener, but that's mostly by design*. Still, it's a great book because it is bursting out the seams with information, from the history of maternity care to the new fashions and practices. The information is not organized like a boring textbook either; it is presented in a gripping writing style, weaved through stories, and neatly packaged under attention-grabbing subtitles.

Basically, there exists a clash of opinions in American modern maternity care**. The clash is between the obstetricians/gynecologists (representing the organized, insured, medical community as a whole) and the midwives/doulas/women (representing the people who feel that childbirth is a natural process: those who say that most women left to their own devices will be able to deliver their babies and survive without the aid of modern drugs and healthcare). With medical advances have come myriad interventions into American women's childbirth experiences; the perspective held by the midwives is that these advancements and the resulting adopted unnecessary procedures are harmful to women, specifically, and society, as a whole. 

The midwives will have you believe that the hospital is a horrible place to deliver because you will be vulnerable to hospital policies and routine interventions. The doctors will have you believe that you are not safe delivering anywhere else (because, as I have heard now at least three times from my OB, your baby could die).

The more I read, the easier time I have balancing the two perspectives. I am realizing that the true state of modern maternity care is somewhere in the middle: hospital procedures are being reformed to be more "mother-" and "baby-" friendly while American midwives are finding out that they are susceptible to (and influenced by) the same insurance pressures that have made OBs so focused on the active management of labor. 

In order to avoid malpractice suits, OBs are driven to act on, rather than support, the labor and childbirth process. This is one of Block's major points: active management of labor and delivery is defensible in the case of a bad outcome; waiting to see what happens is not. So, at the first sign of trouble, an OB must take action. This starts a cascade of interventions, which too frequently ends with a scalpel to the abdominal cavity. 

How does this relate to my experience? Three weeks ago, my OBs came to the conclusion (based on poor measurements taken by their bad sonographer) that my baby is growing asymmetrically*** and is four weeks smaller in the abdomen than she should be. They immediately referred me to a perinatologist (basically an OB for high-risk pregnancies). After much research and deliberation, I decided to see the perinatologist, if only to remove the categorization of "high-risk" from my pregnancy. At the perinatal care office, I learned that my baby is perfectly symmetrical, but small (measuring three weeks behind her OB calculated gestational age, which is wrong by the way). The perinatologist reviewed the measurements and recommended that we induce labor at 38 weeks. I found this to be quite befuddling. I have a small baby - she clearly needs more time to grow - so my recommended course of action is to take her out early??? 

We asked him why. He looked at me, and then at Kyle, and said "it's very likely that the baby is small because of genetics," however, he continued, with babies that are small for gestational age, sometimes this is due to inadequate nutrition in utero. Since there is no way to know with certainty why a baby is small, we recommend induction for all small babies. Huh.

The doctors have to protect themselves; they simply cannot not recommend induction. Why? Because if my baby is born at a deficit due to insufficient nutrition in utero, then I could sue them for not acting on information indicative of a problem with my pregnancy. I understand that, so I politely decline; it is my decision to make after all.

Iatrogenic prematurity is premature birth caused by the physician, usually via labor induction or scheduled cesarean. The popular belief is that, rather than waiting for labor to start spontaneously at an odd hour, OBs like to induce in the morning, deliver by dinnertime. My OBs have been gritting their teeth to induce me since the first ultrasound measurements came in to suggest that Holly may be growing asymmetrically (see IUGR). Thwarted on that front, now they want to induce me because she is small****. I won't let them.

Opposing the doctors (not taking their "serious" recommendations): that has been challenging, to say the least. They are forceful, persistent, and they have all sorts of nifty diagnostic gadgets on their side. I know that I haven't yet heard the end of the induction talks. Now I am just counting down the days (and appointments) left until my estimated delivery date, hoping that my labor starts spontaneously before the doctors find yet another reason to induce. After that happens, then the medical community and I can move on to battling about something else, like whether I stay strapped to the monitor and/or whether I push in a lithotomy position. 

Bring it on, medical community.

* Block is a journalist, after all. I would not openly call her credibility into question, but I don't think it's unfair to suspect that the information she presents is slightly shaded or exaggerated to heighten its impact on delivery. Furthermore, I trust the data she presents, but also know she may well be withholding data as well in an effort to strengthen her position. As my college suite-mate once remarked, "statistics will tell you anything if you torture them enough"; that is, the analysis of raw data still requires choice (of what's included, what's not, what's meaningful, what's not, etc) and interpretation. By tweaking the variables, thresholds, and analytic methods used, one can significantly alter the outcome of an analysis.

** What follows is a very simple interpretation of the current "issue". It's much more nuanced than what I will deliver here; but I want to make sure to get the basic point across (and I don't want this post to turn into a novel). I am happy to further discuss any aspect of modern maternity care and my findings with any interested readers.

*** At the time, the OBs insisted that it is the asymmetry that worries them, not the size. 

**** At 37 weeks, she weighed 5.5 lbs. That doesn't seem small to me...

Women's Sexual Passages and Orgasmic Birth

I just finished reading Elizabeth Davis and Debra Pascali-Bonaro's book titled "Orgasmic Birth." Davis and Pascali-Bonaro claim that pregnancy and childbirth parallel the experiences of foreplay and orgasm*.

Their perspective is refreshing because it is so different from the one popularly advertised: pregnancy as a medical "condition" ridden with unfortunate and embarrassing physiological changes or "symptoms" and childbirth as a painful, unbearable process (which, thanks to medical advancements, not all of us have to attempt, but which, for those of us who choose to endure it) is made worthwhile only by its result (i.e. the baby).

While I don't quite buy into the orgasmic birth concept** reading this book (and also having recently read Elizabeth Davis' other book titled "Women's Sexual Passages"***) has helped to quiet some of my original fears and anxiety around the task of giving birth. Having never personally witnessed a labor before and being the first among my friends to become pregnant, I had very little information on this topic 9 months ago. In fact, the only information I had on it was that which I had passively received from depictions of labor in the popular media (which, as I already stated, tend to be negative and SCARY).

Now, after having read a healthy collection of natural birth and obstetrics literature and viewed a number of birthing videos, I think I can say (without having personally experienced it) that I know (to some degree) what to expect. And what I expect is neither orgasmic (sorry Davis) nor scary (sorry everyone else); it is a natural, instinct-driven sensory experience that is physically challenging but not unbearable. And I am looking forward to it!

Any day now... :)


* Doing a bit of interpretation here: they never discuss foreplay, per se; however, their description of a woman's experience leading up to the labor and delivery of her baby bears resemblance (in my opinion) to some components of foreplay. For example, the authors suggest that the period of pregnancy is a time during which the woman must take care to become attuned to the sensations of her body and also to her emotions, turn off the analytic part of her brain, relax and open up, and prepare herself physically and emotionally for the experience of labor.

** I'll believe it when I feel it.

*** In this book, Davis claims pregnancy is a sexual "rite" of passage for a woman, in company with other rites such as menarche and menopause. She posits these are meaningful events in every woman's life and they must be celebrated to promote healthy self-esteem in women. Again, interesting stuff. Definitely hyper-feminist (not saying that there is anything wrong with that...), but a good read for its refreshing and different (I might go so far as to say empowering) perspective.

My Un-Professional Medical Opinion

I think that I have a somewhat unique perspective on the progress (and treatment) of my pregnancy for a couple of reasons.

First, I have been educated in research design and interpretation (not medical, but applicable nevertheless). My education helps me to better understand and evaluate (not to mention, to proactively seek out and analyze) credible information regarding test results and the progress of my pregnancy. I've found that doctors don't usually share more information than is necessary to sway their patients toward the medically preferred* course of action. Therefore, if you want to make a wholly informed decision (one that is not biased by your doctor, the current medical fashions, or the pressures placed on the medical community), it's often necessary to seek additional information from outside credible sources to supplement what your doctor is telling you.

The rigid structure of prenatal care can make this difficult: the doctors often expect you to make your decision (read: to take their recommendation) at the same appointment, in which they provide you with the "relevant" (read: supportive of the medically preferred next step, ie shaded, one-sided) information. However, I've found that it's possible to delay just about any medical decision by at least one prenatal appointment and I do so frequently. It's a little frustrating for the doctors, but it gives me time to gather and evaluate all relevant information, thus making me feel more confident in my ultimate informed decision.

Second, I understand and feel comfortable putting my faith in statistics. This comes from both my research education and my many years of experience playing and analyzing poker hands. I understand that when there is a less that 1% chance that my baby will have <this>, the odds are pretty good (in fact, they are excellent) that my baby will not have <this>. In poker, if the odds are in your favor and you know this with a high degree of certainty, you (usually) continue with the hand you're holding. I don't see any reason why medical decisions should be treated differently.

Of course, I am less willing to gamble with my baby's life than with my money. But I find statistics reassuring. In the above example of 1%, I like my chances enough not to pursue further tests or, worse yet, to treat my baby with <choice of drug> in case she happens to be in the 1%. Especially in the latter case, 99% of the time I would be exposing a perfectly healthy baby to drugs where none are needed. This is something that I do not feel comfortable doing, but the doctors prefer it.

My medical team likes to cover all their bases and make even the most favorable odds better. In that interest, they err on the side of preventative care. When the doctors see that I am reluctant to take their recommended treatment because I "feel healthy" and/or I "like my odds" just fine, they don't hesitate to try different strategies for my manipulation. What works really well on a pregnant woman? Appealing to her (likely) emotionality and protective instinct. For example, they think that if they say something like "I've had a baby die because we didn't know to treat for <this>," then I will change my informed decision.  I find this tactic to be under-handed and abusive, not to mention offensive. I imagine this works on a lot of expectant moms. However, thankfully, my rationality and faith in statistics are not easily rattled by proclamations like this.

As I already mentioned, my unique approach to receiving (read: critically analyzing and attempting to have a modicum of control over) my prenatal care somewhat frustrates the doctors responsible for my care. It also sometimes serves to make those around me nervous: how can I refuse treatment, am I being negligent, etc? Rightfully, people will form their own opinions about this. All I can say is this: I love my unborn baby (probably no less than or more than those who take a different perspective and approach to their prenatal care) and I am acting in what I believe to be (from intensive research and careful deliberation) her best interest.

* From my experience, doctors' preferred course of action (at least in pregnancy care) is usually interventionist with a focus on proactive prevention rather than surveillant with a focus (after the fact) on the identification of symptoms and prescription of treatment.

Letter to My Daughter

Dear Holly,

My skinny baby. First, thank you for the Mother's Day card. That was very sweet of you to find a pen and willing body all the way in California to write what you wanted to say to me on paper. I appreciate both your efforts!

Thank you also for directing some nutrients to your legs to grow them nice and long. That effort is going to serve you well one day, when you're running energetically through the daydreams of young boys in our neighborhood.

I understand your hesitation to grow belly fat. I share the sentiment. You're a smart girl, so you're probably thinking it's no use storing lipids now in a place where you won't want them later in life. Of course, it seems like you'd be making extra work for yourself down the line. And, like your parents, you are probably interested in minimizing unnecessary effort. However, I want to assure you that it is okay to get a little pudgy around the mid-section. After all, you're a baby and, among other things, babies are thought to be cuter when they are round. I say that not to suggest that you should care deeply about what people think (you shouldn't), but to help you understand that being aesthetically pleasing is in your best interest: there are lots of studies that show that attractive people tend to have an easier time acquiring positions of power, for example.

Is power important to a baby? Absolutely! Think about it.

Now, the doctors are recommending that I keep you under the (Doppler) microscope so that we can monitor your growth. But, I don't want to do that to you. I have faith in you and trust that you will grow in precisely the way you intend and want to, naturally, and without the need for spectators. So, let's make a deal: I will trust you to spread the nutrients around to all areas of your body (so that you're healthy when you join me and daddy in the world) and you can count on me to keep the doctors out of your sanctuary until you show me that you are ready to come out.

Love,
Mommy

3rd Trimester Sonogram & The (Assumed) Infallibility of Obstetricians and Lab Results

About three weeks ago, we had our third trimester sonogram for Holly. Among other things, the doctors use the third trimester sonogram to confirm their estimated delivery date (EDD) for the baby and to verify that (a) the baby is growing properly (or, as I understand it, according to the pattern that is typically observed in the population), (b) the amniotic fluid volume is sufficient to support further growth, and (c) the placenta appears normal and has not implanted at a place that would preclude natural delivery of the baby.

The results from the sonogram suggested that Holly is 2 weeks smaller than expected from her calculated gestational age. Naturally, the OB (who is trained to see pathologies, even where none exist) took this in one of the worst possible ways and suggested that my placenta may not be working properly. Note: the alternative explanations are that (a) the OB's EDD is wrong (wait - "OB" and "wrong" in the same sentence - but that's blasphemy!), (b) the fetus is perfectly normal but just smaller than typical (but that would imply that a degree of deviation from the norm is perfectly normal... weird!), (c) the ultrasound technician did a poor job with the measurements (perhaps due to being distracted or unmotivated that day; hey, it happens!), (d) the measurements are within the normal range of error and therefore normal (note: the ultrasound error rate for calculating gestational age is 2-4 weeks), or (e) there is a developmental abnormality in the fetus. 

Per our doctor's insistence, we scheduled a follow-up sonogram for Holly, to allow the doctors to confirm and have peace of mind that she is in fact growing at an acceptable rate. They plan to do this by comparing the two sets of measurements. The follow-up sonogram is this afternoon. 

I think that my little girl is already very smart. She heard the re-test was coming and decided to have a nice big growth spurt for the doctors over the weekend. I can tell because my baby bump grew into a baby mountain and I am now feeling her movements much more strongly, which suggests to me that she is crowding out the available space and no longer floating suspended in the middle of the amniotic fluid. 

Attagirl!

If she's anything like her mother, she'll shoot the ultrasound technician a smug look at her re-test. :)

Battle Hymn of the Tiger Mother (Remainder of Book)

I just finished Amy Chua's "Battle Hymn of the Tiger Mother" and have come away from the book with a few general reflections.

First, I respect and admire Amy for her resilience and selflessness as a mother. Some would argue that her aggressive and demanding parenting style is not in fact selfless (Chua even acknowledges this viewpoint in her book), but I see it as such. Much like my own mother (who, like Chua, is not American), Amy forfeited some independence and personal "fun" for the benefit of her daughters' proper (in her opinion) upbringing. I admire that. But what I admire even more is that Chua managed to do all of this while remaining productive in her career, running her household, taking care of two dogs, and planning frequent vacations and special events for her family. I am exhausted just thinking about all that she did, which leads me to my next point:

I can understand how a lot of parents would be reluctant to do what she did. Chua even admits that it wasn't fun for her to supervise piano and violin practices for several hours every day; obviously there were other things the woman could do. Every day she chose to be there for her children rather than to succumb to her personal desires. She chose to (on innumerable occasions) feel hated and resented by her daughters rather than to relent in the interest of feeling loved by them. I think it takes a very secure, self-assured person to do what she did; and certainly one with a solid long-term perspective.

Like any parent, Chua wanted to set her daughters up for future success. She had a coherent strategy for achieving this (which is probably more than most can say) and she had the determination and resilience to execute the strategy against all opposition (which is, again, probably more than most can say). She made mistakes along the way, but she was thoughtful enough to promptly realize those mistakes and re-evaluate her strategy, which leads me to my last point:

Whether or not she would agree with me, I believe that Chua achieved success* with both of her daughters using the "Chinese" parenting style. Here's why:

***SPOILER ALERT***

Although Lulu ultimately gave up the violin against her mother's wishes, she learned and internalized the qualities for success that her mother instilled in her during the violin years: ambition, determination, passion, perseverance, and lots of practice. Toward the end of the book, after she takes up tennis, it becomes clear that Lulu is applying these skills to challenge herself to become a great tennis player. Lulu demonstrates that she is driven to succeed, just not in the activity that her mother had desired for her. The desire to be better (and to eventually be the best) and the knowledge of how to  achieve her goals are qualities that will get Lulu far. I don't believe it's a question of "Western" vs "Chinese" but I do think that it was because of Chua's high expectations of her daughters that they learned to expect so much of themselves.

On the whole, Chua's book was entertaining and inspiring** to read. I enjoyed reading it for its unique perspective, especially because Chua seems to be an intelligent and thoughtful person and proved capable of offering strong arguments in support of her claims***. Her actions are quite radical when evaluated against those typical in "Western" culture, but they are reasonable and never incongruent with her long-term goals****.

* I suspect Chua would disagree because of her inability to control Lulu and Lulu's public defiance, which as she says is uncharacteristic of a well-raised "Chinese" daughter.

** Inspiring not in the sense that it has convinced me to raise my daughter the "Chinese" way, but in the sense that it's gotten me to think about what kind of mother I want to be and how much I want to invest in my children's future success but also in their happiness, in my happiness, etc.

*** Yes, I believe her arguments were strong.

**** At least, this is the depiction I get from the book. I understand the author in writing the book may have provided a biased account for some of the stories.

Note to Readers and Must-Buy Reference Books re: Childbirth and Breastfeeding

When I worked as a business analyst, I tracked my projects, hours, and output weekly. I regularly saw results for my effort and my workload was ever-changing thanks to my (often times) swift resolution of open projects. For 9 hours a day, I maintained a high level of productivity for the company to meet the demands of my job and I found even the most seemingly arduous objectives attainable under the stresses of the work environment.

By design, my life is no longer stressful nor demanding. I am reminded to enjoy it while it lasts.* However, I can't help but actively look for ways in which I can measure my successes and achieve a sense of accomplishment from my daily work. The household tasks are easy and un-interesting to me; and there is, fortunately for my husband and our finances, only so much baby shopping that I can take.

Being output-oriented, I have tied my personal feeling of success somewhat to the publication of these blog posts. Lately, my blogging has become less frequent because of the time I am spending on intellectual pursuits not related to parenting.** However, I find this writing personally valuable as it helps me to organize and crystallize my thoughts; therefore, as a note to readers I'd like to say that, I will soon start to publish posts related to other subjects of interest as well.*** I'll include the topic in the post title for clarity.

I started this blog with a focus on parenting, but now I see that I have put the cart before the horse, so to speak. I took a step back this month and have re-focused myself on breastfeeding and the process of natural childbirth. To that end, I've been reading these books: The Womanly Art of Breastfeeding by Wiessinger, West, and Pitman of La Leche League International (LLLI) and The Birth Partner by Penny Simkin. I have read at least 100 pages of each so far and am very happy with their content and with the perspectives depicted therein.

I try not to buy any books that I can rent from the library, but I saw very much value in personally owning both of these: they are very detailed on their subjects; they are quick to read and easy to understand; and they are organized well to serve as reference books, so that you can read and refer back to parts as they become relevant in your experience.

The Womanly Art of Breastfeeding is written by mothers (members of LLLI) and covers all aspects of breastfeeding (obviously) as well as the benefits of belonging to a network of mothers, such as LLLI. The book is written from the perspective that what's natural is best for both the baby and the mother: LLLI encourages (and provides much evidential support for) breastfeeding (versus formula feeding) and for staying home and personally caring for your infant. However, I should note that they do also offer what appears to me to be useful advice for mothers who must return to work as well (on how to manage the transition, etc).

The Birth Partner is written for expecting dads, doulas, and other labor companions. We bought it for Kyle, but I am finding it very informative (and comforting to read at this time) as well.**** It gives a very detailed description of natural labor at all stages (something that, from my experience and understanding, medical professionals don't care to spend time informing women about). It also gives helpful information related to labor and delivery, such as what to take to the hospital or birthing center, possible labor complications and ways to manage them, the effects of labor medications, and how to get started with breastfeeding. One of the biggest messages throughout the book is that labor is a natural process and that natural, vaginal delivery is easier for a mother that feels supported, calm, and optimistic. Penny Simkin gives the reader a variety of tools with which to ensure the latter.

After reading Simkin's depiction of the natural progression of labor, I can see how a mother and her labor companions can be quickly overwhelmed by the experience if they lack the knowledge of what to expect. I would highly recommend this book to all expecting mothers, fathers, and labor companions (or, really, anyone who wants to be able to understand and empathize with a woman who's going through labor). Those considering an elective C-section for fear of natural delivery would also benefit from reading this book (at least in the sense that the unknown would become demystified and they would be able to make an informed decision about their method of delivery).*****


* Apparently, babies can make life chaotic.

** I constrained this blog only to that subject in the beginning and have been reluctant to change that.

*** Probably a welcome change for most of you. ;-)

**** It is very important to me and Kyle that I deliver our baby naturally. We looked into delivering in the care of a midwifery group versus an obstetrician (in short and among other things, midwives have much lower C-section rates than OBs); but were thwarted from this pursuit by the combined factors that (a) our insurance is not accepted by neighboring midwifery practices and (b) we do not feel that the difference in treatment is worth the significant increase in labor costs. We spent a lot of time on this important decision and I'd like to discuss it at length in a separate post. If you find this intriguing, stay tuned; I'll have that up in a few days.

***** If it's not clear by now, I tend to place a lot of value on informed decision-making.