doula ethics: discuss

I have not had time to fully digest this discussion, so can only present its sides here:

The initial comments (at MamaMidwifeMadness):

I want my client to know that the OB practice she has chosen includes two amazing OB's who I'd be delighted to birth with myself, but also one physician who (nurses report surrepticiously) is almost single-handedly responsible for the hospital's not insignificant c-section rate and abusive horror stories from teenage and other under-served mothers. I can't tell her this.

The critique (at Grabapple):

I can see that she fears retaliation if she breaks the code, if she passes on a rumor…even if she tells the client it may just be a rumor. I get the feeling there are consequences for breaking the protective silence around patient abuse that nurses, midwives, and doulas witness, apparently. That’s the only sense I can make of her post. She has to choose whose side to be on, and being on the woman’s side is too risky.

The response:

I try my hardest to serve the women I work with with my head and my whole heart. I sometimes wish I could share with my clients every little thing which my experience and training have taught me. I know though, that that is completely unrealistic and probably not even that helpful for most clients. I work hard to help them become empowered, educated and informed consumers of pregnancy and birth care.

First, I encourage you to read all three posts in their entirity. I have only excerpted wee pieces here to give you a sense of the issues. But there is really a lot here: the difference between first-hand observation of behavior versus rumored behavior; birth being political; what education constitutes "empowerment" of a client and what becomes advocating a certain viewpoint. These are great questions to contemplate.

I will add that I used to give clients a copy of Ina May Gaskin's article on cytotec. I felt it was in their best interest to know about the cytotec controversy before being offered it in labor. I have stopped doing this. Instead, if a client is being induced, I discuss the methods I have seen offered. I tell them that the natural birth community has concerns about the use of cytotec. If they ask about these, I encourage them to look on-line or offer to bring a copy of the article. If they are unconcerned ("I trust my doctor"), I leave it at that.

Similarly, with induction generally, I encourage people to do their own research and balance that against their own priorities. For the woman I worked with who was pregnant through artificial insemination and had experienced three prior pregnancy losses AND was herself a NICU nurse (and therefore only familiar with less-than-optimal birth outcomes), an elective Cesarean at 39 weeks was the preferred option. When she told me it had been scheduled, I asked whether she had gotten all her questions answered, whether there is a risk to waiting to see if labor starts on its own. This was my gentle way to encourage her self-educaton. She was adamant that this was the best course.

Fine. Telling her that her doctor is rumored to like c-sections would not have helped anything. In fact, it would force her to "choose" sides: the doctor or me. Bad, bad, bad.

And worse? If I had taken an advocacy role, gotten her to switch doctors or postpone the surgery, and then something bad had happened. THAT is how doulas get sued.

As it is, she now feels she was pressured into the surgery. But she has switched her GYN care to midwives and plans to use them for future pregnancies. Our relationship is preserved and we have been able to talk through her frustrations with the first birth together.

Education is not advocacy. On a client-by-client basis, education is the most doulas can and should do. Save advocacy for other fora.

Documenting Loss

Get out your tissues.

A news story pointed me to Now I Lay Me Down to Sleep. It is a non-profit organization that makes professional photographers available to take pictures of babies that die in utero or after birth. The photographs are beautiful and horrible at the same time. They look like the studio photos parents proudly display in albums or on desktops. Except that the purpose of these images is to preserve the memory of a baby the parents only held for a few hours, days or weeks.

I have been thinking about posting pictures of Louis, the son we delivered at 20 weeks' gestation. This Saturday will be the 10th anniversary of his birth and death. The problem is, I hate the photos. One of the nurses took them. And though in fact he was dead in the photos, I don't like it that he looks dead. His mouth hangs open, his skin is bruised, a little blood shines at the edges of his nostrils.

The pictures of me and my spouse with Louis are equally clinical. We each look into the camera with our bloodshot eyes.

When I see the pictures at Now I Lay Me Down to Sleep, I wish deeply that I had a similar image by which to remember Louis. What those photos convey, that mine do not, is the love and tenderness these parents have for their baby.

For that reason, when my clients' baby was stillborn in September, I did my amateur best to photograph him as they'd want to remember him. I photographed her labor and the baby's birth. I took pictures of his precious feet, ears, face. And of his fingers held in his parents'. I wish I had the skills of a professional photographer. It is a relief to know that others are recognizing the value of this documentation.

Please share this resource widely. I wish I had known about it two months ago.

The Grief Journey

A little over a week ago the couple whose baby died in utero held a ceremony to honor him. It was profound.

They live across the street from a great city park. They got the city's permission to claim one of the recently planted trees (the city has stopped its memorial tree program, so the closest thing it could offer was association to a tree already planted to replace one of the ash trees felled by the emerald ash borer; that there is this scientific and community connection somehow feels fitting -- the couple are both scientists themselves). They had a memorial marker engraved with their son's name, birth date and acknowledgement that he taught them about "joy, love and community."

On the day of their tribute some 40-50 people gathered at the tree. We made origami decorations out of paper they provided. Some people brought flowers to lay on the ground; a few had stuffed animals. One person had tied a note to a stone and laid it on the new mulch.

There was a slow, peaceful rhythm as different people stepped forward to the table to make their ornaments, then hang them before blending back in with the crowd.

Eventually -- at what felt like exactly the right moment -- the couple stepped up to the tree. They had been standing off to the side watching people gather, though I only noticed them as they entered the group. It was magical. One minute I was unsuccessfully searching the crowd for their faces, the next, they were suddently right in front of me.

They hung a string of what looked like homemade prayer flags on the tree. Then each read a meditation he or she had written to and for their son. The sky was grey. Snow was flurrying. The parents' words were occasionally lost to the wind or to emotion. In part to hear better, in part out of the reflex to cocoon this couple, our group tightened in and around them. We witnessed their stories; they bore witness to their son's life.

When they were done reading, we stood silently for a few seconds. Then one person stepped forward to hug them and another. Again we were back to the slow rhythm, the dance into the circle's center and out as different of us felt called to give a physical sign of support and sympathy.

The whole ceremony was unscripted. In fact, the father said at one point, "We don't know what we're doing." And yet, it was as perfect as any tribute to a lost child's life and parents' grief could be. It was honest and spontaneous and raw.

The couple invited us to their home across the street. We drank mulled cider and nibbled -- who had an appetite -- at a table full of food. From every room at least one window faced the park. One could easily see the recently decorated tree, a bold collection of color in an otherwise dreary landscape.

I have gotten permission from the family to link to the blog they've set up to chronicle this loss. I know you will only visit with respect and a loving heart.

quick apology

I have been having a hard time logging into my blogger account lately, both to update my blog and to leave comments on others'. Anyone else having issues? I wonder if it isn't a not-so-subtle way to encourage migration to Blogger beta.

Anyway, that mostly accounts for my silence. That and the Thanksgiving holiday and several deadlines at work.

The Letter of the Day is "B"

Blogiversary: My second was last Friday. Two years of thinking, writing, conversing about birth. I can't imagine stopping any time soon.

Beer with Bloggers: This Thursday at Frenchie's in Ypsilanti. Anyone who blogs or reads blogs in the Ypsi-Ann Arbor area is invited. Coordinated by Mark Maynard, whose daughter helped with the logo:



Breast Yeast: (not unrelated to beer, either...) I want to write about this soon and have been wanting to do so for more than a week. Just waiting for a few minutes to pull together a few coherent paragraphs

Bravo: to my spouse whose dissertation defense was yesterday and who summarized and presented his research so clearly, passionately and intelligently. It's been such a long haul; we're almost there. I couldn't be prouder.

F.O.

The reason for red, grey and black on the brain (yesterday's puzzle still open for entries, BTW)?



Pattern: Child's car sweater, from Knit It!, Spring 2006; my own intarsia pattern for the red cross and my modifications to the car pattern for an ambulance.

Yarn: Wool Ease Worsted in Ranch Red, Oxford Grey and White.

If I had it to over again: I'd make more contrasting color rows along the bottom to accomodate the roll. I'd also start the ambulance lower so it doesn't crowd the neck so much.

Final assessment: delight! For my first venture with fair isle knitting and intarsia, I was very pleased with the results. I also was thrilled that my conversion of the pattern, originally calling for chunky weight yarn, to worsted weight worked. The size is as I'd hoped. A bit big for my four-year-old.

Disappointment: The son may never wear it. I went with Wool Ease because it was cheap. And machine washable. I didn't want a $70 sweater ruined by a day at preschool. But I was assuming he'd wear a turtleneck under the sweater and never notice the wool itch. Guess what? Since last winter the boy has developed a deep -- as deep as four-year-old passions can be -- aversion to turtlenecks. No matter I have red, white AND grey hand-me-downs from his brother. He won't wear them.

Here is the $20 ambulance sweater, modeled, possibly for the only time (and with much bribing), by its intended recipient:

Front:


Back:


Coming off (within 4 minutes of putting it on):

Interesting Theme

Last night I went to the library and browsed CDs while my son stacked up books to check out. I came home with a random assortment of discs whose only shared feature was my interest in their content.

OR SO I THOUGHT.

Notice anything in common here?



O.K. so I helped you. What's up with the red? And, in five out of six, the red, grey and black?

Actually, I may have red and grey on the brain for a good reason, which I hope to show you tomorrow.

In the meantime, here's a challenge to you music afficianados: what are the artists and titles of the albums pictured here?

I may have a prize for the winner.

--doulicia

Earning one's fee

Whenever I attend a fast, uncomplicated birth (which, you may remember, rarely happens for me), I feel guilty about my fee. On a few occasions, I have even given some money back to the clients.

At these times my spouse gently but firmly reminds me that I do not charge extra for protracted births. From his perspective, the person who loses a partner for hours/days at a time, it all evens out. I have learned to joke with clients that if they end up feeling like they overpaid for my services, they can be happy that their birth was so easy -- they'd probably prefer that than having the kind of labor that wrings every last cent's worth out of their doula investment!

But focusing on the birth itself is only part of the story. As Vancouver Doula illustrates so well in yesterday's post, labor and deliver is just the tip of the iceberg.

Independent of her post, I'd been thinking about this issue recently. A few nights ago I was on the phone for 45 minutes with a recent client who has breast yeast. Some of our conversation was technical breastfeeding discussion but most of it was commiseration. At the end she said it was so good to vent.

This is a client whose birth went so well I was afraid she'd think I was a waste of money. Since that time she has said repeatedly how she and her partner felt so much more calm heading into the birth and during it because they had a doula. That calm came from our hours of conversations and e-mails, and from their knowledge that the doula would be a familiar face and constant presence.

I have heard this many times before.

Not everyone is anxious heading into birth or faces breastfeeding issues postpartum. But it is part of the birth doula's role to provide support before and after birth. The impact this has on the birth itself and on families' general satisfaction with the birth/postpartum experience is hard to measure. Yet it certainly factors into my ability to feel reasonably comfortable about the fees I charge.

If you live in SE Michigan and knit...

Hold on to your britches!

The Rhinebeck vendor with "the most coveted yarn,"* whose product makes knitters want to "back up a trailer and take it all home,"** THAT vendor is coming to Ann Arbor and Flint in the next few weekends.



Briar Rose Fibers is making a little road trip to the area on three upcoming Saturdays. Here's the schedule (reprinted with BRF owner Chris Roosien's enthusiastic permission):



Open House at Nancy Melet's
Saturday, November 18th from 10-5
218 Pine Ridge St.
Ann Arbor, MI



Open House at Nancy Melet's
Saturday, December 2nd from 10-5
218 Pine Ridge St.
Ann Arbor MI



Open House at Michael and Kay Melet's
Saturday December 9th from 10-5
3806 Wroxton, Apt #4
Flint, MI



Only rigid family fiscal policy allows me to ensure I won't buy it all in the first hour on the 18th.

*Spincerely Yours
**Knitorious

This time, it's personal

What could be better to a worrying hypochondriac (not that I know any) than a website that gagues your risk of disease based on your answers to nutrition, lifestyle and family history quesions? Exactly.

Head to www.yourdiseaserisk.com, a Harvard University project, and be prepared to learn not only where your risk level is, but what you can do to improve it.

However, much as I want to lower my risk of ovarian cancer, I will not be having my tubes tied.

Enjoy.

Is medicine a craft or an industry?

So asks Atul Gawande in his most recent submission to The New Yorker, "The Score." It is about how Apgar scores changed the way obstetrics did business. If you haven't read it, you should.

The Apgar score, as it became known universally, allowed nurses to rate the condition of babies at birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.

The score was published in 1953, and it transformed child delivery. It turned an intangible and impressionistic clinical concept—the condition of a newly born baby—into a number that people could collect and compare. Using it required observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered.

This saved babies that were previously put aside to die because they weren't breathing at birth or were thought to be too small to survive. It also justified the expansion and use of various technological assessments and interventions.

Over the years, hundreds of adjustments in care were made, resulting in what’s sometimes called “the obstetrics package.” And that package has produced dramatic results. In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred)—and a hundred and twenty thousand newborns (instead of one-sixth that number).

But the rub? Improvements needed to be generally applicable. Never mind, as the article illustrates, that some physicians had outstanding outcomes using forceps. Their outcomes were better than those of Cesarean deliveries, in fact. Unfortunately, their results were not easily reproducible. Forceps technique takes up to two years to master. Even then not all doctors had the right touch.

By comparison, Cesarean deliveries are relatively easy to teach, learn and execute.

In answering the craft versus industry question, Gawande sides with the latter.

If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability...

After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.

The rest of the article is given to one woman's story of a surgical birth, a description of Cesarean surgery itself, and the debate about rising C-section rates and elective surgical delivery.

The article ended sadly, with Gawande's acknowledging the "waning of the art of childbirth."

The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost.

Let's give thanks again for our midwives, who keep those skills alive and available to women today.