Belly Tales

Seems like ever since the FDA announced that two more women have died after taking RU-486, one of the drugs used during a medical abortion, the abortion debate has reached a new pitch as pro-lifers have eagerly added this news to their arsenal and pro-choicers have feverishly girded themselves for pitched battle. Naturally, this has been reflected in the blog community, and several very well researched, well-written and articulate posts have emerged. As an avid reader, I don’t even know where to start. Here’s the cream of the crop. (Extra points if you stay up past your bedtime reading blogs on nights before exams):

Rachel at Women’s Health News has a very thorough and astute break-down of the issue, complete with linked resources and recent research on the subject, reminding us that at this point, further research is needed on both approved and off-label uses of mifepristone (RU-486) and misoprostol before any firm conclusions can be drawn. She also points out that the maternal mortality associated with RU-486 still appears to be much lower than the maternal mortality associated with live birth, and that no one has bothered to look at the mortality rates associated with other prescription drugs.

Via Feministing: Speaking of other prescription drugs, Media Girl was very quick to point out that the current death toll caused by Viagra is 5,640…and no one seems much concerned about this.

The link between abortion, women’s rights and women’s sexuality has become increasingly clear as fundamentalist groups begin to take aim at their next target, birth control (I guess because banning abortion seems to already be in the bag?) Salon has written a very bone-chillingly scary feature on this subject, highlighting Mary Worthington’s blog, No Room for Contraception, which promotes the idea that contraception causes health problems, destroys a woman’s fertility and can even lead to the spread of sexually transmitted diseases by encouraging sex. (Check out her post on how the use of contraception opened the door for homosexuality by allowing sex to be seperated from procreation.)

Which has led to Dan Savage’s painfully funny (funny because it’s Dan Savage, painful because it’s so true) plea for a Straight Right’s Movement (also via Feministing):

Straight Rights Update Earlier this month: Republicans in South Dakota successfully banned abortion in that state. Last week the GOP-controlled state house of representatives in Missouri voted to ban state-funded family-planning clinics from dispensing birth control. “If you hand out contraception to single women,” one Republican state rep told The Kansas City Star, “we’re saying promiscuity is OK.” On the federal level, Republicans are blocking the over-the-counter sale of emergency contraception and keeping a 100 percent effective HPV vaccine—a vaccine that will save the lives of thousands of women every year—from being made available.

The GOP’s message to straight Americans: If you have sex, we want it to fuck up your lives as much as possible. No birth control, no emergency contraception, no abortion services, no life-saving vaccines. If you get pregnant, tough shit. You’re having those babies, ladies, and you’re making those child-support payments, gentlemen. If you get HPV and it leads to cervical cancer, well, that’s too bad. Have a nice funeral, slut.

What’s it going to take to get a straight rights movement off the ground? The GOP in Kansas wants to criminalize hetero heavy petting, for God’s sake! Wake up and smell the freaking holy war, breeders! The religious right hates heterosexuality just as much as it hates homosexuality. Fight back!

And finally, the coup de gras: Bitch PhD has assembled an impressive mini-carnival on articles pertaining to the recent deaths, anti birth control trends, and the humbling, human cost of unwanted pregnancies that is so rarely taken into account whenever this cold, legal debate comes up.

While you’re there, be sure to check out her Heroine of the Week, Cecilia Fire Thunder, President of the Oglala Sioux in South Dakota, who has personally vowed to start up a Planned Parenthood facility on the Pine Ridge Reservation, where the laws of the State of South Dakota don’t apply.

Seriously, forget your homework. Spend the rest of the night reading. It does a soul good.

We take time out now from our regularly scheduled Revolution to give you this small homework update. This week, like last week, is going to be a killer week. Chapter Three of my research proposal is due on Monday, two case presentations in two seperate classes are due next Wednesday, and the mother of all antepartum exams is THIS Wednesday, covering embryology, gestational diabetes and bleeding during pregnancy. All of which are such small, unimportant, simple topics that of course I got my studying done weeks ago and am looking forward to acing this exam. *cough* The embryology in particular is a black hole capable of devouring small villages, goats and all. You wouldn’t believe how complicated it is (or maybe you would). Day one, zygote, day three, morula, day four, blastocyst, day five the blastocyst divides into an embryoblast (aka future baby) and trophoblast (aka future placenta). Every three to four days, the growing organism gets a new name. The embryoblast goes on to become the bilaminar disc, composed of the epiblast and hypoblast, which then goes on to become a trilaminar disc, where the hypoblast morphs into the endoderm, the epiblast morphs into the ectoderm, and both contribute to the formation of the mesoderm. Meanwhile, back on the ranch, the trophoblast has become two parts as well: the syncytiotrophoblast (try saying that nine times fast…pronounced sin-sish-oh-tropho-blast) and the cytotrophoblast. Syncytiotrophoblast goes on to invade the endometrium (aka implant), while the cytotrophoblast encircles the baby and aspires to someday become the chorion. And this brings us up to day…seven.

I really don’t have a handle on this material at all yet (and the exam is…Wed???). Day one through ten is easy compared to all the bits about the differentiation of the chorion and the decidua, the formation of the primary, secondary and tertiary villi, the eventual fusion of the chorion leavae with the chorion frondosum, which in turn (I think) fuses with the decidua basalis, which then somehow fuses together to become the amniochorionic membrane…I think. It’s all a bit cloudy.

I wish we could somehow break it down into simpler terms, something along the lines of: bunch of cells, cells divide, eventually, around 3rd month, you’ve got amnion, chorion, and embryo. 6 months later, baby. Voila.

I think my brain is going to implode shortly. That must mean it’s time for bed.

I’ve haven’t been writing much lately because the school/work/school/work vortex has been unusually intense for the past two weeks. I’ve been having a hard time staying afloat, and on days when it seems really difficult to take care of basics, like feeding myself and getting enough sleep, blogging unfortunately gets relegated to the very bottom of the heap, and as the last thing on my list on any given day, it hasn’t been happening lately. However, rest assured I am still reading, even on the days that I’m not writing. I’ve been going through a phase lately where I’ve been devouring the words and ideas of other feminist/women’s health/anti-oppression bloggers; there’s been a lot of input coming in (although not so much coming out), and my mind lately has often felt jumbled and full and busy digesting all of the new information I’ve been learning. The wheels have been turning, BIG TIME, lately.

There are a lot of things intersecting in my life at the moment which are bringing power, class, racism and equality to the forefront of my thoughts. I’ve been thinking a lot about midwifery in the United States, and how on many levels it functions as a luxury item available to those who can afford it and are educated enough to know that they want a natural childbirth in the first place—about the ways that racism and inequality exists in this mostly white, mostly female profession. I’ve also been thinking a lot about privilege, and power, and the ways that privilege and power affects my life, both as someone who is oppressed, but also someone who oppresses. Before I can do anything to adjust the balance, I first have to see and acknowledge exactly how the scale is tipped, and how and where I fit along the continuum. Where do my own prejudices exist? In what ways do I, as a student midwife and nurse, as a well-educated health care provider with a good solid job and health benefits—in what ways am I not acknowledging my own power? In what ways am I blind to inequality, and in what ways am I complicit in maintaining the tipped scale, and most importantly, in what ways can I change this??

Exposure to amazing women on the web, such as Melissa at A womb of her own and Dark Daughta at One Tenacious Baby Mama, have been helping to blow open the doors and throw wide the curtains. One Tenacious Baby Mama’s essay, Breaking It Down: Acknowledging The Emotions Attached To Recognizing Oppression And Achieving Consciousness should become required reading for every single human on this planet. Her blog, in fact, should become required reading on your bloglist.

Through these blogs, I’ve also become exposed to other feminist/reproductive rights and justice/anti-oppression/activist blogs, like Vegan Kid, Tortillas Duras, A Life Less Convenient, Woman of Color and etc. etc. (there are SO many amazing blogs to read that if you throw yourself into it, you too can achieve new pinnacles of procrastination).

Discovering these blogs has made me accutely aware of some of the shortcomings in Belly Tales, which I will hopefully be addressing in the coming months (stay tuned! BIG CHANGES ahead), but also of the possibility for unique and far-reaching political change and activism that exists through the medium of blogging. Which, of course, is nothing new to folks like the Daily Kos, Talking Points Memo, Body and Soul and etc. etc., (see their blogs for blogrolls ad infiniti): political bloggers the world over who have been doing this for years, and not just doing it, but writing essays on doing it, on the political power of blogging, and exactly what it means to blog, and exactly what that entails. However, to date Belly Tales has been more on the journal end of things, which is fine, since I intended this to be a chronicle of the daily ups and downs of a student going through midwifery school, but having seen the way in which blogs can be used to affect change in birth, and birth politics, and feminist issues that don’t just revolve around abortion and abortion issues, I feel like a kid in a candy store. My eyes are wide and my lips are puckered into a perfect ooooh of amazement, and all I can think is: wow, I want to do that too.

So, I’m going to try to make this site a bit more like a blog, and a bit less like a journal (although there will still be all kinds of fun journally bits about the daily calamities and triumphs of your ever intrepid student midwife). There are a lot of other amazing women who are already doing phenomenal feminist blogging, and if I can’t do it even half so well, the very least I can do is link to them, and call attention to their amazing posts. Which is a start. There has also been talk brewing of forming a progressive, politically active, reproductive justice community and this sounds to me like an idea whose time has come. The old adage “if you’re not part of the solution, you’re part of the problem” seems particularly apt. I’ve “met” some amazing women through this website. If we can link together and start a community and a dialogue on justice and reproduction and the power and welfare of mamas and babies, we could get a lot done. Care to join us?

Welcome to the first (but hopefully not last!) guest writer on Belly Tales! Melissa, author extraordinaire from A womb of her own has been gracious enough to write about the Canadian midwifery system for us. Melissa first became interested in midwifery through her anti-racist feminist activisim, and ended up writing a master’s thesis in Women’s Studies on midwifery in Canada. Then she realized that she actually needed to stop writing and start doing, so now she’s a first year student midwife in Toronto, Ontario. Thank you so much for sharing your thoughts with us, Melissa! (And, to all you other foreign student midwives out there, if you’d like to write an article for Belly Tales about midwifery in your country, we’d certainly love to learn more about midwifery around the world! Don’t be shy!) And so, without further adieu, here we go:

Before I explain the current midwifery situation in Canada, it’s important to talk a bit about history. I strongly believe that we need to know where we came from to understand where we’re going. Midwifery was criminalized in Canada in 1865, two years before we became a nation. That doesn’t mean that midwives stopped practicing. In fact, since obstetrical training was generally only a few days of doctors’ education, many physicians in rural area worked in conjunction with midwives, or even looked to them for mentorship. Not surprisingly, many women preferred midwives to doctors, and it wasn’t until births moved to hospitals in the early 20th century that midwifery really started to decline.

Midwifery wasn’t a coherent set of practices or philosophies. Many women who immigrated to Canada had midwifery knowledge. Aboriginal women have been practicing midwifery as long as they’ve lived on this land. Practices, therefore, were as diverse as the women who birthed babies.

Aboriginal midwifery has played a vital role in Canadian history. Aboriginal midwives played central roles in Aboriginal communities, as healers, teachers, spiritual and moral figures, and as women’s helpers. When European colonizers came to Canada, Aboriginal midwives used their skills to catch their babies, and in some cases acted as cultural liaisons.

This important role was not given the respect it needed by white Canadians. Concerned with health conditions in the North, the Canadian government forced pregnant Aboriginal women to leave their homes and give birth in hospitals in the South. While midwifery in the North is starting to come back, these evacuations continue today. Aboriginal women who are deemed “high risk” are forced to leave their homes and families and stay in Southern hospitals, sometimes for weeks. Sometimes they don’t speak the language. Cultural practices, birth traditions and the importance of family in the birth process are ignored. Aboriginal people worry about the effects of children being born so far from home. This practice has also meant the decimation of the traditional Aboriginal midwife. Canada’s history of residential schools, where Native children were removed from their communities and taught that white culture was superior, has also helped to erode Aboriginal midwifery. Given the important role that midwives played in Aboriginal communities, it can be argued that the erosion of Aboriginal midwifery is tantamount to the erosion of Aboriginal communities themselves.

When midwifery was eventually legalized in Ontario, Aboriginal women asked that Aboriginal midwives be exempt from regulation. Due to the history of abuse and degradation by the Canadian government, Native people have been skeptical about the benefits of state interventions. The result of this is the Aboriginal Midwives exemption clause in the Ontario Midwifery Act. It states that Aboriginal people can self-designate as midwives, and practice in ways that they define. Aboriginal midwives have a different educational system and different midwifery practices than registered midwives. (This doesn’t mean that there’s no overlap; some Native women become registered midwives instead of Aboriginal midwives).

The 1980s saw the resurgence of midwifery in Canada. It had never disappeared, but a combination of political factors made midwifery palatable to the public once again. One of these factors was the growing consumer advocacy movement in health care. People were questioning biomedical frameworks and hierarchies of power. The other important factor was the growing feminist movement, which sought to put birth back into women’s hands. These influences are integral parts of midwifery regulation today.

Midwifery was finally legalized in Ontario in 1994. Canada was the last industrialized nation to decriminalize midwifery. Other provinces followed, and today midwifery is legally recognized almost everywhere in Canada. With the exception of Alberta, it is fully funded everywhere that it is legal. I’m going to turn my attention now to Ontario, partly because that’s where I live and go to school, and partly because other provinces have followed Ontario’s midwifery model.

Midwives have been incredibly successful in organizing. Our services are completely funded for any woman living in Ontario, regardless of whether she is a Canadian citizen. We work in independent practices with other midwives. We have complete autonomy over low-risk births, and in many cases of medical complications we remain primary caregivers.

Midwifery is based on three principles: informed choice, choice of birthplace, and continuity of care. We work with women throughout pregnancy, birth, and for six weeks postpartum. During this period of time, we’re women’s primary caregivers. We support women giving birth in homes and hospitals. In Ontario birth clinics aren’t allowed yet, although some exist under the radar.

Those of us trained in Ontario go through a four-year university program. The first year and a half is devoted to courses in biology, social sciences and women’s studies. During the second part of the program, we do rotations across the province in midwifery clinics.
We see pregnancy as normal and natural and rarely in need of medical intervention. My personal philosophy, which is shared by other midwifes, is that pregnancy is a special time in women’s lives, and should be respected as such. This means that the birth of a “perfect” child isn’t the most important outcome of pregnancy. We need to understand pregnancy as a cultural and spiritual part of women’s lives. Furthermore, the needs of a fetus are compatible with the needs of its mother; if we care for women, the needs of their babies will be met.

Midwifery in Ontario takes a holistic approach to health. We work with women’s families and communities, as women define them. We work within women’s cultural frameworks. We respect women’s spiritual understandings of pregnancy and birth.

This may sound awfully idealistic. I’m hesitant to paint such a rosy picture of midwifery in Canada. To be sure, midwifery regulation has had some very positive impacts on the way we practice, particularly in terms of being able to offer our work free of charge. On the other hand, we have a high C-section rate. Many of us fear that the number of hospital births we attend is leading to the erosion of home birth in Canada. Some of the regulations have not benefited the women we serve, but rather have been put in place to protect us legally. Our clients in some ways have fewer choices than they had before legislation.

Another important thing to consider is that midwifery is still a predominantly a white space. Because of systemic racism, midwives of colour were excluded from the regulatory process. Many women of colour also feel that midwifery is not a welcoming place, and that their needs aren’t met in the education programs or when practicing. Furthermore, while there are probably thousands of immigrant women living in Ontario with midwifery skills, it is very difficult to get foreign skills recognized. I have written extensively about this on my blog. While I think that this is a critical issue, for the sake of space I urge you to take a look at my website for more information about this. (Start with In which Melissa is schocked by racism, then move on to When do our priorities make us complicit in racism?, followed by Racism and Reproduction and Creative projects for white folks working against racism and go from there).

Midwifery, one could say, is Canada’s oldest and youngest profession. We’re still dealing with a lot of growing pains. But many of us are intensely political and committed to issues of equity and reproductive justice. We have a passion to work with women, as the word midwifery implies, and will continue to work to provide women with the best maternity care possible.

So, during every learning curve (and especially in health care), you go through the godawful phase where you know nothing, everything is difficult, your work is incredibly slow and laborious, you feel pathetically inept and incompetant, you are continually overwhelmed, and generally, find yourself wondering why in the world you ever wanted to be a nurse/doctor/midwife etc. etc. in the first place. Well…at the moment, I am RIGHT in the middle of this phase, and it SUCKS. Big time.

I remember going through this as a new nurse. My first six months on L&D were TERRIBLE. I made a gazillion mistakes. I got yelled at by doctors, charge nurses, and patients—sometimes all three in one day. I blew at least 10 IVs before I could start one, and each blown IV brought my dwindling confidence to a new low. Patients would ask me questions and I would have NO idea what the answer was. In general, I felt like the world’s biggest idiot, and a pretender, at that. There were so many nights when I would come home exhausted while still adjusting to 12 hour shifts and just cry into my pillow, or cry on the phone to a friend, or cry in person with a friend over coffee…and then have to wake up the next morning and do it all over again. It was torturous. I thought it would never get better.

However, it did. I stuck with it, dragging my sorry ass to work each shift, and after about 6 months, I started to feel like I had a clue. By 8 months, I was enjoying myself. I became the IV queen on my unit, able to start those hard-to-get IVs that other nurses couldn’t start. By a year, I finally felt like I was a good nurse—competant, caring, able to get things done well, but also in a very timely manner. I had made friends on the unit, the charge nurses had grudgingly started to like me, I had earned the doctors’ respect and liked working with many of them, my patients would send me thank you cards and chocolates and champagne, and generally, I loved my job and felt like I was doing it well.

The point being, after working so hard to get to that place as a nurse, it’s really difficult to go back to square one as a midwife, and start all over again. I know nothing, especially when it comes to prenatal care, ambulatory clinic, or managing clinic patients. I can’t do anything well, or quickly. The management process seems to be beyond me. SOAP notes are the bane of my existence. One of my patients at clinicals yesterday complained because I was so slow (it took me 1.5 hours to do an initial prenatal visit, including complete health history and exam. My preceptor said that in general, a revisit should take about 15 minutes long, and an initial visit half an hour… … … uh…right…). It’s a vicious circle. I am uncertain and don’t manage my patients or my visits well, which only makes me feel even more incompetant, and then I manage my patients and visits even more poorly. I left the clinic last night in tears, wondering why in the world I wanted to be a midwife.

This morning, at least I can remember why I want to be a midwife, but being a doula or childbirth educator and forgetting this whole midwifery thing still seems pretty appealing. I left clinicals yesterday thinking that I never wanted to go back. I’m sure I will go back (next week, in fact), and I’m sure it will get better eventually, but ouch. At the moment, it just sucks.

A friend of a friend recently asked me a question that I couldn’t answer. She is in her late 30s, has a two year old daughter, and has been breastfeeding on demand for the past two years. She and her husband have been trying to have another child, but she just recently learned that she miscarried after their first attempt. She has only recently started getting her period again, and was wondering if the breastfeeding could negatively impact her body’s ability to get pregnant again. I speculated that the high levels of prolactin which occur during breastfeeding might inhibit ovulation, just as high levels of estrogen inhibit breastmilk supply by competing with prolactin for binding sites in breast tissue, but I told her I wasn’t really sure and that I would investigate. I thought that somehow estrogen and prolactin were counter opposites: one could not exist in high levels while the other was around. Turns out I was waaaaay off base. Here’s what I found:

During pregnancy, the corpus luteum, acting on instructions from the placenta, secretes the estrogen and progesterone necessary to maintain the pregnancy. These high levels of steroid hormones simultaneously supress Follicle Stimulating Hormone (FSH) and Leutenizing Hormone (LH), the two hormones most responsible for ripening an egg and then triggering ovulation—after all, if you’re already pregnant, there’s no need to ovulate. After delivery, once the placenta is removed, the high levels of estrogen and progesterone no longer exist, and the levels of FSH and LH gradually begin to rise again, preparing the body for ovulation. Eventually, as the levels creep up, the pituitary takes notice again, and begins to release more FSH and LH through a negative feedback loop, which eventually will trigger ovulation.

“Most nonlactating women resume menses within 4 to 6 weeks of delivery, but about one-third of the first cycles are anovulatory, and a high proportion of first ovulatory cycles have a deficient corpus luteum that secretes sub-normal amounts of steroids. In the second and third menstural cycles, 15% are anovulatory and 25% of ovulatory cycles have luteal-phase defects…Lactation, or breastfeeding, further extends the period of infertility and despresses ovarian function. Plasma levels of FSH return to normal follicular phase values by 4 to 8 weeks postpartum in breastfeeding women. In contrast, pulsatile LH stimulation is depressed…in the majority of lactating women throughout most of the period of lactational amenorrhea.” [1]

In other words, after not menstruating for so many months, it takes the body a few tries to get the delicate hormone balance back up to speed again. The first few cycles either don’t release an egg, or if an egg is released, the corpus luteum, which is responsible for secreting enough progesterone to maintain the pregnancy until the placenta can take over, isn’t quite up to the task. This is called a luteal phase defect, and it’s a very common cause of early miscarriages. In women who are breastfeeding, the process of returning to normal ovarian cycles takes even longer.

In breastfeeding women, FSH, the hormone responsible for ripening an egg, returns to normal pre-pregnancy values fairly early, but LH, the hormone responsible for triggering egg release, continues to be surpressed due to the breastfeeding. (However, contrary to popular belief, prolactin is not at all responsible for this supression. It’s the constant suckling and stimulation of the nipple itself which actually suppresses ovarian function, which is why on demand breastfeeding is so essential to maintaining lactational amenorrhea.)

So, there you have it. To answer the question: it will probably just take a few more cycles for your body to get back into full swing in terms of ovulating, but continued breastfeeding did not contribute or cause the miscarriage in any way, and will not prevent conception. Most likely, the miscarriage was caused by a short luteal phase or corpus luteum that just wasn’t quite ready to maintain a pregnancy, and this will no longer be a problem once your body goes through a few more cycles and gets used to ovulating again.

[1] Hatcher, R.A. et. al. (2004) Contraceptive Technology, 18th Revised Edition. Ardent Media, Inc.: New York.