Belly Tales

Yes, it’s true, my antepartum/well-woman gyn ambulatory clinicals ended today, with a lot of mixed feelings involved! On the one hand, I’m thinking: thank the gods that’s over, because I need every spare millisecond to study now. On the other hand, I was just getting to the point that I was starting to feel like I had a clue, and was actually beginning to feel like I was doing an okay job (how’s that for a tentative sentence?) The pieces were just starting to fall into place, just in time for me to leave. And while I still have many objections to the clinic, such as how medical the care is (which, some would argue, is a good thing, but in my book midwifery care is very different from medical care…although it certainly incorporates many important aspects of medical care… but with a kinder touch…and the care at this clinic was definitely on the more medical end of the spectrum, if that makes any sense at all), I did learn an awful lot while I was there. The importance of speed was omnipresent, and I had more than one preceptor explain to me that unfortunately, that’s just the reality of our healthcare system, and that I should enjoy myself as a student because that’s the only time in my career that I’m actually going to have time to spend with a client…and maybe that is the case when you’re working in a large, hospital-based clinic, but damnit, why does it have to be like that?? These women deserve so much more than 15 minutes of time, and even though a midwife may be able to give them a very high quality 15 minutes, it’s still 15 minutes! For myself, I think I’m really going to have to think about where I want to practice when I graduate. I’ve always known that I’ll be doing homebirth someday, but homebirth isn’t something I am prepared to do as a new graduate. My original plan was to get a job in a hospital practice for a few years after graduating just to finish learning the ins and outs of the System, getting confident in my practice, and finally (finally!) moving on…but now I’m thinking that maybe I should graduate, and move immediately into where I belong: apprentice myself to a homebirth midwife, learn about the other side to midwifery care, the side that involves hour long prenatal visits, and using herbs more often than drugs, and existing almost completely in a world where birth is viewed as normal, and you never have to worry about appeasing the system, or worry about “taking too much time” with a client…but is that reality, or would that just be me turning my back on women that need my help, in order to work as a luxury midwife in a luxury setting, with the luxury of time?

But I digress. The point is, I learned a lot in clinicals. Tons. Basic stuff: I can now put in a speculum and find the cervix right away almost every time. I’ve learned how to be gentle with my exams, and how to ease women into them. I’ve taken some very good advice from a very wise midwife who’s been doing this for years, and have worked hard to get into the habit of always telling women that their cervix is beautiful (because how often do women hear that their bodies are beautiful? And especially from a healthcare professional? And especially that particular part of their bodies, which they have probably never seen, and may never have even thought about before…but how nice to hear that it’s beautiful! Wouldn’t that make you feel good about your body?), ensuring that they have tissues in their hands before I even begin the exam (a small modicum of control during a very exposing and vulnerable experience), and telling them that their pelvis is nice and roomy, just perfect for giving birth (and even if their pelvis isn’t enormous, who knows how big their baby is going to be? It could be a tiny little six pound baby that will slip through a small pelvis with nary a squeak. I just don’t think there’s any point in planting seeds of doubt about a woman’s ability to give birth vaginally, and certainly not during her initial prenatal visit, when you have no idea how large her baby will be! Most women grow babies that are the perfect size for their pelvis, assuming they’re allowed to labor in an upright position, and use whatever position they need during the birth, and squat and rock and roll and etc. etc.; epidurals are another thing altogether, don’t get me started). I’ve gotten much better at looking at women’s labs, taking a health history, starting to see the larger picture and formulating the appropriate plan to take care of them in the best manner possible (although the plans are still pretty difficult). All of this is stuff I wasn’t capable of 2.5 months ago, so these are all huge steps.

I do wish learning hurt a little bit less. I wish all of this were an easier process. I’m really getting nervous about my intrapartum clinicals next semester (actually catching babies????? You’ve GOT to be kidding me!). Antepartum is so complicated and difficult as is, and I still have SO much more to learn—I can’t even imagine intrapartum. But it’s nice to be able to look back over the past two months and see that progress has indeed been made. And then breathe a huge, whopping sigh of relief because thank the gods it’s over, and I can finally turn my full attention to my homework!!!

Oh, and I nearly forgot: a year ago today I wrote the inaugural post for this website. Wow. Was that only a year ago???

When I’m swamped, I usually don’t have time to post anything here, which is a shame, because it doesn’t allow the faithful reader a full blow-by-blow account of the ins and outs of being a student. So, here’s a five minute post just to render the reality of studenthood a little more clearly for those who’re interested: aaaaaaahhhhhhh!!!

Each semester the students are given modules to complete with the core competencies written down for every class. The modules are long. Here’s a small sample, from our antepartum module:

8.3 Discuss the components, timing, purpose, indications, contraindications, risks v. benefits, normal and abnormal results and appropriate followup for deviation from normal for the following tests:

Right…and that’s just section 8.3 of the 13 sections which makes up the first competency of our antepartum class (there are three competencies in antepartum). And then there’s a module for Well-woman gynecology, and a module for OB Pharmacology, and a mini-module for Professional Issues, and a module for Research. And, in a glorious climax of stress and work, we’re getting to the end of the semester, where all of the final exams occur, and the papers are due, and the modules are supposed to be completed. So, we’re working our butts off to get everything done in time, and then, once the modules are completed, we can actually hunker down and begin to study. So, yes, the life of a student…

(And this is not in any way trying to scare or deter any of you future student midwives out there who are reading this and starting to freak out…I’d like to say that it’s all worth it, and you make it in the end, except that I’m not quite there yet, and at the moment, I can’t see the forest for the trees…and I spend at least a few minutes every day saying to myself “why in the world am I putting myself through this??”…however, I guess if you’ve been called the way most midwivery students are called, you don’t have much of a choice in the matter).

If I’m not posting much in the coming week or so, it’s because I’m working on my never-ending modules. However, Lobby Day is this coming Tuesday, so I’m sure I’ll have a few things to say about that. (Lobby Day is a day organized by NYSALM for the very specific purpose of gathering as many midwives as possible in Albany, and talking/lobbying with our congress[wo]men for the bills which the midwives of New York State are supporting, and generally promoting the profession of midwifery etc. etc. I went two years ago and it was a lot of fun—I’m sure this year will be just as satisfying.)

But first, another AAAAAHHHH!!!! And then…back to work on the modules.

Via Feministing, there’s a rally being held today by the New York City Alliance Against Sexual Assault at Union Square, which started at noon today. While this notice is a bit late, there’s a 24-hour vigil and “Say-So” (Sexual Assault Yearly Speak Out) with continuous reading of survivor’s stories that will be going on all night until tomorrow at noon. So, if you’re around the Union Square area today or tomorrow (you know who you are), stop by and show your support. I’m definitely going to try to stop by sometime tomorrow. (And I wonder why I can’t seem to find the time to finish all of my modules…)

The pendulum swings in one direction, and then it swings back again. Last night I was awash with guilt and worried that I hadn’t done the right thing. Today, as I continue to process and sift through my thoughts on this subject, I am beginning to change my mind on some of it. The circumcision v. mutilation question is one that I’ve firmly figured out in terms of advocacy: when talking about FGM, when discussing it in class or with colleagues or other health professionals, I will absolutely refer to it as mutilation, because that’s what it is. But is telling a woman she’s been mutilated, and calling it “mutilation” to her face, the right thing to do? On reflection, probably not. Especially if she doesn’t view it that way at all. And as for always addressing it every time I see it…I don’t know that that’s the right call either. The more I think about yesterday, the more I think that maybe I did do the right thing by not pursuing it: she was making it very clear that she didn’t want to talk about it, tackling this issue was in no way relevant to the current exam or her current situation as a postpartum woman with a new baby, and as a student in a clinic, chances are good that I will never, ever see this woman again. So was it my place to try to get her deal with something she didn’t want to deal with at that time? Absolutely not. And yes, FGM is something that can’t be ignored in the clinical setting, and is absolutely something that shouldn’t be tip-toed around, especially when discussing this issue in general, and educating and advocating against FGM in public…but in terms of doing the best thing for the women we serve, bringing up painful memories or turning FGM into an “issue” for her (when in fact it might not be) is definitely not the right call. So, I guess the motto should be: follow her cues. And if this is something that’s going to be addressed, it’ll need to be done over the course of several months, in a situation where the woman and midwife will be able to establish a trusting relationship, especially since it’s such a delicate subject. It might take several visits before she’s even able to talk about it. Who knows what I’ll say next time I see it, but at least I have a better idea of where I stand now.

And with that, I’m off to cook dinner, and then work on my neverending modules.

The exam today began like any other routine postpartum exam: we talked about her birth, cooed over her baby, was she having any problems? Breastfeeding was going well? Bleeding had stopped? Had she started having sex again? What was she planning on using for birth control? Then, after all the listening and talking and note taking and question answering, we finally moved around to the exam, which also seemed routine enough until we got to the pelvic portion. It didn’t hit me immediately—I just kept staring at her vulva while a small voice in the back of my mind kept nudging me that something wasn’t quite right—and then I finally saw it: she had no clitoris. She had no labia minora. There wasn’t anything except her outer labia, and the introitus (opening) to her vagina, and a thin, white, well-healed scar running up the center of her vulva, from her vagina to where her clitoris should have been. You’d think this would have been glaringly obvious, except that I think some subconscious part of me was in denial, willfully trying to make me see something that wasn’t there.

And breathe.

“Oh,” I said, as calmly and casually as I could, “I see you’ve been circumsized.”

“Yes,” she said, “back in my country.”

And then I sat there for another few seconds, on my stool with her legs in stirrups on either side of me, wondering if I should say anything else. What should I say? Should I ask her how she feels about it? Should I ask her if it bothers her? Should I ask her if she’s planning on having her daughter circumsized? Was there anything I could do for her? Was there anything I should do for her? We’d learned about female genital mutilation (FGM) in school—the different types and degrees of mutilation, the different surgical procedures that can be done to de-infibulate women—but actually seeing it was like a slap of cold water to the face. And yet, at the same time, I was very hesitant to impose my judgements on her. Asking her if it bothered her implies that it should bother her; asking how she feels about it is a more neutral question, but she was definintely giving me signals which seemed to indicate that she didn’t really want to talk about it.

So what did I do? I didn’t say anything. I proceeded with the rest of the exam. It was a Type II mutilation, her introitus and vagina were perfectly normal, the laceration from her delivery had healed nicely, there wasn’t any infibulation present, and she was obviously able to give birth vaginally without complications from the FGM. I finished the exam, wrote my note, talked about it briefly with my preceptor, and then moved on to the next woman.

Except that now I can’t shake the feeling that I didn’t handle the situation correctly—in fact, the more I think about it, the more certain I am that I handled it very incorrectly. I’m not sure exactly what the correct way of handling it is, but I feel like I didn’t advocate or educate or do my job as well as I potentially could have. And I can’t get the image of her vulva out of my mind, either. It’s not something you ever want to see, and having seen it now, it’s not something I’m ever going to be able to unsee.

What’s the right balance to strike? We try so hard as midwives to be tolerant and respectful and non-judgemental of the cultural practices and beliefs of the women we serve that it’s too easy to look at FGM as a cultural practice, and avoid questioning it or challenging it for fear of stepping on any toes, or making a woman feel that we’re not being respectful of her beliefs and practices. I was scared of saying anything because I didn’t want to impose my own judgements of what’s right and wrong on her (i.e. my culture thinks clitoral hood piercing is cool, sexy and trendy, but I’m going to sit here and tell you that your cultural practice of FGM is actually violence against women?). How can you tell her that FGM is an act of violence when she might firmly believe that it is actually an act of love? When she might be grateful to her parents for insisting that she have it, so that she wouldn’t be unsightly and ugly in the eyes of her culture? Should I be the one to challenge her, or dissuade her of her long-held beliefs? And what if challenging this ends up throwing her entire worldview into chaos, and whereas before she was accepting of the FGM, afterwards she starts to think about it more and it begins to torture her? As if she hasn’t been injured enough. Is it my place to be the one to tell her that it’s wrong?

Was all of this floating around somewhere in my head when the word “circumcision” came out of my mouth? Probably. And that’s probably why I did say “circumcision” instead of “mutilation”. Mutilation is such a loaded word—such a terrible word! How horrible to tell someone that they’ve been mutilated! And yet calling it “circumcision” is like putting a thick veneer of acceptability onto a procedure that is unacceptable. Circumcising men doesn’t cause medical complications such as shock, homorrhage, possible death, long-term urinary incontinence, lifelong reproductive problems, cysts, keloid scars, absesses, not to mention permanently destroying their sexual function or ability to enjoy sex—or sometimes just their ability to walk without difficulty or pain.

Calling female genital mutilation “circumcision” is like calling genocide “ethnic cleansing” or calling rape a “forced sexual encounter”. It’s making something that’s violent and painful and oppressive and horrific into something that’s clinically palateable, something that can be politely discussed in the literature from a safe, removed distance, something you can say in a professional setting as if we were discussing a new haircut: “Oh, I see you’ve been circumsized. Yes, do you like it?” No! If beating women into a bloody pulp every Friday night was a specific cultural practice (and some days, it feels like it is), would we turn our heads and say: well, that’s just their cultural belief, and who are we to question it? If a man had no testicles and no penis, but just a thin white scar exactly where those organs should be, would we call that “circumcision”? I think not. FGM is a prevalent, worldwide form of descrimination and violence against women. Notes to self: it can’t be glossed over with antiseptic terms like “circumcision”, it can’t be tolerated as a cultural belief, and it can’t be ignored in the clinical setting.

So…that’s what happened today. I’ve been trying to wrap my head around it all night. I have no idea what I’ll say next time I’m in this situation, but I know for sure that I will definitely call it what it is: mutilation. And I will definitely say something, instead of just letting it slide. But what to say?????

Here are some great resources on FGM, most of them courtesy of Women’s Health News:

Female Genital Cutting — National Women’s Health Center
Female Genital Mutilation: Legal Prohibitions Worldwide — Center for Reproductive Rights
Female Genital Mutilation: A Human Rights Information Pack — Amnesty International
Female Genital Mutilation — Unicef
STOPFGM
RAINBO — Research, Action and Information Network for the Bodily Integrity of Women
Prevalence of FGM — US Dept. of State
Female Genital Cutting — USAID
Female Genital Mutilation — AAP Bioethics Committee Policy Statement
Possessing The Secret of Joy — a novel by Alice Walker

Huge congratulations to my dear friend K who just gave birth to a gorgeous baby boy on Thursday, 4/13/06 at 12:09 pm at home, in a kiddy-pool (I’ve only heard a brief account of the birth, but it sounds as if the baby was born into her husband’s arms)!!! He’s a gorgeous chunk of a baby, too: 9 lbs, 7 oz. Unfortunately, I wasn’t there as I had originally hoped, but I’m SO glad everything went so smoothly for everyone involved. Hopefully there will be birth stories and pictures to come. Sooo happy for you, and so proud of you, honey—he’s absolutely beautiful. Congratulations!!!

Speaking of the devil…I just popped over to The Mommy Blawg, and what should be there but an amazing article by Suzanne Hope Suarez that first appeared in the Yale Journal of Law and Feminism: Midwifery is not the Practice of Medicine. This article raises and supports so many of the points I just touched upon in my last post regarding the dangers of the overmedicalization of birth, the prosecution of midwifery and those who fall outside the medical system, and the economic and competitive motives which often underlies this prosecution. Robbie-Davis Floyd is even mentioned, too:

Obstetrical interventions pass for science, even though their use in normal pregnancy is irrational. According to anthropologist Robbie Davis-Floyd, obstetrical interventions fulfill a rational societal function by diminishing our high-tech society’s extreme fear of birth. Specific cultural services are performed when obstetricians “bring forth a new social member through a maze of wires and electronic bleeps.” Obstetrical rituals convey core values that center around science and technology. Belief in them as “necessary” sustains patriarchal institutional management. We let monitors, intravenous devices, and drugs give birth instead of women, turning the bodies of women who give birth into “machines.” Faith in technology provides a comfortable refuge from the unknown.

Even though this article was written in 1993, almost everything it discusses is still true, or even more true. The c-section rate is no longer 23%, it’s a whopping 29%. Things keep getting worse, not better. No joke. This article is AMAZING, complete with references! Go read it IMMEDIATELY! I cannot stress this enough. We should print out copies of this and tape it to the walls of hospitals, or hand it out on the street, or just randomly place it in mailboxes. This article needs to become public knowledge, ASAP. The time to rediscover midwifery is NOW.

The New York Times has been turning out a lot of articles on birth, pregnancy and midwifery, lately—seems like there’s been at least one major article a month for a few months now. Here’s the latest one, from last week, which centers around the prosecution of Jennifer Williams, a CPM practicing homebirth in Indiana. Because CPMs aren’t licensed or recognized by the state of Indiana, Jennifer is being prosecuted for the practice of midwifery without a license—Indiana being one of eight remaining states which still doesn’t recognize CPMs certified by NARM.

By and large, the article is pretty fair and objective, but I think the case against the hospital—how dangerous and damaging the overmedicalization of birth can be—and the reasons why a woman might choose NOT to have her baby in a hospital, is missing from this article, or else given very short shrift. There’s still a small hint of “those crazy midwives who deliver babies at home without any medical knowledge at all!” to this article, and it always saddens me when midwives get press like this.

“No one complains until a baby dies or a mom dies,” Professor Tovino said. But once the issue arises, she said, legislatures often become involved as well, with doctors and midwives engaging in a bitter struggle over the proper regulation of midwives, one driven by a mix of motives that are difficult to disentangle.”There has always been a tension between true quality-of-care concerns and anticompetitive concerns,” Professor Tovino said.

Around the nation, there are some 3,000 midwives without formal medical training, according to the Midwives Alliance of North America. About 1,100 of them, including Ms. Williams, have been certified by the North American Registry of Midwives, a private agency whose evaluations are recognized in some 20 states. In Indiana, though, only doctors and nurses may deliver babies.

[...]

Mr. Apsley said his decision to prosecute Ms. Williams was driven solely by the law as it currently stood. “We can all have different opinions about the speed limit or the age of consent or whether drugs should be legalized,” he said. “Those decisions are for the legislature.”

He added that the evidence against Ms. Williams was strong.

According to an affidavit filed by Rick Isgrigg, an investigator with the Shelby County Sheriff’s Department, Ms. Williams conducted a dozen prenatal examinations on Oliver’s mother, Kristi Jo Meredith; monitored the fetal heart rate during labor; made a surgical incision known as an episiotomy when she detected fetal distress; performed frantic CPR on the baby when he emerged; and sutured the incision afterward.

I love the use of the word “frantic” there. When is CPR not frantic? I assure you, it’s frantic in the hospital. I’ve never seen resuscitation done at a homebirth before, but I’m sure the midwife had oxygen and the proper equiptment, was certified in Neonatal Resuscitation, and probably knew what she was doing…albeit frantically. (In theory I know what I’m doing, but I’m still frantic every time a baby comes out blue and I’m the one who needs to begin the bagging).

Where’s the other side to this? Where are the statistics regarding how many babies die every day in hospitals all over this country, or how many doctors are sued for negligence or malpractice? And of course, the excuse given is that more babies die in hospitals because hospitals always manage the dangerous, high-risk births, which is true—hospitals do handle the high risk births, but mistakes are made in hospitals just like they’re made in homes. And then, where are the statistics depicting the number of unecessary invertions performed in hospitals that damage the mother and baby (or both)? The number of unecessary episiotomies cut, the number of baby’s bruised by forceps, scalped by vacuums, the number of women who no longer enjoy sex because their pelvic floor is toast after a pair of forceps made their vagina look like a fire-cracker had gone off inside of it, the number of totally unecessary cesareans, the number of spinal headaches, uteruses ruptured by pitocin, postpartum hemorrhages caused by impatient doctors tugging on the cord or manually removing the placenta?

I could go on and on, but this isn’t really about the safety of homebirth (which many studies have verified, including last year’s large prospective cohort study in the BMJ). This is about choice.

“It is not illegal to have a home birth,” Ms. Welch said, noting that about 1,000 Indiana families had their children at home each year. “But doctors and nurses are choosing not to do home births.”The current law, Ms. Welch said, drives midwives underground. “I don’t want to have a midwife hesitate to take a woman to the hospital because she is afraid she will be arrested,” she said.

If a woman wants to have a homebirth, who is she supposed to turn to? If doctors and CNMs aren’t performing homebirth (for whatever reason), a woman’s choices and options are severely curtailed—either she succombs to the system, and has her baby at a hospital or birthing center with a legal practitioner, or she has a homebirth anyway, though not necessarily with a legal practitioner. Even in states where homebirth is legal, practical barriers are in place which limit the number of practitioners who can offer homebirth as an option. A perfect example of this is what’s going on in the capital region of New York right now: homebirth is legal in New York State, and it’s legal for CNMs/CMs to offer homebirth, so long as they have a signed practice agreement with a collaborating physician. However, doctors in the capital region are refusing to sign collaborative agreements with homebirth midwives, so these board certified, legal CNMs/CMs are forced to work underground, illegally…or else, no longer offer homebirth services to women in the capital region. What kind of choice is that?

If a state does nothing but put up barriers to homebirth so that it’s virtually impossible to have a homebirth legally, and then continues to punish women and midwives for choosing to have a hombirth illegally (because that’s the only way to have a homebirth in that state), women are caught in a no-win situation. While the midwife is the one being prosecuted here, it’s really homebirth itself that’s indirectly under attack.

This reminds me of the prosecution of another midwife in Pennsylvania, Judith Wilson, a CPM with over 20 years of experience who is being charged with Involuntary Manslaughter, Endangering the Welfare of a Minor and Unauthorized Practice of Midwifery after the death of Isaac Daley, a footling breech baby she delivered in 2002. When it became clear to Judith that the baby was in the footling breech position, she explained the risks to the parents, John and Healther Daley, and recommended that they transfer to the hospital immediately. However, John and Heather, weighing all of their options, made an informed decision and chose to stay at home, willing to bear whatever consequences occurred. This is called CHOICE. Now Judith is being prosecuted by the state, even though John and Heather Daley do not blame Judy, continue to support her, and refuse to press charges. More information on this case can be found at The Mommy Blawg.

When the state steps in to prosecute a midwife for continuing to help and support a couple who has made the informed decision to give birth at home, despite the known risks, what is really under attack here? And what else was Judy supposed to do in the situation above, after explaining to the family about the footling breech, and recommending that they go to the hospital? If the family refuses, what more can she do? Abandon John and Heather Daley in the middle of their birth, in order to legally save her own skin? As Barron H. Lerner pointed out in his essay in the NY Times yesterday (Saying No Is a Patient’s Choice, However Risky), the choice to turn down medical options or interventions is always a choice.

Women choosing to give birth at home are taking a big risk, said Dr. Kevin R. Burke, president of the Indiana State Medical Association.

Well, that’s your opinion, Mr. Burke. But they should still be allowed to take that risk, if they so choose. Just like people should be allowed to have an abortion, if they so choose, or refuse a life-saving blood transfusion, or choose to die at home, forgoing all of the drips and transplants and procedures that could prolong their life for another 10 months. For some reason, though, birth, and homebirth in particular, triggers gut reactions in people which have absolutely no basis in reality. Personally, I think it has everything to do with what Robbie Davis-Floyd discusses in her book Birth As An American Rite of Passage: birth, as one of the major rites of passage in our society, is something that needs to be controlled by our society so that it upholds our cultural beliefs and values (i.e. the trancendence and dominance of technology). Choosing to give birth beyond the bounds of these controls necessitates the need for even tighter controls, hence the prosecution, and the barriers in place which restrict homebirth, and all of the hew and cry which arises whenever a story like this comes out. Call it a fantastical theory, if you like, but it rings true ot me.

Guess who just signed up for her Birthing From Within level one mentor training?!? Guess who’s been wanting to become a Birthing From Within certified childbirth educator for years now, and who’s so excited she’s nearly pissing herself?? And, guess who gets to attend this workshop in her own backyard (New York City, baby), taught by Pam England herself??

Awww, c’mon, just take a wild guess. This calls for one very exuberant *squeeee* of joy!