Belly Tales

I just discovered the most amazing videos over on You Tube about a traditional midwife working in Mexico. I’m sure many of you have probably seen them already, but I was just blown away!! It’s amazing to watch the way she uses her hands to massage, assess, palpate…turn a breech baby. A midwife’s greatest tool is her hands. I wonder how many of the women I see in the clinic come from traditional midwifery practices like this. American midwifery must seem very different to them. At it’s heart, I think the respect and tenderness and kindness to pregnant women remains the same, but we could learn so much from traditional practices like this. It makes me want to quit my job, fly down to Mexico and study with her for a year. In any case, enjoy!

A few weeks ago, Dark Daughta over at One Tenacious Baby Mama asked me for a contribution to her new weekly series entitled Reloaded, which happens every Sunday and features old posts that are worth posting and reading a second time (oldies but goodies, as she calls them). She wanted posts that I was particularly proud of, “something that really kicks ass analytically, politically” etc., and I quickly discovered when I was combing through my old posts that I don’t really have much in the analytical/ political/ highly opinionated/ kick-ass vein. It seems that my blogging style overall tends to be of the objective-news-reporting variety, or at best the highly-researched highly-factual variety; in other words, the variety that is so factual and evidence-based that no one can really argue or disagree with what you’re saying; in other words, the risk-free variety. Which is good to know about yourself, I guess, because it then prompts a bunch of really good questions, like: WHY AREN’T YOU TAKING MORE RISKS? Why aren’t there more highly opinionated, highly political, highly analytical, highly kick-ass posts on your blog? What are you scared of? Pissing someone off? Causing controversy? But really…is there any other point to a blog than opinion? If all we’re after is the news, we’ll read newpapers and news sources, thank you very much. Blogs are supposed to comment on things. So, good to know. Note to self: enough with the reporting on things. Get commenting instead. Go out on that limb. It’s about time, don’t you think?

Anyway, I sent Dark Daughta a few posts. One on the Keeper (still one of my proudest feminist and environmentalist statements), one on the UK’s new birth agenda (Maternity Matters), and two on female circumcision (Circumcision or Mutiliation? and Further Thoughts on FGM).

I was curious to see what Dark Daughta would think of them. Leave it to Dark Daughta to not only think about them, but to write an explosive 1000 word treatise as well. She picked my posts on female circumcision, of course, and then ran with them. Ran is a polite word for what she did. More like smacked the posts upside down, flipped them inside out, and then shook all of the loose change out of their pockets. She took everything I had thought after my first encounter with a circumcised woman, and all of the conclusions I had come to at that time (and this had involved a lot of thinking back then, trust me), and managed to turn all of those thoughts, all of those culminations of thought, absolutely, irrevocably, upside down. In the space of just one post. Leave it to Dark Daughta to challenge the hell out of you.

Just a few highlights, here:

Dear Student Midwife:I’m glad that you’re asking yourself questions about how best to proceed. …Maybe examining the culturally based and biased and ofttimes downright racist, response of many privileged feminists who were not born into cultures where genital circumcision is practiced might offer some much needed space inside which there might be less emotionally and politically charged room for a true examination of the issues.There is a power relation here. Are parents in western societies hunted down and denied access to safe male circumcision? Why is the WHO advocating for this procedure when there is a fast growing segment of the male population that is crying out against it?

When male circumcision of babies who can’t make the choice for themselves is enshrined as a part of at least major world religion, are health care practitioners strategizing about how best to stigmatize grown men who present penises that are mutilated? Are feminists of conscience refusing to sleep with men who are circumcized? Are we looking on them with pity and defining them as mutilated? Are we strategizing about how best to divest them of custodianship of their sons so that we can keep them safe from circumcision? Is anyone noticing that the actual side effects of male circumcision…besides those that go horribly wrong…are minimal because these surgeries are done by skilled practitioners in sterile settings?

I don’t agree with either kind of circumcision. But I can’t fail to notice that one is filled with shame and stigma heaped on those who experience it, while the other is thought of as a throwback that should be done away with but is still tolerated and executed in hospitals.

Being useful is definitely not going to include making any circumcized wimmin feel uncomfortable and on the spot about the decisions of their parents. So, labeling a woman’s cuts “mutilations” without checking to see what if anything she says about her own genitalia will go a long way to making a practitioner seem like a judge and not as someone a woman can potentially confide in or turn to.

Because really, the shock and the unfamiliarity with the view below is ours, not theirs. If we’re gonna pay lipservice to accepting the anatomy of the vulva, we’re going to need to work at really understanding and respecting that wimmin come in all sorts of configurations for all sorts of reasons.

This “who is civilized” and “who is babaric and uncivilized” binary split that serves the west/the north, giving our cultures a much needed oppressive ego boost needs to GO!

Yowsa. And those are just the highlights. I’d highly reccommend that you go and read the rest of the post, because she writes with so much passion and conviction, and has this incredible way of phrasing things in ways that I would never, ever think of.

Now, how do you respond to a post like that? I didn’t even know where to start. First I had to do a lot more thinking on the subject, which I’ve been doing for the past several days and nights. I wrote an e-mail response to her, which she published in last Sunday’s Reloaded V which started to flesh out some of my thoughts. And now I find myself here again, having done yet another 180 on the subject (my apologies for repeating some parts of my e-mail, but this is pretty much where my thinking is at right now).

I think Dark Daughta is right on a lot of counts. There is indeed an inherent racism/ oppression in a viewpoint which has decided to call one form of ritual cutting “mutilation” while at the same time leting so many other types of cutting fall under the category of “circumcision” or some other word, and therefore under the umbrella of cultural acceptability (male circumcision, labioplasty, clitoral hood piercing, episiotomy etc.). I can see how that is indeed our culture (and by that I mean western culture) taking its own viewpoint on what constitutes a healthy vulva and setting it forth as “right” and “correct” and that anyone else who does anything different to their vulva (especially something brutal or harmful and something we as a culture don’t fully understand) is therefore wrong and backwards and oppressed and brutalized by their own culture…and that this “mutilation” is therefore a form of violence against women. This viewpoint then lays the groundwork for our invasion of their culture; in other words, this viewpoint basically gives us permission to enter their culture and tell them what’s right and wrong, and that they have to stop this cultural practice. And many huge, big name organizations like UNICEF, the World Health Organization, the US Dept. of State, Amnesty International, USAID etc. etc. have all issued policies and statements which call for an end to this practice, and have programs or policies in place which exist to help educate and save these women from their fate.

Calling something “mutilation” implies, by its very nature, that those who are “mutilated” need to be saved. That makes sense, and I see that now, but I had never before thought of it in those terms. So further thinking on this is prompting me to start to refer to this ritual as “circumcision” again rather than “mutilation”. I do appreciate that my view of what constitutes a healthy vulva is certainly not everyone’s view, and who am I (or who are we?) to decide what is or is not the right kind of vulva? Why is labioplasty or clitoral hood piercing okay, while female circumcision is not? And what would happen if circumcision was done well, by medically-trained people using sterile instruments, sharp instruments, making clean, hygienic cuts? So many of the problems inherent in this practice comes from the scarring and infection which is secondary to the cuts themselves. If there was no scarring, if there was no infection, would the damage be less? As Dark Daughta pointed out, female sexuality stems from a lot more than the tiny nub of flesh which is the clitoris. If the clitoris is removed, but in a clean and precise manner, using sharp, sterilized instruments (rather than a rusty tin can or a piece of glass etc.), would women be able to retain a higher level of sexual functioning? I never, ever would have thought that an underground feminist movement to provide clean, hygienic, medically-trained female circumcisions is not that far off from what feminists were doing in the 70s with their underground abortion clinics to provide clean, hygienic, medically-trained abortions, but yeah, I do see the similarity.

I wrote in a comment on my first post that “I undrstand that there are a lot of cultural and personal reasons involved in choosing [male] circumcision, and I don’t feel like it’s my place to say.” So if I can so graciously back out of the debate when it comes to males, why can’t I do the same with females? To say that these girls aren’t educated about the pros and cons of the procedure, that they’re forced into it by their parents and their culture at a young and vulnerable age (usually at puberty), and that they therefore aren’t making informed consent doesn’t hold up, either, because the same can be said of male circumcision. Baby boys are absolutely, positively NOT making an informed decision when it comes to having their penises cut or not. It’s a decision that their parents are making for them for many different reasons, just as it’s a decision that the culture/ parents are making for the girls who are receiving female circumcision. And I ask again: what right do I have to step in to this decision-making process and tell someone that they’re wrong, or that this decision is wrong? I have no right whatsoever.

Now, before someone comes along and rips into me, let me just make this very very clear: I am not advocating female circumcision, nor am I advocating male circumcision. I am not condoning either practice, nor am I saying that they’re both fine and acceptable, and that they should continue unhindered. All I am saying is that it’s not my place to judge these practices, and it’s not my place to make these decisions. Since I’m not a member of a culture that practices female circumcision, the rich cultural context with which this practice resides is lost on me. The shame or humiliation someone of that culture might feel by not being circumcized and therefore not being a full participant of their culture is something I’m never going to be able to empathize with. And I am questioning whether it is right for our culture (Western culture) to go on huge “Stop Violence Against Women” campaigns in cultures which are not ours, in contexts which we don’t fully understand (and probably can never fully understand).

I do think that these practices need to stop. But I don’t think that the impetus for changing this is going to come from us (from the West), and I don’t think it should. If it’s going to change, it needs to come from within; from women and advocates who are of these cultures, who understand the context, who can see the patriarchy at work in such acts, and who want to rise up against it. And when they do, we as Westerners can and should support them with all of the resources our rich, privileged cultures afford us.

I guess the only sticking point I still have at this point is the following: if you’re a member of a culture, and if it’s all you know, and if you’re never exposed to anything else, you will never have the objectivity necessary to ever question or rise up against these practices that you have seen and been a part of since birth? And maybe that is where an organization can step in and offer education to members of these cultures; ideally, the education should come from members of the culture themselves. I think the folks over at RAINBO are on the right track, and if we as Westerners want to support the education of women (and therefore indirectly the hope that eventually these practices might stop), we can do this by supporting organizations like this.

As far as being a practitioner, the take-home lesson here is once again very simple, and very difficult to fully learn: LISTEN TO WOMEN, and DON’T JUDGE. How is it that I can see this so clearly on issues like abortion, where I absolutely, 100% feel that it is not my place to say, and that since I’m not carrying her baby or walking in her shoes, I have no right to judge at all….and yet issues like female circumcision still bring about huge, heaping amounts of judgement? As a white woman from a privileged background, I’ve been trying for awhile to own my privilege, and see the way that this affects my point of view on everything. This is a difficult, never-ending task, and while I feel that I’ve managed to own this on several more obvious issues, this is an issue I hadn’t even picked up on. I guess the ultimate, life-long goal for every evolving human soul is to continue to move towards a state of less and less judgement. To become as close to non-judgemental as you can possibly be. I say possibly, and “close to” because I think being non-judgemental is an impossible goal. Our psyche, our sense of self, our identities, our culture, our experiences and background and upbringing, everything we use to know ourselves as who we are–all of this is based on judgements which we have formed through living, judgements which we have consciously or unconsciously absorbed, and I think it’s impossible to seperate yourself from them. I am not using this as an excuse. Moving towards a more non-judgemental state requires very close and painful examination of those life experiences and background and upbringing and culture. It requires seeing the ways that your life experiences and culture has potentially prejudiced you, seeing the ways you are privileged, seeing the ways that power affects your identity–power you have, or don’t have, or have in some areas but not others. It requires seeing where you come from, seeing the way that this has formed your world view, and then seeing the way that this outlook affects how you see others. That’s a huge part of becoming less judgemental.

The LISTEN TO WOMEN and DON’T JUDGE take-home message means that all future encounters with women who have been circumcized will involve calling it circumcision, following her cues, and letting her talk or not talk about it, as she desires.

Anyway, those are my thoughts on this subject at this moment in time. Granted, I will continue to think, and I’m sure my thoughts will continue to evolve. I’d be really interested to hear what others think about this as well. It is a very sticky subject, and it’s not about to get any more clear any time soon.

I am a working girl at last!  Finally, after weeks of overcoming bureaucratic hurdle after hurdle, I am finally working!  Today was my first day at my new job as a new midwife at a busy Brooklyn hospital.  I can’t even begin to describe to you how exciting it was to get an employee ID with my name and the credential of CNM on it, or my CNM “stamp” that I’ll be using to write prescriptions.  All incredibly official.  A little bit surreal.  I was issued sets of scrubs, two long, white lab coats, spent a portion of the morning talking to the benefits coordinator about my benefits, and then, in the afternoon, was plunked down in the middle of a busy prenatal clinic, in true dyed-in-the-wool sink-or-swim midwifery style.

And how fantastic it as to be back in the midst of pregnant women again!  Listening to fetal heart tones, doing  Leopold’s maneuvers, estimating fetal weights, listening to women complain about their swollen ankles and over-active bladders and sore backs (normal, normal, all totally normal).  The computer system is cumbersome, I’m really, really slow, I have absolutely no idea what paperwork is needed to be filled out for referrals or ultrasounds or triple screens, but I suppose I’ll get there eventually.  The slow, painful, very steep learning curve has begun.  I can’t wait to look back in 6 months and see all of the incredible progress I’ve made—that is the light at the end of the tunnel.  In the meantime, I’ll be exhausted, overwhelmed, and making a lot of mistakes.  Oh joy.  But yes, oh joy!  I’m actually an employed midwife now.

So, I’m back in the blogosphere again, and realizing that I’ve been missing a lot of important news by taking a vacation for a few months. Here’s a quick overview of some of the stories I’ve found most pressing (and/or impressive) lately, even though some of these stories are old news by blog standards, and many other people have already done a much better job at covering them than I have.

First, Verizon Wireless, the cellphone megagiant, has gotten itself into a heap of trouble by initially refusing to allow NARAL Pro-Choice America to host a text messaging service on its network. Verizon initially claimedthat company policy allows it to refuse “highly controversial” and potentially “unsavory” messages from being distributed on its network. NARAL quickly shot back with an action alert and Verizon was flooded with thousands of e-mails and text messages from angry subscribers, and several anti-censorship groups also joined the fray. Quickly realizing it had made a huge mistake (especially when it discovered that other cellphone networks like Sprint and AT&T had approved the NARAL text messaging service without a whiff of protest), Verizon reversed its position, allowing the NARAL text service to go forward, and issued a statement in the press, but NARAL is still hounding Verizon to put its new public policy in writing. Interstingly, since the issue dealt with text messaging and shortcodes, the story was picked up not only by pro-choice and anti-censorship news carriers and blogs, but by sites like Ars Technica and Slashdot.

Sticking to the technology theme, the website Facebook recently started banning pictures of women breastfeeding from user accounts, and in some instances has banned specific users altogether (for example, Karen Speed from Australia, who has chronicled the entire event on her blog, One Small Step for Breastfeeding). Facebook banned certain pictures on account of their “obscene content” and asserted its right to remove pictures as a violation of its terms of use policy, but as the Sydney Morning Herald points out, it’s not exactly clear what constitues an “exposed breast”, which is the specific violation, and Facebook hasn’t provided any further. clarification. Right. So, breastfeeding is obscene, and women aren’t allowed to post their own pictures of themselves breastfeeding on their own facebook accounts. If this bothers you as much as it bothered me, go join the new facebook group entitled Hey, Facebook, breastfeeding is not obscene!

In other news, a 43 year old Russian woman has recently given birth to a 17 lb. baby, her 12th baby to date. Wow!!

Finally, this is a quick reminder to local folks that the 5th annual Miles for Midwives will be occurring this weekend, Oct. 6th, at Prospect Park. The 5K run/walk helps to raise awareness for midwifery, as well as raise money for the ACNM local NYC chapter, and Friends of the Birth Center. My beloved boy and I will both be there, of course, running and sweating in the sunshine. Race time is 10:00 am, rain or shine. If you’re interested in joining the race, you can register at Active.com.

Finally, the long-awaited SUNY Downstate Gala will be occurring this coming weekend, celebrating 75 years of continuous midwifery education. SUNY Downstate is actually the oldest and longest running midwifery program in the country, and is commerorating the event by a day-long educational symposium featuring speakers such as well-known author Barbara Katz Rothman and keynote speaker Joyce Thompson, CNM, followed by a dinner-dance. Sounds amazing! Go Downstate!

Guess today is Catch-up From Chicago day. In addition to the very long post on the ACNM, MANA and CMs which I just posted below, I also wanted to “unofficially” post the 2007 ACNM Student Report, which I helped to draft at the annual meeting this year with approximately 20 other student representatives from around the country. This report is drafted annually by the student reps to summarize and present student concerns to the ACNM as a whole, and is published every year in the Quickening, the ACNM newsletter. As you might surmise from my post below, the issue I was most concerned about was the representation of CMs, which translated into joining the committee that was drafting the paragraph on Professional Issues, i.e. the newly proposed DNP and how this will affect midwifery education. I’m putting this behind a cut, because again, it’s a very long document and I’m not sure how many people are really interested in reading this in its entirety, but I have been wanting to post this up here since the convention for posterity, more than anything else. So, here you go: (Read on …)

So, I wish I had more to report (actually, I have a lot more to report; somehow, our program seemed to totally skip of vulvar problems and conditions, such as lichen sclerosus and lichen planus and hidradenitis suppurativa and vulvodynia, so I’ve been learning about all of this while studying for my boards, and it’s very interesting stuff which deserves a post all on its own)…but in any case, my last week or so has been mostly spent with my nose in a book.  On the one hand, it’s been quite frustrating (I’m so sick of studying, truly!) and on the other hand, quite gratifying (almost all of it is review, and I think I know a lot more than I think I do), with the usual mix of stress and nerves thrown in for good measure.

My board exam is this Friday, at 9:00 am.  It’s 185 questions, and will take approximately 4 hours.  When I finish, I will find out immediately if I passed or not.  If I pass, I’m a midwife (!!!!!!!), certified and DONE and eligible to become licensed.  Mega-hella-w00t!  But I don’t want to get too far ahead of myself.  Today was IP cram day.  Yesterday was AP cram day.  Monday was Primary Care cram day.  Last friday was Family Planning/ Well-woman Gynecology cram day.  Tomorrow is PP and Professional Issues.  Tomorrow will also be practice-tests-until-your-fingers-fall-off day.  My birthday is on June 30th, btw.  I’ll be turning 30.  So, I will potentially be able to celebrate being a midwife and turning 30 on the same day.  How cool would that be????

But I don’t want to get ahead of myself.  One day at a time; for now, I’ve gotta get back to the nonstop STD/TB/HepB/pap management review.  Yeah, baby.

Graduate: 6. -verb (used without object): to receive a degree or diploma on completing a course of study (often fol. by from): She graduated from college in 1995.

Which is exactly what happened a few weeks ago, on May 29th, at Carnegie Hall, with all of the usual pomp and circumstance. And there was MUCH rejoicing! (w00t!) But first, I’ve got to tell you the story of how I almost missed my graduation, and how I managed to get to Carnegie Hall on time only by the very barest skin of my teeth.

Remember how I was in Chicago the weekend right before my graduation, at the ACNM convention? And remember how I was leaving on a flight from Chicago at 6:00 am, to arrive at New York’s La Guardia airport at 9:02 am, which would have given me plenty of time to collect my things and take a taxi to Carnegie Hall? And remember how I swore up and down to the universe that NOTHING could go wrong, period? Well, as it turns out, EVERYTHING went wrong. It was an absolute disaster. Now, looking back, it sure as hell makes for one fabulous story, but at the time, I thought my graduation day was going to be spent at Midway Airport, in Chicago, and I was an absolute wreck.

So how did this happen? Well, like this: most flights are overbooked, i.e. over-sold, and most of the time, this isn’t a problem. The airlines do this to protect themselves against the inevitable last minute cancellations and the people who, for one reason or another, don’t show up for their flight. However, when a flight is overbooked, and everyone DOES show up for the flight, there’s a bit of a problem, and some people end up on the standby list. How do they determine who is on the standby list and who is not? By those who have a confirmed seat v. those who do not. So here’s a piece of free advice: make sure you have a confirmed seat! If, for some reason you don’t actually have a seat number assigned to you or chosen by you when you book your flight, you’re assigned a seat number at the airport when you check in, which is all well and good assuming that there are seats left. But if the flight is overbooked, your seat number is assigned only on a first-come, first-serve basis, and if all the seats have been assigned, and you don’t have a seat number, you are on the standby list, and if there are no extra seats, you are S.O.L. Which is exactly what happened to me at Chicago. It was the day after Memorial Weekend, I guess more people had shown up than they were anticipating, the flight was overbooked, and I didn’t have an assigned seat number. Apparently I was supposed to have called two weeks in advance to confirm my seat number, but that was in the very very very fine print of the online ticket confirmation itinerary, which I failed to read (and which most people fail to read). So, I had a ticket, but no seat.

I was eighth on the standby list. There were absolutely NO available seats, and 13 of us in total were S.O.L. I can’t even begin to tell you about the fear and shock and disbelief I went through when I saw the door to the loading ramp shut and the flight take off without me on it. I think I made a very compelling case for sympathy as I stood at the desk in front of the gate holding my graduation robes in my arms, sobbing and saying things like “But I have to be at Carnegie Hall at noon because I’m graduating!”, as if just saying it would somehow make the Universe respond, or make another flight appear out of nowhere, but sympathy obviously wasn’t going to get me very far. There were no other available flights to La Gaurdia leaving from Midway that would get to New York in time. The next available flight on this particular airline (ATA Airline, fyi….I would absolutley, 100% NOT recommend them to anyone, and I will never be flying them again, period) was leaving from O’Hare aiport at 1:00 pm. My graduation was at noon. Cue panic.

There was another man (I forget his name) on the standby list who had a lecture to give at noon in front of an audience of 300 people, and there was another woman (Sarah) who had a job interview that morning which she was going to miss, and the three of us were the most desperate out of all the rest on the standby list. The man pulled out his laptop and started looking for other flights online, I called my beloved boy in an absolute panic, and the woman started looking at the departures board. We found another flight leaving at 7:00 am on Southwest airlines, arriving at 10:00 am…not to La Gaurdia, but to this very obscure, very small airport smack in the middle of Long Island (McArthur Airport…and no, I had never heard of it before, either). So, the next thing I knew, I was buying a one-way ticket to fly to Long Island, calling my beloved boy, and trying to figure out who to get from remote Long Island to the center of Manhattan in under two hours. Long Island Railroad wasn’t going to work—there was no way I was going to get to the train in time (it left once an hour, at 10 minutes past the hour, and there was no way I could get from the airport to the train station in 10 minutes). So then what? Driving seemed to be the only way forward, with all of the traffic jam perils inherent in that.

As luck would have it, my father had flown in from Nebraska the night before for my graduation, and he was staying with my grandparents, who also happened to live on Long Island (although much closer to the city than McArthur Airport). They had been planning on taking the train into the city, but after a few frantic phone calls, they agreed to meet me at the aiport on Long Island instead, and then we would drive into the city and make a mad dash for it. So now, cue short, stressful flight with me in a cold sweat the entire time, then cue agonizing drive into Manhattan, where every minute spent stuck in traffic on the Long Island Expressway was an eon, I swear. I bit every scrap of nail available to me; I bit my fingers to the quick. I would have bitten my toe-nails if I was flexible enough to reach them. The clock on the dashboard kept ticking, and with each passing minute, I was simultaneously hopeful and devastated. We hit a large amount of traffic shoftly after passing Manhasset, Long Island, and then we had to make decisions: Midtown tunnel v. Triboro Bridge, FDR v. going down 5th Avenue or Central Park West? Aarrrgggghhh!! However, somehow, miraculously, we were nearing Columbus Circle around 11:45 am (they had wanted the graduates there promptly at 11:00 am to get us lined up appropriately). Stuck in traffic again, I actually got out of the car shortly after we’d passed Columbus Circle, fully clad in my graduation robes, and proceeded to flat-out run the rest of the way to Carnegie Hall.

I arrived sweating and panting, was barely able to explain to the ushers what program I was graduating from, but somehow got pulled along to the right place in line, where I had just enough time to slip in between the other, much less sweaty students, and then the music started and we were walking out into the hall to take our seats. The ceremony began while my dad (thank you so much, dad, for your amazing driving!!) was still parking the car, but he was able to get a seat during a break in the speeches. I was so grateful to be there! I just kept looking at the beautiful hall around me, the other graduates, the stage, the speakers, with so much wonder and gratitude; I didn’t care how I looked (a bit of a sweaty mess), I didn’t care that my cape was askew (a friend was able to fix it while we were in line before walking across the stage), I didn’t care that the speeches were long, and somewhat boring….didn’t matter. I was AT my graduation, I was graduating, I was there to walk across the stage and receive my diploma, and that was all that mattered.

I can’t even begin to describe what it feels like now, to actually be a graduated nurse midwife. This huge accomplishment, this goal I have been working towards for so long, has been achieved, and I can look out now from a place that I have dreamed about being at for so long now…it doesn’t quite feel real yet.

And now, on to the What Next part of this post. What next? How do you actually go from being a graduated nurse midwife to being a real, employed midwife, with a license and a degree and a job? Well…that is the new adventure I am about to embark upon. I’m taking the national midwifery board exam on June 29th. (Note to self: you really need to start studying more vigorously for that.) I’ve applied for a few jobs. I had one interview two weeks ago, and they seemed quite eager to hire me, but alas, they thought they had three available positions, and it turns out they only had two. So who knows what comes next. Hopefully successfully passing my boards, and then becoming employed, a real midwife with a real job, very very soon. I’ve been neglecting this site lately, but I will try to pick it up again, especially since this is such an exciting time in my life right now (although also a very stressful time) with lots of changes happening very quickly. I will certainly keep you posted.

After signing off yesterday, I had some lunch then promptly attended three educational sessions in a row, two of which I paged. The first was entitled Cervical Ripening: What We Know and Why A Paradigm Shift is Needed for Reducing the Incidence of Preterm Birth, which focused on how our preterm labor treatments (tocolytics) are very utero-centric and concerned only with stopping contractions, while cervical ripening is often a much predictor for preterm labor. There is a lot of new research in this area, and new therapies aimed at counteracting cervical ripening might be more effective in stopping preterm labor than simply stopping contractions (which may, but often does not stop cervical ripening in any way). The speaker was very knowledgeable on her topic, which was her area of research and interest, but aside from presenting her own research, which is microscopic tissue analysis of the cervix under ultrasound to assess for markers of tissue disruption and increased water retention (precursors to ripening), there was not much which was immediately applicable to take away from her lecture. You get the sense, however, that in another 5-10 years, there will actually be drugs and assessment tools and treatments available to combat this aspect of preterm labor, which is very exciting.

The next educational session I went to was on sexual dysfunction, presented by a doctor who has spent years heading up a sex clinic in downtown Chicago and mentoring other medical and nursing students in sex therapy. While she had many, many (often sad, often hilarious) fascinating stories to relate, she really didn’t get into the nuts and bolts of sexual dysfunction in any great detail, at least not in any way that is immediately clinically applicable in terms of helping, counselling and treating couples with dyspareunia, anorgasmia, vaginismus, unconsummated mariages and premature ejaculation (although apparently you can use SSRIs, which notoriously have libido-killing side effects, to help delay and slow down men who have rapid ejaculation problems). Still, it was overall a fascinating topic, and really made me realize how little I know about sex therapy and sex counselling, which is indeed something a midwife should be pretty well versed in. While I certainly feel comfortable asking women about their sex lives, and discussing all aspects of sex and a person’s sexuality, specific treatments and counselling techniques are not at all in my repertoire, which is something that can be fixed with a little bit of reading and education.

The third educational session I attended was Menopause: Case Studies of Hormone Therapy, which was fabulous. I was astounded by how well the researchers knew the material. They made the very valid point that even though the Estrogen/Progesterone arm of the Women’s Health Initiative (WHI) was ended in 2002 due to the alarming increase in the rate of breast cancer, the other arms of the trial continued, and information is still pouring in from all sides, as well as from other studies that are now in progress. One of the speakers (Mary Brucker, CNM) termed it “research sushi”: after a large randomized control trial such as the WHI, you’re often left with more questions than answers, and in the ensuing years different aspects of the larger study are often chopped up (like sushi) into more specific questions and newer, smaller studies are mounted to try to tackle all of the questions raised. With hormone replacement therapy (HRT) at the moment, we’re apparently very much in the research sushi phase. It’s still a very grey, very unclear and ambiguous area, with very few clear guidelines or answers. While the WHI did a great job of scaring people so much that HRT is now often avoided at all costs (even when it can be very beneficial on a short-term basis for symptomatic relief of menopause), some of the information gleaned from WHI is actually, surprisingly saying the opposite. While the combined estrogen/progesterone arm increased the risk of breast cancer, apparently the estrogen alone arm of the study actually had no increased risk in breast cancer among the women treated with estrogen , and and a nearly significant decrease in risk (28% in the estrogne-alone arm, v. 34% in the placebo arm), which raises the question of whether all hormones are bad, across the board, period, end of story, or whether some hormonal therapy might actually have a very valid place in symptomatic relief (it also raised the question of what to do about women receiving unoposed estrogen without progesterone to balance it out, which has been shown to increase the risk of endometrial cancer). As you can see, very confusing stuff. They also delved into alternative treatments, such as the use of soy and phytoestrogens, Tibolone (which is used in Europe and actually had a worse Relative Risk for developing breast cancer than the combined and estrogen alone arms of the WHI), and compounded, bio-identical hormones, which also might not be the be-all-end-all cure that they are often touted as. Really, really fascinating stuff. I wish I was better versed in all of this, too, but I still find menopause and HRT very confusing.

Today started bright and early after a fairly late night dinner with a few other student midwives from Florida and North Carolina, mostly spent comparing our program experiences, mutually stressing about the board exams, and reviewing test questions that one of the students had from the test prep workshop she’d attended earlier that day. This morning I attended a great lecture on the Social Marketing of Breastfeeding, and how commercial marketing techniques can be very effectively used to market breastfeeding, especially when you break it down in terms of product, pricing, placement and promotion. She had all kinds of examples of ads from formula companies, which we then deconstructed in the class to root out the hidden, and often very sneaky and damaging hidden messages in them. Again, realizing how important language is: using the word “breastmilk repleacement” instead of “formula”, which makes it sound like a far inferior version of breastmilk, rather than a special, carefully planned, secret recipe which is just as good as breastmilk. We also talked about the importance of not only talking about the benefits of breastfeeding, but the risks involved with not breastfeeding. Again, none of this was new to me, but it was a very well put together and very concise presentation, full of good tips and suggestions, and it has really inspired me to work harder on my breastfeeding promotion and education (”selling” this amazing product—breastmilk!).

The schedule got a bit messed up, there are a few announcements on room changes and cancellations and switching of times, so the lecture on hormonal contraception counselling which I really wanted to attend, I missed. Instead, I ended up in a fascinating discussion panel on the horrific health disparities which still exist in our country, and the ways that midwives can work harder to amend these. We watched a small section of an upcoming PBS special entitled “Unnatural Causes: Is Inequality Making us Sick?”, which will air this winter in a 7 part series, and was incredibly eye-opening and terrifying in many of its implications. For example, the clip we watched demonstrated again and again that the areas of a county or city or state which have the lowest socioeconomic standing (which goes hand in hand with the highest crime rates) also have the highest rates of heart disease, pre-term birth, infant mortality, death by diabetes, hospitalization for asthma, lowest environmental standards, highest pollution and toxin exposure…the list went on and on. From the PBS website on the series:

Former U.S. Surgeon General Dr. David Satcher and his colleagues calculated that in 2002, 83,570 African Americans died who would not have died if black-white differences in health did not exist, a rate of 229 “excess deaths” per day. That’s the equivalent of one Boeing 767 being shot out of the sky and killing everyone on board every day, 365 days a year. And they are all Black. According to a by-now landmark study by Dr. Colin McCord and Dr. Harold Freeman, African American males in Harlem are less likely to reach age 65 than men in Bangladesh.

There are by now thousands of studies tracing the pathways by which racial and socio-economic status affect health. But there is virtually no popular media—no print, TV, nor web—that translate this research into forms that can build public understanding of how social policies are de facto health measures. As a result, the ‘common-sense’ wisdom remains that the poor and peoples of color get sick because they have unlucky genes, or they are just too lazy and undisciplined to to eat right, exercise and abstain frm drugs and booze. Similarly, it’s still widely believed that top executives who are dropping dead from heart and artery disease when in truth it’s their subordinates.

After watching the clip, we then moved into a very fascinating, (and very encouraging!) roundtable discussion. Midwives have always traditionally worked with underserved, indigenous populations, and it was amazing to hear about some of the changes and work that is being done around the country right now. You could feel the energy building in the room as people continued to come to the mircophone to speak. By the time the sesssion ended, the conversation had barely gotten started. Because the session is going to be repeated tomorrow, it was suggested that rather than starting over, we simply pick up the conversation again where we left off, which may or may not happen depending on how many people from today’s lecture attend the session tomorrow. In any case, though, I would watch the PBS documentary when it comes out, because it is going to raise A LOT of questions, and cause a media-world storm to descend on this long ignored issue.

Which now brings me to the present moment.  Time to find some lunch, and then sit in on an afternoon session review of the 2006 STD Guidelines (because, while I’m here, might as well attend lectures which will be useful on our board exam).  Tonight is the opening ceremony and dinner, followed by the long-awaited opening of the Exhibit Hall.  I can feel my money disappearing already.  Can’t wait!  Much more to come!

I passed!!!!!!!!

Last Friday I was a very lucky duck: I was able to attend a screening of The Business of Being Born at the Tribeca Film Festival, hosted by Friends of the Birth Center, along with a post-show talkbalk with the Abby Epstein, the director of the movie, and Ricki Lake, the producer, followed by a cocktail reception. Given that the tickets to the screening (with proceeds going to Friends of the Birth Center) had sold out in less than 24 hours, and the line waiting to get in was a roll-call of who’s who in the New York City birthing community, I felt very lucky and very privileged to be part of this experience.

Most of the early press on the film has been encouraging rather than caustic, and everything I had heard by word-of-mouth was nothing but positive. I actually know many of the midwives and nurses and one or two of the doctors that are feautured in it, and I trusted their voices and their ability to speak accurately about birth and midwifery. Even so, I must admit I’m always a bit trepidatious when it comes to anything about midwives in the mainstream media. I’m always worried that somehow the media will get it wrong—they won’t get the full picture, they won’t understand the smaller details, they’ll paint our profession in broad, misinformed strokes, or they’ll fall back on stereotypes—with the end result being that the much-needed media attention, instead of being a welcome and helpful boon, actually does nothing more than continue to misinform and confuse the public about exactly what it is we do. It’s often a mixed blessing. I was also concerned that this film might be disregarded as too far out on the fringe—that it would come across like a very slanted Michael Moore documentary and therefore not have the universal appeal needed in order for it to be taken seriously by the mainstream public.

These fears were somewhat allayed when the announcer for the film—a man—came out and assured the men in the audience that if they were expecting to suffer through a “chick flick”, they were in for a very pleasant surprise. Apparently he had been on the Tribeca Film Festival selection committee, and it was one of the other men on the committee who had first approached him about the film, saying that he had really kind of liked it and needed a second opinion. As it turns out, the film’s biggest supporterters on the selection committee were these two men, both of whom had known absolutely nothing about birth prior to watching the film, but had found it to be a very fascinating, informative and well-researched documentary. The announcer kept it short and sweet, and then, without further adieu, the lights went down, and the film began.

The Business of Being Born sets out to explore the business of maternity care in our country. Along the way, the film raises a lot of difficult questions, which it then attempts to answer: why are the infant and maternal mortality rates in the US the second worst in the world when compared to other developed countries? Why do midwives deliver 60-80% of all births in other developed countries, but only 8% here? Why is our cesarean rate so high, especially when compared to other countries which have a much lower cesarean rate but much better overall outcomes? Why are so many mothers so disatisfied with their birth experience or maternity care? Why do so many of our births occur in hospitals? Why is the prevailing attitude towards birth one of fear, rather than of trust and normalcy? You know, just the sort of complicated questions which keep midwives up at night, but which very few other people ever stop to think about (I’m pretty sure it was Pat Burkhardt, director of the NYU Midwifery program, who rightly points out that most people do more research on buying a new car or appliance or camera than they do on their choices and options when it comes to birth). The film tackles these complicated questions from several angles, including the vicious circle of medicated birth (epidural leading to pitocin leading to more epidural leading to nonreassuring fetal status leading to cesarean, all done in cute cartoon format), the pervasive fear-mongering of birth on TV and in the media, the status symbol of “too posh to push” and “designer deliveries”, insurance issues, malpractice issues, even touching upon possible implications of disturbing the delicate “love cocktail” of hormones present in unmedicated births which facilitates bonding and maternal instinct. Quite a big mouthful to bite off for one small film.

The opening sequence of the film begins at 3:25 am, as a homebirth midwife (Cara Muhlhahn) prepares her birth bag before heading out to a birth. This footage is interspersed with people discussing their initial perceptions of midwifery and midwives. Not surprisingly, many of the people being questioned have either never heard of midwives before, or assumed that they were untrained granny-midwife types. A few people express disbelief that anyone would choose to have birth somewhere other than a hospital, or with someone other than a doctor. One man says something like “I didn’t even know midwives still existed”. We cut back to the homebirth midwife in her apartment, packing her bag. The idea that midwives are untrained grannies more likely to treat you with herbs than a prescription is quietly challenged by her preparations: we see her checking her oxygen tank, preparing her suture and syringes, counting vials of pitocin and other medicines, packing liters of IV fluid still neatly sealed in their bags, along with IV tubing, and then setting off to the birth.

Without a doubt, one of the best things about this film is the sheer number of unmedicated births that it shows. While attending and seeing births was something that was familiar and commonplace to many people at the turn of the century, in its move from the home to the hospital, birth has become isolated from everyday life, no longer thought of as a routine, normal occurrence. Today, most people have never been to a birth prior to having their own baby. What few births people do see are usually on TV, where they’re either wildly dramatic, such as the screaming, frantic woman on ER, or complicated and scary, such as on A Baby Story, where it seems like routine, normal vaginal births are often passed over in favor of dramatic life-and-death births, which probably garner much better ratings. Also, whenever birth is seen on TV, it is unfailingly (inevitably) set in the hospital. However, The Business of Being Born thankfully turns all of this on its head, showing what real, normal, uncomplicated, unmedicated birth actually looks like—something most people have probably never seen before. The audience is exposed, perhaps for the first time, to the sights and sounds of unmedicated labor. Instead of screaming and drama, women are shown rocking and swaying, moaning and grunting and sweating. Instead of beeping machines and alarms sounding, heads emerge from between legs in relative silence as the mothers are left undisturbed, pushing with quiet concentration and determination. We’re shown births attended by midwives in homes and birthing centers, births in tubs and pools, births squatting and standing; we even see Ricki Lake’s homebirth, in a bathtub.

While many famous, leading authorities (Michel Odent, Marsden Wagner, Ina May Gaskin, Robbie Davis-Floyd, to name a few) and many leaders in the New York City birthing community spend a lot of time discussing the issues behind the business of birth in the film, it’s often the images themselves which speak the loudest. Forget what the experts are saying: the audience is actually able to see it, with their own eyes. The images of women concentrating and pushing with power and strength, in tubs, kneeling on beds, supported by their partners, squatting or rocking, versus the images of women flat on their backs in the hospital, covered in tubes and oxygen masks, being told to “push!”, their legs in stirrups or held by staff, supine on gurneys being wheeled to the operating room, provides a message far more clear and visceral than any book or 5-hour lecture on the subject could manage. This, more than any other aspect of the film, probably provides the greatest education to the audience.

One of the issues raised at the talk-back session after the show was the decision to include director Abby Epstein’s birth in the film. Although she was planning on having a homebirth with Cara Muhlhahn, she went into labor at 35 weeks, and because her baby was breech, she needed a cesarean. While including this birth at the end of the film does put a bit of a damper on the natural-birth/homebirth high of the film, at the same time it demonstrates a very crucial point: homebirth and midwifery care is safe care. Midwives don’t take stupid risks, they have good clinical judgement, and they make good calls; they’re not going to try to deliver a premature breech baby at home. I also think it’s important for the audience to see that birth doesn’t always go according to plan, and that flexibiilty and the ability to roll with a change in circumstance is one of the most important aspects of a successful birth experience, and that support during these difficult transitions is also key. This birth also shows the system working exactly the way it should: the midwife takes care of the low-risk patient, but when low-risk becomes high-risk, the patient is transferred to the back-up doctor, and seamless, excellent healthcare is provided to the woman.

Perhaps the only problem with this is the fact that the care is almost too seamless. When Abby Epstein mentioned to her doctor that she was planning a homebirth, his enthusiastic response is just a little too quick. You can’t help but wonder: if the camera hadn’t been there, capturing the moment, would he have so readily offered to serve as back-up, or would he have tried to talk her out of having a homebirth using scare tactics or punitive manipulation? (This is by no means a statement on this particular doctor in the film, whom I personally know to be very supportive of midwives and midwifery, but rather a statement on the larger, more generalized attitudes of doctors towards midwifery and homebirth). In reality, it’s rarely so smooth a transition, and doctors are rarely so enthusiastic when they hear that their patients are planning a homebirth. While the film touches briefly on the competition between doctors and midwives and the fact that many doctors are vehemently anti-homebirth, the smooth transition of care between Abby Epstein’s homebirth midwife and back-up doctor is potentially misleading. The audience can walk away from the film thinking that this is a very easy thing to arrange, when actually, one of the biggest barriers to providing homebirth as a viable option to more women in this country is the lack of back-up providers and the challenges faced in trying to arrange appropriate back-up; rather than being smooth and easy, it’s often complex, frustrating and fraught with politics.

My only other critique of the film is that it is perhaps a bit too black and white: homebirth v. hospital, midwife v. doctor, unmedicated, natural childbirth v. monstrosity of tubes and terror. While the film did follow a hospital-based midwife (Catherine Tanksley), and showed midwives in hospitals, the emphasis seemed to be on homebirth. The truth is that in this country far more midwives practice in hospitals than they do in homes, and the word “midwife” is not synonymous with “unmedicated childbirth”. While midwives are experts in normal, unmedicated births, we’re not anti-epidural or anti-hospital. We can prescribe narcotics and pain relief in labor, we can order epidurals, we can support a woman through a medicated birth experience just as easily as an unmedicated birth—it really just boils down to the desires, needs and expectations of the woman and her family. Unfortunately, I can very easily see a woman walking away from this film and thinking “well, midwives are great for natural childbirth, but I want an epidural, so I guess that means I’ve got to go to a doctor”. While all of the beautiful, natural homebirths in this film are a joy and privilege to watch, I think one or two equally beautiful and joyous hospital births attended by midwives might have added a more balanced perspective to the film.

Nevertheless, overall I thought the film was truly amazing; it brought tears to my eyes on several occassions. Rather than being far out on the left fringe as I had feared, I was actually blown away by how mainstream and accessible it was. It begins with the assumption that the audience knows absolutely nothing about birth and the business of birth in this country, and then moves on from there, using a simple and easy-to-understand, yet powerful and engrossing format and narrative. Forget the Ricki Lake Show; I think this film will be a new highlight in her career, and I’m very grateful that a film like this has finally been made. I want all of my friends, my beloved boy, my family, my peers, to see this film so that they can finally see and understand exactly what it is that I do, and why I do it, and what I believe in. Hopefully this film will be picked up by a national distributor and shown in cities all over the country; hopefully soon it will be playing at a theater near you. If it is, you’ll have to go and see it—and bring all of your friends with you!