Belly Tales

Chlamydia is the sexually transmitted infection du jour in our clinic. On a daily basis I probably encounter at least one, often 2, and sometimes 3-4 women per day who have it. For the majority of the women I see, learning that they have an STI is often like a wake-up call. They usually get treated, then their partner gets treated, and then, to their credit, they often remain STI free for the rest of their pregnancy. Many of them choose to break-up with the partner that infected them, or stop sleeping with him/her altogether, or else become religious in their condom use. However, sometimes it’s not that easy. In one woman whom I’ve been taking care of since I started my new job (i.e. over 5 months now) she’s had chlamydia 3 times. In other words, she’s been reinfected twice after being treated, probably because her partner has 1) never been treated or 2) keeps getting reinfected himself. In another case, a woman has been treated twice for chlamydia now because her husband has multiple wives, and obviously we still haven’t gotten all of them treated yet. I spend much of my day talking myself hoarse about safe sex, strict condom use and the importance of getting partners treated. And then the CDC releases studies which show that nearly half of all adolescent African American girls have had at least one STI, compared to only 20% of all white and Mexican-American teenagers (keep in mind that the predominant populations in our clinic are African American and Hispanic). It makes me want to cry. We get fifteen minutes alloted to us on our templates to take care of an OB or gynecology revisit. That’s fifteen minutes to conduct an entire interval history, address any questions or concerns, follow-up on lab results and order upcoming tests, do the physical exam (listen to the fetal heart tones, Leopold’s, measure the fundal height etc.), and then write a note on it. Fifteen minutes is barely enough time to tell a woman she has chlamydia, what the treatment is, how important it is that she get treated and then not reinfect herself, how crucial it is that her partner is also treated, and how essential condom use with future partners is. It’s like the tip of the ice berg when really these women need so much more than just counselling on safer sex and strict condom use. They need to learn how to assert their power—how to put their foot down with a partner that may potentially be cheating on them, how to say emphatically “no condom, no koochie” and not buckle in to seduction or pressuring, how to choose and insist on respectful partners. It’s like staring at a huge, roaring wildfire, and your only weapon against it is a tiny fire extinguisher. So what do we do? Keep trying to extinguish the chlamydia, one case at a time, and keep talking ourselves hoarse about safe sex.

Without getting into a huge amount of detail here…I had a new OB patient recently who came in for her initial visit and eventually told me that she wasn’t sure who the father of the baby was….becasue she had been raped by four men. She had gone to a different hospital immediately afterwards and had had a rape kit collected, and had already been through one round of testing for STIs and HIV, all of which had come back negative. The semen analysis is still pending. She’s been seeing a therapist weekly since the rape, and has the full support of her very large family. Because of her religious beliefs she will be continuing with this pregnancy and plans on giving birth in early September at our hospital. I was stunned, and didn’t even know where to begin with her. I talked a little bit about how rape and trauma can come up again during pregnancy, and especially during birth, but she’s only 10 weeks pregnant at the moment, so I didn’t see any point in getting into that deeply just then. I suggested that we could talk a lot more about it as the birth approached, and she agreed that that sounded like a good idea. We talked a little bit about postpartum depression, and depression in general, and I made a very thorough assessment of her support system and resources, and they all seem ample. In addition to the therapist she’s currently seeing at the other hospital, she was also visited by our social worker, so that additional resources at our hospital can be offered to her as well. I asked a few very broad questions about what she was thinking or feeling about the pregnancy, but she didn’t want to talk about it very much, so we moved on to other topics. And then we did the actual physical exam. She had as much control over the process as possible. We made a deal that whenever she felt uncomfortable or scared or uncertain, all she had to do was say “stop” and I’d stop. So that’s what we did. My assistant held one of her hands (her other hand was between her legs and on top of my hands as I guided in the speculum) and we gently talked her through it. She would tense up, say stop, then we’d stop, let her collect herself and calm down, and then when she was ready, we’d guide in the speculum another half inch. We went inch by inch. It took about 10 minutes total to get the entire speculum in, then I collected the samples and removed the speculum as soon as possible. She actually seemed to handle it amazingly well (I was close to tears).

I can only imagine how birth, which can be so traumatic in its own right, can bring up so many terrifying memories and associations with trauma and rape. Birth is another situation where she can potentially feel vulnerable and exposed, in a situation that she can’t really control, experiencing pain, perhaps feeling helpless and angry and powerless (and keep in mind that this will be a hospital birth and not a woman-on-her-own-turf-at-home-birth). So here’s my question to all you midwives and doctors and nurses who’ve been doing this a lot longer than I have, and who have probably been present at births with women who have a history of trauma or rape (or women who have survived rape or trauma and gone on to birth yourself). Do you have any suggestions? When it comes closer to the time of the birth, what should we focus on? I have many thoughts about where to start: avoiding vaginal exams during the birth, offering early pain relief if desired (maybe a prophylactic epidural before the strong contractions even begin), letting her dictate when and how to push, making her environment as calm and serene as possible…what else am I missing? Any good books on this topic? Any posts that you’ve written which I should read? Anything at all would be helpful, because I still have another 8 months of prenatal care with this woman prior to her birth, and I want to try to make it as healing and empowering as possible (or, at the very least, not compound the trauma with more trauma).

The other day I discovered a postcard at my local yoga center urging women to participate in a birth survey, which instantly piqued my interest; apparently this survey has already been going on for some time, although I have only now heard about it. A little research has revealed that the Coalition for Improving Maternity Services (CIMS) has launched a new program entitled The Transparency in Maternity Care Project, which is intended to research and explore maternity care in this country, with an emphasis on improving the transparency of maternity care. Unlike other areas of medicine, hospitals and maternity care providers are still pretty cagey when it comes to being open with their numbers. What is the c-section rate for specific doctors or hospitals? What is the VBAC rate? How many providers perform episiotomies? How many elective cesareans or inductions occur annually? Hard numbers like this are always notoriously hard to come by. And of coruse, beyond the actual numbers themselves, women’s experiences with maternity care providers and services and overall satisfaction is often something which is overlooked. It seems like The Transparency in Maternity Care Project is trying to fix all of that, and is acting as a follow-up to the Listening to Mothers surveys which occurred in 2002 and 2006. Like Listening to Mothers I and II, a survey lies at the heart of The Transparency in Maternity Care Project, which can be found at the following website: www.TheBirthSurvey.com. The pilot survey is occurring in New York City right now, between July 2007 and July 2008.

There were many reasons to choose New York City as our pilot site.

First: New York is a large, high profile city offering a wide variety of birth options.

It is a densely populated and well-networked urban center. There is easy access to multiple press/media outlets. Approximately 125,000 births occur in NYC per year. Forty-four hospitals provide maternity care services. The majority of the country’s obstetricians are trained in NYC. Two Free-standing Birth Centers are in operation. An established homebirth community thrives. Nearly 10% of births in NY are attended by midwives.

Second: The Grassroots Advocates Committee will be piloting the project in partnership with Choices in Childbirth (CIC), an active grassroots organization based in NYC.

CIC is well connected with the NYC birth community. CIC publishes The New York Guide to a Healthy Birth – in 2007, 20,000 copies advertising The Birth Survey will be distributed free to the public. A member of the GAC and CIC is based in NYC and will be engaged in the day-to-day oversight of the pilot.

Third: New York State is one of only two states with a Maternity Information Act.

The MIA provides the public with legal access to intervention rates at the facility level. Choices in Childbirth is connected with the NYS Department of Health and has already collected the intervention rates for all New York hospitals.

So, if you live in NYC and have given birth in NYC, here’s your chance to discuss your experience and provide valuable information and feedback about birth in our country. Please participate in the birth survey ASAP. As for the rest of the country, the project plans to unveil a national survey next summer, but if you’re super motivated, you can provide feedback about your birth experience at www.drscore.com.

So, you’re probably wondering how it’s going. I’m in the middle of my third week as a new midwife, and it’s going…okay…so far, I guess. I wish I could sound more confident and enthusiastic about it at the moment, but I’m having a hard time feeling very confident or enthusiastic these days. Which is not to say that I am not absolutely *thrilled* to be finally working as a midwife, or delivering babies, or taking care of so many beautiful pregnant women (I am!!!), it’s just that my general state lately has been one of extreme nervousness and tension and uncertainty. Which is, according to many of my loving and supportive preceptors, something that is expected, and something that is normal for a lot of new grads, but even so…it’s not a very pleasant place to be living in at the moment. Even if I did expect that it would feel like this.

I think the nerves and tension is all coming from the sudden onslaught of responsibility. I feel unbelievably responsible, for everything, at the moment. Heavy with repsonsibility. I’m taking my patients home with me, worrying about them at night. And I’m so scared, with all of this new responsibility, that somehow I will totally, terribly mess something up. Which I’m sure I will, given that I’m new, and bound to make mistakes, and that some of the best learning you ever do is from your mistakes. It’s just…I can’t make huge mistakes. I really can’t. These are people’s lives and bodies and pregnancies and babies on the line, so…no mistakes, right? Except that how can you learn a new job, as a new grad, and not make mistakes? Do you see where the tension headaches and the knots in the middle of my back come from?

I’m still on orientation at the moment. I have three full months for orientation, which means that my orientation will finish sometime around Jan. 10th. Ostensibly, I can ask for more time, if I feel like I need it, but I do recognize that there is a strong hope that by three months in I will be able to work like a fully functioning midwife, someone who can be an asset to the practice. And I hope the same as well, although at the moment, I’m a bit terrified of being on my own, and I certainly don’t feel ready for that. Have I mentioned lately how NUTS this practice is? How busy and crazy and overwhelming and exhausting it is? Which is fabulous, on the one hand, and is certainly one of the reasons I picked this job (after a year of this, just think of all of the amazing experience I’ll have)…but, on the other hand, is incredibly overwhelming, exhausting, crazy etc.

The sheer pace of the place is enough to knock you out: in the clinic, on average, the midwives are seeing about 25 patients a day, often more like 28-30. IN ONE DAY? Good lord, how do you even have time to say hi to that many women, let alone ask them all about their health and bodies and pregnancies, or deal with all of the many problems and questions they have? Just to give you an example: one of the women I was taking care of last week had had a positive chlamydia test two months ago, had been treated, had then slept with her partner again (who had not yet been treated), had contracted chlamydia again, and had then been treated again. She had also had a positive PPD test (for tuberculosis), an abnormal pap result, and a prior cesarean, in the Dominican Republic, and was desiring a vaginal delivery this time around. So on my visit with her, we were talking about safer sex and what that involved, abstinence until her partner could be treated, a referal for her partner to the male STI clinic, the need for a chest x-ray (to follow-up on the positive PPD test), the need for a colposcopy during her pregnancy (to follow-up on the abnormal pap smear), and the importance of getting the operative report from the hospital where she had had her cesarean in the Dominican Republic, so that she could be counselled for a VBAC and receive a trial of labor with this pregnancy (in order to have a trial of labor at this hospital, women need written proof of the fact that they had a low-transverse uterine incision during their cesarean, and are therefore at lower risk for uterine rupture). And then we went ahead and did all of the normal pregnancy visit things: is the baby moving? How’s your diet? Looks like you’re gaining a good amount of weight. Vital signs stable? Urine dip negative? Measure the uterus, palpate the baby, listen to the fetal heart, review warning signs and danger signs. Are you still taking the prental vitamins and iron? Any questions? And then, after all of that, we did a chlamydia test one more time to make sure that she’d been adequately treated. The entire visit took me about an hour. And rightly so. But technically, she was a revisit, and was supposed to only take about 15 minutes. On average, I’ve been seeing about 9-10 women a day, on a good day for me. I just can’t go any faster than that without missing something or forgetting something or not picking up on something…in essence, making a mistake.

And labor and delivery…wow. Where do I even start? I’m going fine so far, I’ve delivered three beautiful babies so far, but that’s only because I’ve been sheltered by my preceptors so far, and am not truly doing the entire job yet. They’ve been giving me one or two patients to manage so far, or else they plunk me down in the middle of triage to sort out all of the incoming women, and that’s fine. But that’s about as much as I can do right now. And meanwhile, beyond the doors of triage, there are all of the women who are in labor, who I can’t really keep track of at all. Room 5 is 6 centimeters dilated, room 7 is 8 centimeters dilated, room 8 needs another dose of cytotec, room 10 needs another note written on her at 2:00 pm, and room 5 and 7 need a note written at 2:30, and room 10 will need a note as soon as the cytotec is placed, which will happen just as soon as one of the midwives gets a chance…I have no idea how to keep track of the floor. I have tunnel vision. Keeping tabs on one or two patients is about as much as I can handle, and that is plenty to keep me busy. More than plenty. Admitting a patient, and getting through all of the paperwork, takes me a solid hour or so. I’m being very thorough…I’m proud of my notes, but I’m slow.

And the thing is, it’s okay to be slow right now. No one is yelling at me to be faster….yet. But I know…I dread…that soon enough, too soon, I will be off orientation, and then I’ll be in trouble. And granted, I’m sure that my ability to handle all of this will increase tremendously in the next three months, and worrying about running the floor at this point is fruitless and stupid, because no one is asking me to run the floor yet. So why even worry about it at this point? And yet, I can’t stop myself from thinking about it. I find myself worrying about everything right now.

The BBC has put together an amazing series of articles on birth and maternal mortality in developing countries. This year, at the half-way mark towards the Millenium Goals set for 2015, we’re not even close to reaching the desired 75% reduction in maternal mortality. These articles explore the reasons behind these failures: everything from lack of US funding for the United Nations Population fund (ostensibly because the UNFPA doesn’t outlaw abortion) to the low status of women in developing countries, the low priority given to women’s health issues, unsafe drinking water, lack of access to medical facilities and skilled birth attendants, infection, poor nutrition and low birth weight.

“These women are dying not because we don’t have the means to save them, but because we (the world) have not determined whether they are worth saving.”

Why women still die to give birth

Action needed on maternal deaths

“They thought I was cursed” (article on maternal fistulas)

In pictures: fighting maternal mortality

Check out the older articles from 2005 and 2006 as well. Really excellnt, but really sobering reading.

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.

Amanda from Pandagon and Jessica from Feministing, both of whom were lucky enough to attend the National Advocates for Pregnant Women Summit a few weeks ago, decided to continue to explore many of the issues and topics covered at the summit through weekly guest bloggers hosted on Feministing. The first two are up already:

Jill Morrison on Laws that Punish Pregnant Women and Priscilla Huang on Killing the Immigrant Body.

Both are fascinating and highly recommended reads. Can’t wait to see who the new guest blogger will be.

National Advocates for Pregnant Women just concluded its 4 day Summit To Ensure the Health and Humanity of Birthing Women in Atlanta, GA, this past weekend. This summit, one of the first of its kind, was organized by NAPW and NAPW’s director, Lynn Paltrow, to explore the grey area where pregnancy, birth and the law intersect. In our increasingly litigious society, the debate about reproductive choice and reproductive freedom is not limited only to the debate over abortion; women are constantly facing difficult decisions, constrictions and legal battles on a daily basis simply to be allowed to give birth where they want, how they want and when they want. It seems like one of the overt aims of this conference was to widen the terms of the discussion and to get the reproductive rights advocates talking with the pregnany and birth rights advocates, demonstrating how these two debates are really just different ends of the same spectrum, and how all womens’ rights are being constricted, whether they choose to have children or whether they choose to have an abortion.

The Summit program covered everything from the overbearing and disempowering birthing machine in this country to our culture’s rampant fear of birth, from the legal restrictions being placed on VBACs, contraception and abortions to the disturbing rise in fetal rights, where mothers with substance abuse problems are prosecuted for “child abuse” on behalf of their unborn fetus, instead of being offered the care and treatment they need….and so much more, more, more. I really wish I could have attended! NAPW even offered several bloggerships to a few of the lucky feminist, birth and reproductive rights bloggers who were able attend. Too bad we didn’t get a longer winter break; school started again on January 9th, alas.

It’s been absolutely fascinating reading the reports and thoughts of many of the bloggers who were able to attend. I’ve linked to a partial list of the blogs on the Summit, so that you can read for yourself. It’s almost as good as being there (although not quite).

Feministing: Semi-live blogging from NAPW Conference

Gymno: Sick Blogging

Gymno: Summit Day 1 (cont.)

Is there no sin in it: NAPW Conference is happening now!

bird in a bottle: More Lynn Paltrow love (and a prelude to Blog for Choice Day)

bird in a bottle: Language and Gender, Part Deux

bird in a bottle: Why I want to be Dorothy Roberts when I grow up

Angry Black Bitch: Thoughts inspired by sessions

Angry Black Bitch: Thoughts inspired by debates, particularly the VBAC v. cesarean delivery debate.

Pandagon: NAPW Summit kicks off

Pandagon: NAPW Summit: end of the 1st Day

Bitch PhD: Join this Organization

Women of Color: The first part of the conference

And even more from brownfemipower here and here and here, and finally: Midwives of Color.
Oh, and this is just too cute not to pass on.

And finally, a word or two from the demi-goddess herself: Lynn Paltrow’s article in the San Francisco Chronicle, On the Anniversary of Roe v. Wade

On vacation, just popping in briefly (the beloved boy just looked over my shoulder at what I’m doing and said “I can’t believe you’re posting while on holiday”). Uh, yeah. So, anyway, the semester is over. It was pretty intense at the end, with three hefty exams one right after the other: our neonatology final, followed by our intrapartum final (which took me three hours to complete…I was scribbling down to the very last second), and finally, our postpartum final. I’m pleased to report that I did well on all my exams; I guess it’s comforting to know that all that stress is actually going towards a good cause.

Anyway, I was browsing on the BBC’s website today and found two articles that are worth passing on:

First, a woman in Devon with a didelphic uterus gave birth to triplets. She carried identical twins in one of her wombs, and a singleton pregnancy in the other, and both eggs were fertilized at the same time. Apparently the odds of this happening are five million to one.

Also from the BBC, new research suggests that women with bowel problems such as ulcerative colitis and crohn’s disease might be at greater risk for premature birth and low birth weight babies, in part because inflammatory bowel disease can apparently restrict the amount of nutrients a baby receives during its development. The rate of birth defects in babies born to mothers with these diseases was also found to be twice as high as compared to women without inflammatory bowel disease, although overall the research felt that early detection and proper treatment could help eliminate these problems. Does anyone subscribe to Gut?

Right. It was a hard, but wonderful semester, and right now, I really, truly am on vacation. I’ll see you all in the new year.

Today I missed one hell of an opportunity: I was invited, along with several other feminist bloggers and activists (and cheers to Melissa from A Womb of Her Own for asking them to extend the invitiation my way), to partipate in a conference call with Lynn Paltrow, the executive director of National Advocates for Pregnant Woman, aka NAPW. Unfortunately, my class on shoulder dystocia ran late, and I wasn’t able to join the call in time. Nevertheless, something needs to be said about Lynn Paltrow and NAPW. This is an oganization that seems truly committed to starting up a sincere dialogue on the inequalities, challenges and legal barriers that are placed in front of women—and in particular pregnant women—that prevent them from accessing the help they need and deserve. And not just “opening up a dialogue” in the politically-correct sense that looks good on a mission statement, but an honest, open, all-encompassing debate that encourages women, lawmakers and organizations to move beyond the pro-this/ anti-that polarity. And not just “inequalities” in the abstract sense, but a real examination of the socioeconomic, racial, educational, sexual and gender unfairness that every woman on this planet has to deal with every day (to quote Shannon from Egotistical Whining, who was able to attend the conference call: “I’m just saying it’s not super difficult to include people of color in your political movement.”) It seems like this is an organization that doesn’t dwell on whether or not a woman should be allowed to have an abortion (although NAPW has a pretty strong opinion on that, I’d wager), but on the social circumstances which lead women to seek abortions in the first place, or to carry unplanned pregnancies to term. This is an organization that asks “how” instead of “why”, taking the punitive blame off of the woman, and turning the microscope onto the world she lives in which forces such choices to be made.

We live in a scary, scary world right now. I was looking over some of the articles Lynn Paltrow has written or commented on, such as Blaming Pregnant Women, The Pregnancy Police Are Watching You, The Rights of “Unborn Children” and the Value of Pregnant Women and Do Pregnant Women Have Rights? , and I was shocked, not to mention frightened, by how far current and proposed laws have gone at eroding the civil liberties of women. While the Unborn Victims of Violence Act was blinking somewhere on my radar, it was mostly framed in terms of what this meant for abortion rights, without taking in the larger picture. I had no idea things had gotten so bad (guess I need to be reading The Mommy Blawg more often, huh?). These articles talk about cases where women have been forced to undergo surgery against their will; where women have been jailed as criminals for “murdering” their children through drug use; where fetal rights have been found to trump the rights of the living, breathing women who are “housing” them…women who used to be entitled to their own personal freedom and life, liberty and the pursuit of happiness…until they got pregnant, that is. Granted, these cases are rare, and seem like aberrations rather than the norm, but in a legal system that is built on precedent, even a single case can yield terrifying future implications.

As Melissa from A Womb of Her Own rightly pointed out, though, this goes beyond the abortion debate. This isn’t even remotely about abortion any more. This is about women losing their voice, their rights, their power. And this is about a system that seeks to punish individual women, isntead of asking: why do so many women turn to drugs? How can we help them with that? Why do so many women live in fear for their lives? Surely it’s not just because abuse is a pattern, and some women “just keep dating the wrong guys”, like it’s her fault for choosing such a poor partner, instead of his fault for beating her in the first place? Why do so many women live in poverty? Why do so many of these women happen to be brown or black? Why is the health of a fetus more important than the health of the mother? And if we’re so concerned with the pain of the fetus that we’re now requiring doctors to counsel women about it before performing abortions after 22 weeks, why are we so unconcerned about invasive procedures during pregnancy that hurt the fetus, or circumcision, or children living in poverty and neglect?

Hummm. I bet some of these questions were addressed in the conference call that I missed. *sniff* However, the good news is: NAPW is hosting a summit in January, and we’re in the process of putting together another conference call or interactive chat with Lynn Paltrow and NAPW for midwives, student midwives and doulas. Because, let’s face it: this is something we should be more than just up-to-date on. This is something we should be razor-sharp-cutting-edge on, because as midwives, these aren’t just abstract questions to us, but the lives and choices and challenges of the women we’re taking care of every day.