Belly Tales

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!

I’ve been meaning to post this post for ages, but was never able to finish it during the school year last year. All of this comes from the research project that I worked on last year for 2 semesters as part of my research class, and even though I had to radically alter the goal and purpose of my research proposal in the end, along the way I had the opportunity to do some of the research I was really interested in doing in the first place, and it definitely needs to be shared. This is rather a long post, and it gets somewhat technical in places, but bear with me; a lot of the information here can help you fend off an unnecessary induction or cesarean, so it’s well worth reading. And with that, here we go:

Premature rupture of membranes (or prelabor rupture of membranes, aka PROM) occurs when a woman’s water breaks before she actually goes into active labor. It can happen to women at any point in their pregnancy, and when it happens to women who are still preterm, the danger to herself and her baby is much higher, as are the risks of infection (and many studies have demonstrated that in fact, preterm PROM, aka PPROM, is often caused by infection in the first place). However, the majority of PROM occurs in women who are at term gestation (37+ weeks)—90% of all cases, in fact (Zamzami, 2005), and it’s pretty common, too: PROM at term occurs in 8% of all births. (Hannah et. al., 1996)

In our hospitals today, there is sort of an unspoken rule—let’s call it the 24-Hour Rule. It goes something like this: if you haven’t delivered your baby within 24 hours of breaking your water, something is going to have to be done. In many cases, this something is induction, and in many cases, waiting a full 24 hours before inducing is something that never happens. Providers are often way too impatient and antsy for that, and will generally talk a woman into induction long before the 24 hours has passed. Many providers have the policy of immediately inducing a woman with PROM, either by using prostaglandin gels like cervadil followed by IV oxytocin (pitocin), or by just starting on the pit right away. The rationale for this type of management (often called active management) stems from research that was done in the 1960s (Shubeck, 1966; Rusell & Anderson, 1962) which found that the longer a woman was ruptured, the greater the chance of infection, chorioamnionitis (an acute infection of the chorion, which is part of the placenta), and maternal and/or fetal sepsis.

These early studies advocated immediate induction, and were the beginning of active management. The idea that the length of PROM is responsible for maternal infection is something which has sort of been hard-wired into modern obstetrical practice right now, and in my own experience, I have seen the 24-Hour Rule in effect many a time. Providers often use it to justify the need for an induction or augmentation, i.e. “we need to get your labor moving along, because you’ve been ruptured now for 8 hours…12 hours…18 hours…and you’re still not in active labor”, and as studies have shown, inductions and augmentations, especially for PROM, often lead to cesarean (Mozurkewich & Wolf, 1997; Grant et. al., 1992; Tan & Hannah, 2001). I have seen this deadline held over women’s heads before, and in my most humble opinion, it does absolutely NOTHING to help a woman relax, labor effectively, and have a vaginal delivery. (What’s that old Bradley joke about telling a man he better orgasm soon or else his penis will have to be cut apart to get to the sperm? No pressure, now!)

The thing is…the research from the ’60s, which forms the basis of the 24-Hour Rule, has more holes in it than swiss cheese. For one thing, these studies were retrospective, instead of prospective, which means that they relied on going back and looking at records after the births had already occurred, and never tried to control for any of the gazillion variables that might have affected these birth outcomes other than PROM. Similarly, these early studies were non-randomized, meaning that there might have been selection bias at play which could have muddied the findings. Additionally, both term and preterm pregnancies were mixed together when examining the effects of PROM, which seriously confounds results since preterm infants are much more susceptible to infection, and as I mentioned above, preterm PROM often occurs because of infection in the first place (McGregor & French, 1997). These studies had very imprecise definitions for infection, and the management protocols used were neither uniform or clearly discussed. And of course, NICUs and antibiotic therapy have improved so much in the past 40 years that many of the babies that died of infection in these early studies probably wouldn’t have died if they had been born today. So, as you can see, the studies from the 1960s had a lot of problems, and the fact that modern obstetrical practices are still based in part on the findings in these studies is an even BIGGER problem.

What have more recent studies shown? Well, many studies have shown that strict adherence to active management is often unnecessary, and in some cases, does more harm than good (seems to be a repeating theme when you start to look at obstetrical research—funny, that. And here is where it gets very technical. I’m putting the rest of this behind a cut, for those of you who are interested.) (Read on …)

While studying for our upcoming neonatology final at a friend’s house tonight, I accidentally stumbled upon her beautiful birth record book: Into My Hands from the Eagle Tree Press (which is a really cool website, check it out while you’re there!). My own birth record book, where I’ve been keeping tabs on the vital stats from all of the births I’ve attended as a student midwife, is a very sparse and sad affair compared to Into My Hands. The really nice feature of this book is the fact that it gives you plenty of room to journal about each birth, instead of just writing down quick statistics. In the long run, I think this must really make a difference in helping you to remember each birth, and all of the special moments that made it unique. Paging through my own book, I can certainly recall vividly quite a few of the births, but a few of them are already a bit foggy, despite my vital stats. For one of them, I can no longer picture her face, and it’s only been a few weeks since I caught her baby! Ack! That’s not how this is supposed to go. My friend swears by Into My Hands, saying that as soon as she reads her little journal description of the birth, it all comes pouring back to her. Duh. Journaling about each birth is something I had wanted to do all along, and was hoping to do here on this website, but alas, things have been keeping me very busy of late. The point being, I’m going to get this book STAT, and start using it right away, instead of the birth log I’ve been using so far. I don’t want to forget a single birth. Student midwives/ midwives of the world: check this out!

This is something I’ve been meaning to post about for ages now, brought to my attention by one of my readers. The creative folk behind Birth on Labor Day, which is quickly becoming a an annual Labor Day tradition, have launched an online book club that you can participate in. The Sept.-Oct. pick, The Birth House by Ami McKay, looks absolutely fascinating. I can’t wait to sink my teeth into it, just as soon as the semester is over!

In addition to the moral debate that surrounds giving Gardasil, Merck’s new HPV vaccine, to young girls, the National Vaccine Information Center (NVIC) is also urging against a “universal use” recommendation by the CDC’s Advisory Committee on Immunization Practices (ACIP) on June 29th. The NVIC doesn’t feel that Merck’s clinical trials proved that the HPV vaccine is safe for young girls.

“Merck and the FDA have not been completely honest with the people about the pre-licensure clinical trials,” said NVIC president Barbara Loe Fisher. “Merck’s pre and post-licensure marketing strategy has positioned mass use of this vaccine by pre-teens as a morality play in order to avoid talking about the flawed science they used to get it licensed. This is not just about teenagers having sex, it is also about whether Gardasil has been proven safe and effective for little girls.”

The FDA allowed Merck to use a potentially reactive aluminum containing placebo as a control for most trial participants, rather than a non-reactive saline solution placebo. A reactive placebo can artificially increase the appearance of safety of an experimental drug or vaccine in a clinical trial. Gardasil contains 225 mcg of aluminum and, although aluminum adjuvants have been used in vaccines for decades, they were never tested for safety in clinical trials. Merck and the FDA did not disclose how much aluminum was in the placebo.

Animal and human studies have shown that aluminum adjuvants can cause brain cell death and that vaccine aluminum adjuvants can allow aluminum to enter the brain, as well as cause inflammation at the injection site leading to chronic joint and muscle pain and fatigue. Nearly 90 percent of all Gardasil recipients and 85 percent of aluminum placebo recipients reported one or more adverse events within 15 days of vaccination, particularly at the injection site. Pain and swelling at injection site and fever occurred in approximately 83 percent of Gardasil and 73 percent of aluminum placebo recipients. About 60 percent of those who got Gardasil or the aluminum placebo had systemic adverse events including headache, fever, nausea, dizziness, vomiting, diarrhea, myalgia. Gardasil recipients had more serious adverse events such as headache, gastroenteritis, appendicitis, pelvic inflammatory disease, asthma, bronchospasm and arthritis.

Hmm. This certainly throws a new wrinkle in the story.

You can read the full article over at Red Orbit.

The FDA has recently approved Gardasil, Merck’s vaccine that helps prevent cervical cancer caused by Human Papilloma virus (HPV) strains 6, 11, 16 and 18. This is incredibly exciting news, since this is the first vaccine to target cervical cancer, and the first ever vaccine for cancer, period (amazing! a vaccine for cancer!!!). The vaccine has been approved for young women ages 9 to 26, but the recommendation is to give it to girls ages 11 and 12, preferably before they’ve had sex for the first time.

I was listening to a discussion on the radio this morning about Gardasil and the issues that surround its use, and opinions seem to be pretty reasonable on all sides of the debate. Conservative group are not opposing the vaccine itself, but are arguing against making it mandatory. From the NY Times article on the subject:

“Despite rumors to the contrary, our organization doesn’t oppose the vaccine and we have taken no position regarding mandatory laws,” said Wendy Wright, president of Concerned Women of America, a conservative group based in Washington.

Some groups support the vaccine but oppose mandatory vaccinations because cervical cancer is caused by a sexually transmitted virus.

“We can prevent it by the best public health method, and that’s not having sex before marriage,” said Linda Klepacki of Focus on the Family, a Christian advocacy organization based in Colorado Springs.

That’s a very good strategy, but what if the husband you’ve saved yourself for just so happens to have HPV? While not having sex is certainly a sure-fire way to avoid HPV and other sexually transmitted diseases, women can still get HPV on their wedding night from their very first sexual contact. A vaccine doesn’t promote promiscuity, but rather protects you from a very very very very very common STD that many people (men especially) do not even know they have.

Making this vaccine mandatory may help ensure that it’s covered by insurance companies and federal programs which might otherwise choose not to pay for such an expensive drug (a 3-part series over 6 months, costing $120 per shot, so $360 total). From the same Times article above:

A federal program is expected to provide the vaccine to 45 percent of the children in the United States for whom it is recommended. But state programs that cover other children are having trouble buying other expensive vaccines.

North Carolina, for instance, spends $11 million annually to provide every child with seven vaccines. Gardasil alone would probably cost at least another $10 million.

“Increasingly, states are asked to make a Sophie’s choice about which diseases they will allow children to be hospitalized or killed by,” said Dr. Paul Offit, director of infectious diseases at Children’s Hospital of Philadelphia.

It will be interesting to see how all of this unfolds, but for now, it’s enough just to know that this vaccine has finally been approved. As Dr. Sedlis (the guest professor who lectured us on the interpretation of pap smears) jokingly said, if this vaccine becomes widespread, gynecologists are going to be out of a job in 20 years, since pap smears and the mangement of abnormal paps is their bread and butter. This is a vaccine that could possibly someday eliminate the need for routine pap screening for all women, and make cervical cancer, which is already rare in this country, all but obsolete. That’s pretty powerful stuff!

Addendum:
Slate Article: very astute break down of many of the issues surrounding the vaccine, including the costs, benefits and risks and moral issues, well worth reading.
Moderately Insane: HPV Insanity: interesting break down the risks v. benefits of the HPV vaccine, in very plain English.
Women’s Health News post on HPV vaccine, full of amazing resources, per usual.

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.

We’ve been talking so much about menstruation lately that it seems only natural that the subject of alternative menstrual gear would come up at some point. In fact, just last week we were talking about it after class one day, and I ended up bringing my Keeper to school with me to show to a few curious classmates. Frankly, it’s high time that this website had a position statement on alternative menstrual gear. This is something I believe very strongly in, and something I have personally been using for several years now, and it seems just plain Wrong that I haven’t been talking it up something fierce on my own website already. So, enough is enough. Time to spread the good word.

The word goes something like this: About five years ago, I was broke (notice how much has changed in the intervening five years!). I had recently befriended a woman who lived in my neighborhood, and one evening, while hanging out at her house, I noticed that she had a bunch of terry cloth pads laid out next to her sewing machine, made from a cut-up bath towel. When I asked her what they were for, she introduced me to the concept of alternative, reuseable menstrual gear. I was, to put it mildly, a bit flabbergasted. Keep in mind, I was a good girl from the midwest, who’d only been living in New York City for two years at that point, and still hadn’t fully lost my shy, midwestern ways. The message that our society sadly pounds into the skulls of young women (myself included) is that your period is dirty, something that needs to be kept secret and “sanitary”, and most definitely hidden from others. As girls, we’re taught that menstruation is an unfortunate part of growing up, a curse, or at the very least, a major, monthly pain in the ass—something that needs to be tolerated and dealt with, but rarely something that should be celebrated and enjoyed. As part of our induction into womanhood, we’re inundated with ads from the feminine “hygiene” industry, promoting the benefits of this product over that, and encouring the idea that the selection of a feminine hygiene brand is an important rite of passage. All of this just compounds the sense of shame and embarrassment that so many of us feel about our bodies—magazines are full of ways for us to “fix” our bodies, lose weight and attract the man of our dreams by wearing the right clothes and smelling the right way. Commercials for pads and tampons rave about how fresh, clean and discrete their products are. Douches urge us to “cleanse” our (naturally dirty?) vaginas so that they’re strawberry-scented or flower-fresh (and cause untold infections in the process through drastic vaginal flora disruption).

The feminine hygiene industry is a billion dollar industry that feeds off of women’s insecurities and doubts, and has us all suckered into the idea that spending $200 on menstrual products a year is just an unavoidable part of being a woman. Let me put it this way: do you think men would spend $200 a year on hygiene products if they too had an unavoidable monthly biological process that was part of their healthy life-cycle? I’m guessing not. If men had menstrual cycles, I bet health insurance companies would have started covering the expense of their supplies long ago, since, after all, these products would be essential to the health of the insured, same way insurance companies will pay for prenatal vitamins, or the needles and glucometers of diabetics. Why should women be expected to pay out-of-pocket for something that’s part of their yearly health and wellness? (This is somewhat similar to the “logic” used when health insurance companies will pay for viagra, but refuse to cover birth control…but that’s a rant I’ll save for another day). Women have been using cloth for centuries. It’s only very recently that we’ve been expected to pay every month for the pleasure of bleeding onto pearly white, cotton pads.

One woman, in her lifetime, will go through close to 11,000 pads or tampons. That’s a huge amount of uneeded waste going straight to the landfill. The women on this earth account for 51% of the population. If all of us use 11,000 pads in our lifetimes…that’s gotta be a landfill the size of Australia! It’s worth switching to re-useable products for that reason alone, but wait, there’s more: disposable pads suck! Not only do they take up way too much space, and get tossed out after only a few hours of use, but the packaging that comes with the products (the boxes and applicators) are also nothing but landfill fodder, and often end up washing up on beaches. While the FDA assures us that tampon companies no longer use chlorine-bleaching processes to get those pure, snow-white results they’re looking for, this was a practice that was used for decades before the FDA recently outlawed it, and untold amounts of toxic dioxins have been released into our environment because of it, disrupting ecosystems and bioaccumulating in lakes and rivers. (The FDA was also very quick to dismiss the idea that the dioxins in tampons can cause TSS or possibly cancer, but even without the dioxins, tampons are still perfectly capable of causing TSS on their own, just by being such a lovely, squidgy vector for bacteria and infetion). Sadly, dioxin is a very persistent chemical, and even though companies now use chlorine-free bleaching processes, the damage has already been done. Our children and grandchildren will be drinking and eating trace amounts of dioxin in their water and food for decades to come, thanks to the toxic feminine hygiene industry. And I ask you this: why is it necessary that the cotton and rayon of pads and tampons be bleached in the first place? They’re not sterile products that are used for surgery or wounds; they don’t have to be bleached.

Anyway, to make a long story short, my initial reaction to my friend’s cotton pads was “eeewwww!!”, however, it didn’t take long for her arguments to make sense to me: 1) I was broke, and the idea of saving $200 a year not spending that money on pads was very appealing, and 2) I have always been trying to find ways to make my environmental footprint on this earth a little bit lighter, and using cloth pads seemed like a really simple thing to change, which actually has a very large cumulative impact. So I purchased a starter kit of reuseable cloth pads to take care of all my monthly needs and voila!, I was hooked. I’ll let others extol the virtues of free-bleeding, but for my own part, there was something deliciously empowering about taking this aspect of my life out of commercial, profit-driven hands, and into my own capable, human hands. There was also something immensely satisfying about blowing raspberries at the TV screen whenever an ad for tampons came on, and feeling smug and pleased with the knowledge that while other women spent money on pads every month, I didn’t! Course, this method required a certain non-squeamishness when it came to blood, and a willingness to wear heavy cloth pads in my underwear once a month (which did, I must admit, feel like I had a phone book between my legs every now and then), and of course I had to soak them and launder them appropriately. For about two years, this routine suited me just fine (and cloth pads are great, and continue to work well for millions of women around the world)…but then…THEN…I discovered the joys of the Keeper.

Believe me, once I was finally sold on the beauty and sustainability of cloth pads, I was a true-blue, born-again convert, however, I have found that I prefer the Keeper to cloth pads, which means that in my book, it’s really very VERY good. This little cup is a latex product that fits inside of your vagina and functions a lot like an OB tampon, collecting your menstrual flow without drying out your vaginal walls. It requires insertion with your fingers, and periodic emptying (your collected flow can be conveniently emptied into the toilet, then the Keeper can be wiped off and reinserted); I must admit, it does take a little bit of effort to learn how to get it in and out, but once you master it, this is by far the easiest form of menstrual protection I have ever used, AND it’s ecologically friendly, sustainable, reuseable, and relatively cheap, given that you only have to buy one, and then you’re set for the next 10 years. Another beauty of using a menstrual cup is the fact that you don’t have to change your cup nearly as often as you have to change a tampon. On light days, towards the end of my bleeding cycle, I can happily put my Keeper in during my morning shower, and leave it in all day, and forget that it’s even there. And then, at the end of your cycle, all you have to do is wash it out with antibacterial soap, let it soak overnight in a bowl of water mixed with a tablespoon of hydrogen peroxide, white vinegar or tea tree oil, and that’s it. So, for those of you who like functionality of tampons (and the lack of phone-book-between-your-legs), but would also like to stop feeding the fat purse of the toxic feminine hygiene industry, and do our planet a major favor, a menstrual cup is definitely the way to go. The Mooncup and Divacup are also every bit as fantastic as the Keeper, they’re just made out of silicone instead of latex, so for those of you with latex allergies, rest assured, there are menstrual cups out there for you, too!

That’s pretty much the end of my schpiel. I know that what works for some women certainly won’t work for all women, but I urge you to think about your menstrual choices. Once you start using alternative methods, you begin to wonder why you ever needed a 7th-grade introduction to feminine hygiene products in the first place. I started using alternative methods about five years ago, and I haven’t once looked back.

For further reading:

The Wise Wound by Shuttle, Redgrove & Drabble.

The Woman in the Body by Emily Martin.

Our midwifery department arranged a special treat for us today: a demonstration of the brand new speculum that’s out on the market, FemSpec.

Looks pretty strange, doesn’t it? Has anyone ever used one of these things? Supposedly it works much better than a regular speculum because it doesn’t allow the vaginal walls to collapse inward and obstruct the view, it’s always warm, always sanitary, and a lot softer, more comfortable and less threatening-looking. It’s inserted like a tampon, and then inflated once it’s inside the vagina like a blood pressure cuff. Nifty, ultra-luxe, and definitely designed for private practices that can shell out for the more expensive, new product.

We all got samples, and I gave mine a whirl. My overall impression was that on your average nulliparous woman with an anteverted uterus, this probably works like a charm…but what about women with deeply posterior cervices and retroverted uteri? And the FemSpec is opaque, so how are you supposed to get a good look at the vaginal walls, while you’re in there? The sales rep insisted that “the doctor” will have no problem visualizing the vaginal walls during removal of the FemSpec, but I’m not quite convinced. She also assured us that the extra lever that comes with every FemSpec means that “the physician” will have no problem visualizing those posterior, hard-to-reach cervices. She kept using the pronoun “he” as well.

I’m sure on some level she must have realized that she was talking to a room full of midwives and future midwives, but maybe she was nervous, and unable to deviate from her script, and it just didn’t quite click in her brain. Maybe she had no idea that saying doctor all the time might not fly so well in a room full of midwives who do paps just as often as docs. Maybe she’s just a new, young saleswoman who hasn’t yet learned that you court whatever audience you’re giving your pitch to. In any case, it kind of rubbed me the wrong way.

I’m still hardly competant at using the conventional speculum, let alone the new one. It will be really interesting to see if these actually start to infiltrate the market, and which clinics (if any) will begin to use them. As for me, I’m reserving judgement until I have an opportunity to actually use one in a clinical setting, but a note to FemSpec: teach your sales reps that midwives and physician assistants and nurse-practitioners and sometimes even nurses ALL use speculums, not just doctors. A more all-inclusive sales pitch might actually improve your sales.

Who are these men who love and date and marry midwives (and student midwives)? What an amazing breed! They don’t flinch or grimace when they hear words like “vagina”, “uterus” and “cervix” being bantered around the dinner table, they let you gush on and on about the beautiful birth you saw the night before, and they aren’t too miffed when you stop dead in your tracks to oggle the beautiful pregnant woman walking by. My own beloved boy is of this variety, and I am a lucky woman indeed. He knew absolutely nothing about homebirth when he first started dating me, but now he’s become a fierce advocate. He sometimes pumps me up for work on the days when I’m not in the mood by chanting “bellies, uteri, vulvas, babies” until I finally get excited again. And he buys me really cool books for the holidays, like Peggy Vincent’s Baby Catcher, which I just finished devouring during my flight back from England.

It’s a fantastic book. I mean, seriously, what a fun book! By the end of it, you feel like you’ve known Peggy Vincent for most of your life, and it really makes you want to just find her telephone number and call her up and chat with her (or, in my case, call her up and beg: let me be your apprentice for a year, I’ll cook all your meals, I’ll clean your car with a toothbrush, I’ll sleep on your floor, pleeeaaaase!!). The book begins with Peggy in nursing school, then follows her through several years as a labor and delivery nurse, a birth educator, a student midwife, and finally a homebirth midwife with a busy private practice. She has a very sharp memory, and the writing is descriptive and lovely, and it’s a really fast and easy read; you’re sucked in before you even know what hit you. The narrative is centered around the retelling of birth stories, and the myriad adventures Peggy had as a homebirth midwife, but there’s plenty of commentary tucked in as well. The book ends on a somewhat subdued note, as Peggy is sued by a woman that she wasn’t even officially delivering, and ends up losing her insurance just because she was involved in the first place, even though she didn’t do anything wrong. Sadly, this loss was echoed on the national level in 1991 when CNA Insurance, the insurance carrier for all certified nurse midwives in the US at that time, withdrew coverage from all CNMs who attended homebirths. While the ACNM now provides reasonably priced insurance for homebirth midwives, there are still so many barriers in place which prevent licensed midwives from attending homebirths, with our without insurance. Just look at the midwives in the capital region of NY, my own homestate: licensed, but still having to practice “bare” and undercover. Our society is always so quick to blame and mistrust the midwife—and homebirth midwives especially. Even if she did everything right, even if she was just standing in the room during a bad outcome while someone else was doing the delivery, I’m sure the lawyers and doctors and insurance companies would find a way to penalize her.

I’ve strayed somewhat, though. The point I was trying to make is that Baby Catcher is great! Just to give you a sample, here’s one of my favorite quotes from it:

I remembered my midwifery school classmate, Gaia’s, comment: “Just think about it. As midwives, we meet wildly interesting people and stay up all night with them. We ask them questions about their sex lives, eat their food, feel inside their bodies, snoop around their houses, drink champagne at all hours, and best of all, we get to catch delicious little naked, wet babies. What I can’t figure out is, why doesn’t everyone want to be a midwife?”

My thoughts exactly! And now, I’ve got to hit the sack. Tonight is a school night, and the new semester begins TOMORROW!!