While Facebook maintains that breastfeeding photos are okay, it does have a no-nipple no-areola policy, and will remove photos that other users indicate as obscene, which is apparently what happened with the breastfeeding photos that were originally removed.  I still don’t understand how photos of teenagers clad in lingerie are acceptable while photos of breastfeeding babies are not.  While some people argue that this is for the protection of the women and babies from predators, I really think what it does is send the message that public breastfeeding is not acceptable.  It seems like any use of the breast for anything other than sexual gratification is what’s considered obscene.  In our sex-drenched culture, sexy women in lingerie won’t even make us bat an eyelash, but a baby taking sustenance from a breast….that’s obscene.  How can breastfeeding not be considered “family-friendly”?  It’s the very essence of family friendly — it’s feeding and nourishing said family.  And for the folks who wonder why people would want to even take a photo of a nursing baby in the first place…just look at all the photos taken of babies with bottles in their mouths.  It’s cute, and as a parent, I can only imagine that there’s something very satisfying and fulfilling about watching your baby eat.  Babies are born to breastfeed, and it’s not obscene.  Anyway, kudos to the lactivists of California for making their real world presence felt outside the Facebook headquarters this holiday season.

And with that, I’m off for the rest of the year.  See you next year!

In early December, shortly after the nomination of Tom Daschle as Secretary of Health and Human Services (HHS), the Big Push for Midwives launched a campaign to get Mr. Daschle to attend a community meeting on midwifery and its advantages.  Per the change.gov initiative, discussions on healthcare reform will be occurring around the country between 12/15 - 12/31, and Senator Daschle has promised to attend a few of them in person.  Thanks to the Big Push for Midwives, he was invited to several heartland discussions, including this one in Lees Summit, MO.  I haven’t been able to find any updates or reports from this meeting yet.  I’m not sure if Senator Daschle was able to attend, but it’s definitley the sort of discussion he (and the Obama administration) should be listening to. (Was anyone actually able to attend that meeting?  If so, give us an update, please!!  I’ve been searching the internet for reports on the meeting, but I haven’t found any yet.)

As this excellent recent article in the LA Times (Midwives Deliver by Jennifer Block) points out, midwives deliver much safer care for much lower cost:

The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.The Obama administration could save the country billions by overhauling the American way of birth.

It seems like instead of encouraging midwifery care, the opposite is happening.  Birth Centers around the country are closing at a rapid pace, and Medicaid has recently started to resfuse to fund birth center care:

Over the past few years, CMS (the federal agency that runs Medicaid/Medicare) has begun disallowing federal matching funds for state Medicaid payments for freestanding birth centers services. Birth centers have been recognized by CMS (and earlier, by HCFA) as a Medicaid provider type in State Medicaid Plans since 1987. Recently, however, CMS has disallowed such payment by several state Medicaid Agencies, including Alaska, South Carolina, Texas, and Washington State, claiming that it lacks clear statutory authority and direction to do so. CMS has directed its regional offices to stop federal payments to any state for birth center services.

As this article points out, this is going to cause a huge squeeze on birth centers around the country, and we’ll soon be seeing even more of them close unless something is done.  This is an urgent call to action.  The AACB has several resources on their website listing ways to contact your senators and let them know about this issue, including using this lovely flyer which lists all of the important talking points you’ll need when composing your e-mail or making your phone call (calls are preferrable, apparently, since e-mail is more likely to be lost in the midst of all the e-mails on the federal bail-out).  The reason this is so important is that Medicaid generally sets the standard for insurers.  If Medicaid stops insuring birth center care, other insurance companies will follow suit.  Birth centers are a crucial link in many communities, providing quality health care to diverse populations (including women on Medicaid - you only have to look at the work of Ruth Lubic and the Morris Heights birth center to appreciate that), and we need to keep as many of them open as possible.  Not only does it make great health sense, but it saves money too.

And here’s another great cost-saving suggestion: stop insuring preterm elective cesareans.  When I read this article I just about choked.  I can’t believe insurance companies are willing to pay for this when research has consistently shown that there are still a lot of complications with “near-term” infants (babies born between 34 - 36 wks) such as respiratory distress, jaundice, temperature instability (hypothermia), delayed brain development and feeding difficulties.  Forget the fact that a cesarean delivery is several thousands of dollars more expensive than a vaginal delivery; the real damage in this practice is caused by the increased number of preterm babies and the burden of care they demand.  Prematurity and NICU care accounts for one of the largest chunks of healthcare expenditure.  Even the March of Dimes is calling for a decrease in preterm cesareans.

I’ve always been consistently amazed that HMOs, managed care systems and Medicaid haven’t latched onto midwifery with more enthusiasm.  I wonder sometimes if this is because ACOG and the AMA are able to counteract the economic practicality of midwifery care with a tons of lobby money.  The economic angle isn’t anything new.  The Business of Being Born said the same thing in 2007, and Michel Odent, Ina May, Naomi Wolf, Suzanne Arms, Robbie Davis-Floyd etc. etc. have been saying the same thing for decades.  Maybe in the midst of the recession, the message will finally get through: midwifery care is better AND cheaper.

1. Subscriptions

One of the most important (and hardest) parts of being a midwife is staying current with the latest research and information that’s coming down the pipeline.  While medical journals themselves are very expensive, they’re often a treasure trove of information that’s well worth reading.  If you’re a CNM/ CM, membership in the ACNM automatically brings the Journal of Midwifery and Women’s Health to your doorstep every quarter.  However, if you’re midwife is not a member of the ACNM, getting her a subscription to this journal could be a lovely gift.  If you really want to splurge (and/or if your midwife is an avid reader of medical research), then go straight to Midirs Midwifery Digest, which is England’s premiere midwifery publication, and really is a treat.  They will ship internationally, of course, although it’s a bit pricey.  I had a subscription for a year, and I loved it!  It’s such a breath of fresh air to read actual midwifery research, as opposed to OB research which happens to be applicable to midwives.  And of course there’s Midwifery Today, which is like candy to any birth-enthusiast.  The birth stories are truly inspirational, and Midwifery Today, much more so than the more academic journals, really captures the heart and soul of being a midwife.

If you’re looking for something more along the lines of a subscription for your favorite feminist, then I’d highly recommend Bust magazine.

2. Vulva Puppets

When I first discovered these AMAZING VULVA PUPPETS back in 2006 I very nearly wet myself with excitement.  Since that time, my vulva-puppet lust has been put on a back-burner (due in part to the hefty pricetag, which might make this gift somewhat impractical in a recession year), but I still think that this is cadillac of midwifery gifts, gauranteed to absolutely floor your midwife and send her (or him) into paroxysms of joy.  Just look at how beautiful they are—such a special, fitting tribute to the power and wonder and mystery of the vulva.  The Vulva Puppet Gallery has changed slightly; some of my personal favorite vulva puppets are now under the Limited Editions Gallery (which only works if you click on the color links, rather than the Goddess/Continent links).  These puppets will make an amazing gift for your midwife, particularly at a special juncture in her/his life, such as graduation, a new job, opening a private practice, retirement etc. etc.

3. Birth Secret, by Brian Andreas

I found this print in a gallery in Woodstock, NY, two days before our wedding, and I bought it on the spot.  It’s now become my go-to gift for all of the midwives in my life (and trust me, there are plenty of them), for birthdays or holidays or whenever you want to give someone something special.  The text reads: “In my dream he told me to hold the secret of his birth safe and teach him when he forgot”.  This artwork is perfect for the walls of your midwife’s office or clinic or home.

4. Books

I’m sure Spiritual Midwifery is already on your midwife’s bookshelf, so before purchasing books for your midwife, I first suggest that you puruse their bookshelf to ascertain what they do and do not already own.  Barring that, here are a few interesting and less obvious suggestions:

Pleasure reading:

The Birth House: A Novel

Baby Catcher: Chronicles of a Modern Midwife

A Midwife’s Story

A Midwife’s Tale: The Life of Martha Ballard, Based on Her Diary, 1785-1812
Educational/ Informative:

Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood

Heart & Hands: A Midwife’s Guide to Pregnancy & Birth

Recreating Motherhood

The Technology of Orgasm: “Hysteria,” the Vibrator, and Women’s Sexual Satisfaction (Johns Hopkins Studies in the History of Technology)

5. Jewelry

This might somewhat uphold the stereotype of the hippie midwife with the dangling goddess earrings, but if your midwife is that type of gal, then there’s some great stuff over on Attachments which fits that description.

And that’s pretty much all I can think of for now, although if anyone else has any other great suggestions, please let me know!

South Dakota’s Measure 11 was soundly defeated: “South Dakotans have affirmed by their votes tonight that no vague law can account for every individual circumstance. And that is precisely why women and families, not the government, should make these personal healthcare decisions,” said Sarah Stoesz, President and CEO of Planned Parenthood Minnesota, North Dakota, South Dakota.

The New York Times, in the midst of all the election craziness, published an article on new links between depression and premature delivery which have been recently reported in the Journal of Human Reproduction. The study interviewed 791 women and ultimately gave them scores based on how many depressive symtoms they exhibited–the higher the score, the worse the depression. The study found that the higher the score, the greater the risk of preterm delivery, even after controlling for prior preterm deliveries, miscarriage, socioeconomic status, education and other variables. This is particularly fascinating considering that so little is known about how depression affects pregnancy, and vitally important since depression during pregnancy (and the mental health of women during pregnancy in general) are so often overlooked in prenatal care.

The New Space for Women’s Health (formerly Friends of the Birth Center) is having a fundraiser on November 18th at Babeland called Women Come First. The event, which is co-sponsored by Ricki Lake and The Business of Being Born, offers an opportunity to not only raise money for the new free-standing women’s health and birth center in New York City but an exclusive cocktail party and shopping opportunity. Sounds like a lot of fun! I’d be there if I wasn’t already working that day…

Finally, I’m sure this is going the rounds on the internet, but I think everyone, everyone, needs to watch Keith Olbermann’s special comment on Proposition 8:

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 - 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

Even so, none of this changes the fact that women trying to access reproductive health care in South Dakota face a really tough challenge.  There is only one clinic in South Dakota which performs abortions, and they are done by a rotating staff of doctors who are flown in from neighboring states.  And again, as the Daily Kos has pointed out, the hoops that women in SD have to jump through before actually having the procedure done are incredibly daunting:

The woman must receive state-mandated “counseling.”

The woman must wait at least 24 hours after the state-mandated “counseling” before procedure may be provided.

If the patient is a minor, a parent or guardian of the patient must be notified.

The doctor must offer the woman an opportunity to view a sonogram, and must then record any responses in her permanent medical records.

The doctor must deliver a government-dictated script to women designed to intimidate her and discourage her decision. The mandatory language includes statements of fact which are contrary to all available medical research.

Usually by the time a woman is sitting across from me (a midwife) for her initial prenatal visit, she’s already made up her mind to keep her baby.  But every now and then I come across a woman who’s still conflicted, and we usually have a frank and very difficult discussion about whether she really wants this pregnancy or not, and everything that keeping this pregnancy entails.  This is a hard decision to make in a hospital like mine, sitting across from a provider like me who is resoundingly pro-choice, and is not at all judgemental or discouraging of the woman’s thoughts or decision.  These women are often young, alone, and already scared and intimidated, but if they really don’t feel like they can keep this pregnancy (for whatever reason–and we do talk about the reasons, but only to make sure that she’s thought everything through), I gently refer them to the termination of pregnancy clinic, with compassion and support.  No one is judging them.  Judgement is the LAST thing you should find in your health care provider’s office.

Now, imagine this were South Dakota.  Imagine how much harder it would be to make such a decision if I were legally required to read these women a script containing statements which are medically false and which do nothing but make the woman feel even more intimidated and guilty about her decision.  If I were forced by state regulations to make it very clear that I think abortion is a terrible idea, it would take a very staunch woman indeed to be able to stand up to something like that (and this is not because I’m so terribly persuasive, but only because the power of the white coat is astounding: people automatically trust you a little bit more and believe you’re speaking the truth, just because you’ve got a white coat on.  If you tell them that they need to eat more iron-rich foods because they’re anemic, they generally listen to you.  If you tell them that what they’re doing is wrong, they listen to you too).  And then, to top it off, I’d have to offer these women a sonogram, just so they can see that heart beating some more, and feel even more like a monster for doing what they feel they have to do.  The cruelty of it makes my skin crawl.

In any case, the reproductive rights of the women of South Dakota hang in the balance (and by proxy, the women of the rest of this country too, because if this referendum passes in South Dakota, it’s just opening the door for every other state).  And do not be fooled: the inclusion of exceptions into the wording of the bill in no way changes the fact that this referendum will basically make all abortions in South Dakota illegal, because there is absolutely no practical way to carry out these exceptions, and no doctor willing to test it.  So, what can we do about it?  We can donate money to the South Dakota Campaign for Healthy Families, and we can…(to put a rather neo-conservative spin on it)…pray.