Tuesday, December 28, 2010

Birth Stats: A Doula's Year in Review

I just got home from an absolutely gorgeous birth of a nice big boy. This is most likely my last birth before the new year, though anything is possible. As I have time to do so now, I'll share how things went this year.

Before getting to the birth stats, let me just say this has been a HUGE year for me, full of growth. Though I have been a doula for quite some time, MotherWit is just over a year old. In this year I created and we launched our very successful Birth Essentials: A Course in Childbirth Empowerment prenatal classes. I taught my birth doula training in intensive format for the first time with great success. I also taught for the first time a four day postpartum doula training course. Both trainings required many hours of creation and hundreds of pages of doula training manual writing. The work was well worth all the effort, and I am very very pleased with my amazing apprentices and students.

The MotherWit team opened a physical space, something we had been hoping to do for quite some time. In this space we teach our classes, see our clients, do trainings, have mom/baby groups, apprentice meetings, "Meet the Doula" soirees, and will soon be doing infant massage teaching for parents. We have parties, too. I am thrilled with our cozy space.

MotherWit was asked to do 2 informal, in- hospital doula-led workshops...one 8 hour workshop for new nurses, and one 1 hour workshop for family medicine residents. Oh, what fun! This was a very eye opening endeavour, and we learned a lot about where many medical people's hearts are at...it was all good news. We also learned about how restrictive protocols and policies can be and how they inhibit some of the ways some of these people really wish they could work. There is lots of exciting work to do in these areas to create more satisfactory birth experiences for families who want/need to birth in a hospital. Working together, I truly believe good changes can be made. People often think I'm a PollyAnna and a dimwit for holding onto that hope. But I stand by it. Yes, I am myself a home birther. Yes, I point women who want to take that route to all the resources available whenever it seems they want this option. Yes, I sometimes feel I am being asked to witness train wrecks. Yes, sometimes what happens in hospitals is terribly hurtful and frustrating. But as MOST women are still wanting to birth in the hospital because this is where they feel safest, I feel focusing my energies on ensuring these potentially overly managed births, often the price for this sense of safety, have a lot of input from well informed, well prepared parents. I also feel it is crucial for these women and men to have emotional buffering when necessary. Everyone deserves support in labour, to have their choices honoured, and to feel heard and loved. This is the essence of doula work.

I also went to Madagascar this year! Yes, I am still intending to blog about this experience, but as you can see, work has been crazy! I will get there. It was incredible! The preparation to get this trip underway was no easy feat, and it took a lot of time and energy, again, well worth the effort.

On a personal note, my eldest baby turned 18 and my youngest baby started Kindergarten this year. My sisters came from the UK to visit because one of them got married here in Quebec...a truly lovely wedding. My mom and stepfather had some health challenges that are now, thank Goodness, behind them (ptu ptu ptu). It felt like a real blessing to have Christmas together with everyone in good health. I lost my friend Lhasa to breast cancer early this year. If it taught me anything, it was to seize opportunities and to be very grateful for every day.

I attended 42 births this year and saw 47 babies enter into this world. This is, thank Goodness, 21 births less than I attended last year. My goal had been to attend much less births. While 42 births is still a ton given everything else I've been doing, it was technically still a bit of an easier year in terms of birth attending. I am so glad for the MotherWit team who are slowly beginning to take over the volume of births I'm trying to let go of little by little. My goal is to do significantly less this year so I can focus on teaching, as I have been receiving requests from different places to train doulas. I also REALLY want to finish my book. I had hoped it would have been done this year, but not yet.

Many people think doulas have good stats because we attract couples who want natural births. This is so not always the case. As doula work becomes more mainstream, it is not necessarily those who are hoping for a natural birth who seek out our services. Often it's couples who are savvy of how lost they may become within the hospital system, and just really want an anchor, or to ensure there will be someone there to trust them and give them support when they feel afraid. As I said, everyone deserves support in childbirth, not just those who have the goal of natural childbirth in mind.

The main demographic of my clients are educated middle to upper class couples. They are of varying races, religions, and sexual orientation. While having a large percentage of educated, prosperous couples as clients may sound easy, I assure you this is not often the case. Many of these couples come to birth having been very focused on careers up 'til this point, and are educated about birth via friends (who love to share horror stories), media, and their doctors. The connection they forge with their bodies and their emotional needs as soon to be parents (with our guidance) is often very new. Our way of helping couples prepare for birth is less intellectual and more about encouraging them NOT to trust a clock or a number, but to tune into themselves. It is not easy encouraging women who have spent all their lives in control of things to let go and allow this primal process to unfold organically. They often refer to "those other ladies" who can squat in the fields, not realizing that they are capable of that too. Their doctors also often assume that because they are educated and career oriented that they will be thrilled with the "civilized" way of birth (induction and epidural), so it's often promoted as a good thing for them. One of my clients was offered a planned Cesarean (not often done in Quebec at all), probably simply because she comes from a very wealthy family, and it was assumed (wrongly) that she would feel too posh to push. Believe me, we have our work cut out for us to help women connect to those fledgling, barely whispered of hopes they hold that maybe they could have births like the women in those documentaries, even if they're not planning to give birth at home in a kiddie pool but with a high risk obstetrician at a tertiery care hospital because they're on the long toothed side of 35, and in spite of the fact they are getting most of their childbirth education from a culture who looks to A Baby Story for inspiration. To those of you who really know birth, I know this sounds like an impossible dream. But I am telling you, even though they're not birthing in pools, they are getting to places they never thought they'd go, and these ladies who are often told by their friends and doctors that they WILL be begging for "their" epidurals (as if there's one just waiting to scoop up every birthing woman) as soon as the going gets really tough, ARE BIRTHING NATURALLY! With doulas, anyway. Yes, we still see way more epidurals and Cesareans than we otherwise would if most of these women planned to give birth at home, but substantially more than half of my mamas birthed naturally this year.

Out of these 42 births, only 2 this year were planned outside of a hospital (both were planned at a Maison de Naissance, or Birth House for those of you who don't speak French or Frenglish, which is a free standing birthing clinic run by midwives...no doctors on staff). One lady was transferred from there to the hospital to give birth, and another gave birth so quickly her midwife barely had time to run to her house to catch her baby. All of the rest happened in hospitals. In the downtown Montreal area, hospital birthing women have up to 98% epidural rates, meaning about 2% of first time mothers here birth without epidural. According to nurses, most of those women wanted an epidural, but didn't get it on time. Midwives do not make up hospital staff here. All of these births were attended by doctors.

I had a higher percentage than usual of Cesarean births this year. So, in total, 7 surgical births: 1 planned for twins because both were breech (the doctor on call said he would attempt to assist with a vaginal birth, but the mother chose otherwise), 1 planned for twins because one twin was definitely showing signs of distress before labour had even begun, 1 mom induced with 41 week twins (after 36 hours of labour, things didn't progress), 1 singleton birth planned at 37 weeks for vasa previa, 1 attempted singleton VBAC attempting lady had a repeat C-section for fetal distress due to an abrupted placenta (they thought maybe the uterus had ruptured), 1 planned for twins with a pre-ecclamptic mom with a breech first baby, and one long singleton labour that ended with fetal distress and an emergency Cesarean. All babies were born healthy, or became healthy quickly after birth. This is just shy of a 17 per cent Csection rate, which is the WORST I've ever had. As you can see, the majority of these surgical births involved twins. There is SO much work to be done to support twin moms, who are subject to a crazy amount of intervention.

8 of my ladies had epidurals (the ladies who had Csections only had epidurals at the very end of labour because they knew they were going to have surgery, or were planned, so I don't count them in this stat). 3 were for long, hard posterior labours, 2 were for Cervidil/Pit induced labours, one lady got one at 8cm after her Cervix hadn't changed after 1.5 hours with transition contractions...wasn't attached to natural birth, , and two wanted them when labour started getting really tough because they had both had traumatic birth experiences before and were terrified of experiencing that level of pain for a long time again. They felt it was what they needed to feel safe. Epidural rate, 19%

27 of my clients experienced natural birth. Some were "augmented" because of waters being broken for a long time before labour starting, but they gave birth without epidural or IV narcotics.

Out of these natural births 11 were first time moms (one mom of twins in there), 3 were VBACS, and the rest (13) were subsequent vaginal births, most second and a couple of third babies. 64% natural births.

So, folks, that's this doula's year in review. I cannot thank those enough who had me at their births, and to all those who have helped and supported MotherWit get off the ground. You are all appreciated.

I will leave you with a nice story. I encountered a lovely resident at the hospital today who told me she had been one of the residents to attend the workshop I gave earlier this year. She told me this workshop had really touched her, and that it had been exciting and eye opening. After my client gave birth with her usual beautiful grace, on her hands and knees with her husband helping, and she and her husband and baby had had some time to bond and bask in the glory of their experience for a while, the resident came up to them and said with her eyes shining, "Thank you so much for the honour of sharing in such a special time in your life." The message I really tried to give to the residents was to remember this...that no matter how many births they attend, no matter how interesting of a "case" it may be, these patients of theirs are bringing life into the world, and that it is sacred and special. I emphasized that if those patients will remember anything about the people who were involved with their births, it will be how honouring their caregivers were of them. It was really moving to see this resident not only act as if were not just an ordinary part of her day, but to express the sacredness of their experience with her gratitude. May this trend continue....

Happy New Year!

Tuesday, December 14, 2010

Doula Boundaries re: Finances

Occasionally I will have a client who finds out that when she must have a planned Cesarean, she feels she no longer wants doula services, or wants extra postpartum care instead. If this is planned in advance and all are on board, this is fine. Doulas are flexible, and usually don't mind doing some extra postpartum visits instead, or a friendly termination of services if this is appropriate.

I have heard a few doulas tell me, however, that their clients decided at the last minute they felt a doula at their Cesarean birth was pointless, and demanded other services that were not really within the scope of the birth doula's work, like night nanny-ing or older child care, in order for the doula to earn the fee. If this is something the doula is really happy with, whatever a client and doula want to do is their business. I feel, however, as a reasonably experienced doula, that contracts are essential to establishing clear boundares. I know they can feel uncomfortable to a doula who is so willing to give everything and bend over backwards to serve all the desires of her client. Doulas serve. This is our essential definition. And because birth is so incredibly unpredictable and changeable, flexibility is part of our natures. But boundaries are important. Doulas need to honour their worth and refrain from feeling badly for taking pay because, for example, a birth went very quickly, or from allowing their family income to take a huge financial hit because they weren't comfortable standing up for themselves. This can cause resentfulness and burnout. Contracts make things clear. They are important for doulas, especially for newer doulas who are scared of making a client uncomfortable.

If a client signs on for a birth and has agreed to the listed things in the contract such as "if you choose not to have your doula after your prenatal meetings, you are still responsible for the remainder of the fee", this fee is still owed. Period. Doulas meet with their clients before any official prenatal work is done in order to ensure both parties like the chemistry. That can usually be sensed immediately. If the client decides at the last minute she'd prefer her best friend to you after the work you've done together and fails to contact you for the birth, your contract protects you. It is certainly her right to not have you come at the last minute, but your fee is still due. If a baby comes too fast, for example, we still must be paid. A planned Cesarean is still a birth. It is wrong to assume that a doula's presence is not very valuable for a Cesarean birth. While she cannot go into the operating room with a client much of the time, especially if the mother's partner is going in to support her, there is much we can do after the surgery.

A doula's work is so unpredictable, and outcomes are beyond her control. She should not be penalized for her client's last minute choices. She will not have had time to book another client with such short notice, and this can severely affect her livelihood.

Sometimes clients will expect special services because they decided a doula at their C-section was not necessary, and this is not fair. A doula lovingly and thoroughly prepares her clients for the birth of their baby, however that unfolds. We cannot guarantee a vaginal birth. We can't guarantee anything. To expect that we'll just do something convenient for the parents in place of birth attending is like their asking for a free dessert from a restaurant because despite the effort of our crafting a wonderful and elabourate meal that was requested by them, for whatever reason it turned out they didn't want to eat it, or pay the balance. As it was the customers who came to the restaurant in the first place and placed a request that you have refused other requests for in order to accommodate this one, it is only fair there is financial accountability for the original order instead of having to delve into the chocolate mousse resources to "make up" for the balance they owe. It's not the restaurant's fault the client now doesn't want the caviar and truffle souffle. Now, granted, if the meal were terribly prepared and served, this would be another issue, and should be something the parents can dispute. But generally, signing on for all the prenatal preparation, postpartum follow up, and a birth means that regardless of how the birth has to go, the doula has been asked to provide a service and must be paid according to her contract and not get ripped off because she didn't replace her service with another coveted one. Birth doulas are not babysitters or night nannies. We attend births. Cesarean is birth. The vast majority of clients who want these other services don't even ask whether or not this would require a different payment structure or a different service provider...it is apparent to most. But occasionally some don't, and when this happens, the doula must be firm in standing up for herself, even if this means taking action to get the pay her contract states is owed to her.

I had a client recently who knew before our first face to face meeting she would have to birth via C-section. We decided to do less prenatal visits, decided I would be at the hospital for her and her partner while she birthed, and that I would do extra postpartum work. We were all very happy with this arrangement. I have had other couples ask me, "If I end up having to have a planned Cesarean, I don't feel I'll need you there as I've been through Cesarean before. Can we have something in the contract which states I can refrain from paying the birth attending fee?" And I will agree to that if they know a few weeks ahead of time. This gives me the opportunity to book someone else in their spot. Requested flexibility is not an issue. However, if a client signs her contract in advance knowing she is bound to pay for birth services, whether she asks her doula to be there or not, then that's what she needs to do.

Birth attending is an amazing joy. Sometimes births are short and we make quite a great wage if you add it up hourly. And sometimes with loooonggg births, especially if we missed another birth because someone's birth was very early and loooonngg and another person went very late (this can happen even if you only book one lady per month), you can end up in the hole financially. We have to plan for these occasional contingencies, and take those rare but sad hits. But if our flexible natures which love to serve and to please our clients make us pushovers, we will inevitably get taken advantage of at some point. And yes, it IS true that if we speak up for ourselves and claim our right to decent pay, we can get the reputation of being hard assed. But it also shows we respect ourselves and value our work. Being firm has in fact only helped my business as opposed to send clients running to someone else. When YOU know your value, it is apparent to potential clients as well.

I personally don't quibble about my prices. I don't give people money off here or money off there because they feel my price is high. Every doula knows the feeling of walking into the home of someone who owns a BMW or you see a $1000 stroller in the corner, or the couple just came back from a big vacation to Jamaica, and then the clients want to negotiate a "better deal". I have never had a problem lowering my price for people who clearly are struggling with finances and who seem very committed to investing in their birth experience. A colleague of mine was recently approached by a pregnant teenager who said, "I need a doula, but I have no money. I can bake, and I can knit." This honest, upfront approach impressed her, she agreed, and they both had an incredibly rewarding experience. If women are genuinely disadvantaged, I send them to a doula organization which specifically helps women in need. But for the vast majority of my clients, my price is my price. Those who initially found it quite high change their minds after the birth is done. The 24 hour on call committment, doing our best and pulling out all stops in terms of support in the throes of extreme sleep deprivation, helping clients gather enough information to make choices that in the end spare them from a potential C-section and the recovery time and breastfeeding challenges ensuing from a high tech birth, having to reschedule sometimes 2 days of appointments, missing our 2 year old's birthday party, etc.....this kind of service is incredibly valuable, and the far reaching effects of a satisfying birth and postpartum experience are global. When the birth is done, clients are very aware of all you have done.

Doulas out there, you are amazing. Within a scattered, unpredictable, crazy making job, a firm backbone of boundaries in the area of finances is crucial for your mental and emotional health, as well as that of your family. Never doubt your worth.

Sunday, December 12, 2010

Missing the Forest for the Trees: Birthing in an MRI Machine

I came across the above article from a Facebook friend, and have to say it left me with a dizzying sense of sadness. A woman gave birth in an MRI machine in Germany. The stated intention behind this crazy endeavour was to set up a study which seeks to examine why doctors "have" to deliver so many babies by C-section. They want to unlock the mystery as to why some women can birth 10 pounders and others have 7 pounders which get stuck. They want to understand why so many babies' craniums are disproportionately large for their mothers' pelvises. When the article went on to state the researchers were trying to get a better understanding of the mechanics of birth, I didn't know whether to laugh my head off, barf, or hit someone.

Firstly, even open MRI machines, which is what this woman birthed in, are not in any way conducive to normal labour. I highly doubt she could have been any way but lying on her back. I could be wrong, but from images I've seen it doesn't appear to be possible in another position. So if you are trying to study the mechanics of labour yet put a woman under a machine on her back, can you be seriously believing you are studying something that even remotely approaches normal labour mechanics? The vast majority of women in this world who have given birth normally, meaning unmedicated and largely undirected, would not even conceive of lying on their backs to birth. If the baby is trying to push that nice flexible sacrum away with his face as he begins to extend his wee head, the joints of that sacrum being suffused with lovely, bone-opening Relaxin, what kind of slap in the face is it to find that the sacrum won't move because it's sandwiched between his head and the bed his mother is lying upon...on her back? Mom is directed to resort to purple pushing with people yelling at her that she HAS to create intra-uterine pressure by holding her breath and popping her eyeballs, effectively turning herself into a human pop-gun. The rush and stress of all that direction and being yelled at not to yell when it is all you want to do, makes MY pelvic floor contract at the the thought of it. Purple pushing is NOT NORMAL!!!! But close off the space, and Mom may have to resort to it.

I doubt this nifty MRI machine, closed or not, accommodates the positions most women adopt during physiological labour, which are more hands and knees or crouching stances. And they will probably want to YELL as they push their babies down, and move around a lot, which is probably not great when you're trying to get an MRI image. She will not actually be "wasting" her contractions, or "lessening the efficiency" or "be doing it wrong" if she doesn't surrender to the needs of the MRI machine and the desires of the doctors who "deliver her". But she will likely be made to feel like she is in the wrong, the negative emotions created by this circus contributing to some of the mess I as a doula have to help a woman process after her birth to heal from her experience so she doesn't remain unconfident, traumatized, and subject to depression..and this is without even having birthed in a machine. Women don't birth "wrong". Yeah, sometimes the unexpected happens, and thank goodness for science then, but the way women adjust and adapt their bodies to the process is instinctive, and to change them is usually inappropriate and problem CAUSING. Just check out the powerful, gorgeous, loud birther of Jason Shawn in this YouTube clip. I dare you to tell this woman to shut up and get on her back because that's the "best way"! I in no way see in this clip a woman suffering or out of control...I see a woman expressing her most authentic power, and it is pretty much the opposite of a medicated woman in a machine lying on her back. I don't see why this kind of birth can only happen either with midwives or unassisted. Why can't OBs hold the space for this kind of birth too? It's obviously not like they have to do much.


If you observe a woman birthing and you have the attitude there is something inherently wrong with our birthing design, and you're creating a study to determine her potential biological flaws so the people in white coats can "fix" us, I assure you, you will not be watching a normal birth, mechanics aside. Your doubt filled observations will affect the process. If you are trying to have an orgasm and you sense you're being observed and judged, you're going to lose your mojo a little. If you're trying to have a crap, you have a time limit in which to achieve it, people are observing you and perhaps even commentating, would the efficacy of your bowels not be affected just a smidge? Is it not considered a common thing for gentlemen to have pee shyness when another guy stands beside his urinal? How on earth can we expect a woman experiencing an event as challenging and dare I say as sacred as childbirth be remotely normal in this INSANE context? We're not even scratching the surface here, as there are other reasons many of the cases of shoulder dystocia and "CPD" could be occurring, such as the over use of labour stimulants, epidural anaesthesia, etc, which are all known to have a potential effect upon normal hormonal flow AND mechanics.

As a woman, a woman who knows the triumph of having birthed normally 4 times, and as a doula who has witnessed so many potentially unnecessary hospital horrors my tears could fill an ocean, this whole article did not make me execute jumpy claps at the marvels of science. It made me feel terrified for the future of birthing women, because I really think much of what this study will find is blame for the woman and her brilliant design to justify the expense and effort put into it, as opposed to illuminating the sheer arrogance and danger of trying to determine how birth fails by breaking it down and examining it right down to its smallest particle. What if we were to focus more upon the preventative benefits of nourishing the whole process, perhaps even doing a little humble bowing in the face of such Mystery...woman's mystery...now and again? You know, even Joe Public understands that many Cesareans are iatrogenically generated. Don't these researchers know this?! There is no motherwit here.