The Best Time I Didn’t Deliver A Baby

Dear Millicent,

I now know what kind of person I am in an emergency.  Yesterday morning, I went to meet a couple who I would be doulaing for, ready with my bag of tricks.  I had my lavender oil, my breath mints, my mantras and my own sense of calm. When I got to the door, the baby was crowning, and would be born two minutes later on the bathroom floor.

This happens, and homebirth is not by definition an emergency.  Planned homebirth is awesome.  Doulas are trained for what to do in an emergency delivery, but it is the kind of training that my brain did not hold tightly. I absorbed it like learning how to punch a window out if your car falls off a bridge and is submerged into water: it is big time useful, but also something that only happens in movies.  Except that it all actually happens sometimes.

This was an emergency in the sense that there was no control. Whatever this would be, it would be, and it was happening RIGHT NOW. The dad asked me if I knew what to do. I said what my gut said. “No.”

And then I got thwarted by the fact I don’t know how to use an I-phone.  Me and 911 kept saying “hello” to each other. I was waiting for all those important instructions to pour out–look for this, look for that. But I couldn’t get the damn speaker phone off, and asking for directions about a phone is stupid compared to the fact that a baby is coming out, right now. And it did.  The baby came out. And started crying. It all worked the way it’s supposed to work, and firemen came, and everything got taken care of.

The Iphone never made sense.

For the entire 2 minutes, I had no idea how to help.  I felt like the clumsiest person in the world.  It was all very slow, and very fast. It was all high panic, and incredibly calm.  A part of me surrendered, knowing that I had no idea what to do. And a part of me insisted that there were practical things to do. Look for towels! Pay attention. Watch. Look around for clues. Look for bad things.

But there were no bad things. We weren’t called on for that kind of adrenaline. It worked. It was a household event. Not a crisis. The firemen seemed happy to have such an easy emergency to attend.  All was well. Babies are born every day.

I can’t believe that is how I spent my morning.

When I got home and looked up emergency home birth on the internet, all of the instruction guides (which I imagine freaked out people reading with the laptop set up next to the birthing woman, pissed that the screensaver came on because now they will have to click, then wash their hands again, and that baby is coming!), were amazingly soothing.  They promised that this was rare, and that it usually happened with very healthy moms and babies.  That birth, often enough to hope for the best, took care of itself.  “When in doubt,” one content farm version of instructions said, “do nothing.”*

In the best of emergency circumstances, delivering a baby means lightly holding the head, making sure no cord is around the throat, and catching it. Then, putting newborn on mama’s chest. There are other facts. Babies are blue when they’re born. If the baby isn’t crying, to press its nostrils downwards. To keep the umbilical cord attached.  There is a lot of information, but the basic instructions for a routine birth are simple enough to fit into a small bullet list.  The internet could get you through it.

For myself, I’m not sure in that moment I would have remembered how the internet worked.  But, I now have even more trust in what the body can do.  This was the first non-hospital birth I have been at. It wasn’t an ideal birth. It was scary, and fast, and the amount of adrenaline drenching the house was insane.   I don’t know if the mama is going to remember it as traumatic or wild.  The experience brought home how birth is really about the woman and her body, and that the hospital is an accessory, a location. A minor distinction, one that I had not realized before this, emphasizing how disempowering many hospital spaces are for laboring women.  Also, the immense blessing of people who actually know how to deliver babies, be they nurses, firemen (firepeople?),  midwives, or OBs.

So, lessons learned:

  • Time gets slow in crisis, but crisis keeps moving.
  • Figure out how an I-phone works.
  • Trust women.
  • Babies don’t give a shit about your plans.
  • Sometimes, things work out seriously fine.
**As for the “do nothing” style, there is a whole kind of  planned solo birth where the mother attends herself.  Often, a midwife will be present as backup for complications or support, but the birthing mother will actually deliver her own kiddo.

One for Two: VBACs and Autonomy

Dear Millicent,

In her article “Do Pregnant Women Have The Right to Refuse Surgery,” Rebecca Spence over at RH  Reality Check highlights one of the craziest and mindwalloping aspects of motherhood. You and I have parsed shades of it before, looking at how the sacrifice of parenting is so much more than time and money or giving hugs and casseroles when you just don’t feel like it.

While both parents might gain the privilege of joint dictatorship over their kids’ lives, once pregnant, a woman is pushed into a new definition of selflessness.  Her body becomes a grounds for expectation, judgement, and social know-betterness.  And, while there are lots of glowy wonderful aspects, that other terrifying analogy exists: Mama as host and Baby as blood-pressure-spiking parasite.    Why terrifying? Because parasites usually win, and hosts are never defined by their exhilarating autonomy, are they?

Spence’s article focuses on the NIH’s Vaginal Birth After Cesearean Consensus Development panel, which last week issued a statement that had some good news (mostly that the regulations limiting VBACs needed to scrutinized), but the squirmy argument that there were circumstances where a doctor’s opinion trumped a mother’s wishes regarding surgery.

Spence  emphasizes “the panelists’ comments indicated that a conclusion regarding the ethical question was beyond their scope, yet stated to the press and to the audience that the body of law and ethics that protects the right to refuse surgery was not written for, and may not include pregnant patients.”

Spence asks “Are women who are pregnant simply a different form of person with a different set of rights?”

Obviously, and yet I had never thought of it before, this question is a big question in the field of obstetric ethics, and is simple (treat people well! ) and sticky (it’s ethics!).  Spence writes:

Much ink has been spilled refuting the two-patient model of obstetric ethics, which conceptualizes the interaction between mother and fetus as a conflict capable of being decided by an outside arbiter (be it a judge, ethicist, or doctor), rather than a conflict between the mother and the doctor. The manner in which the panel has cast the problem of obstetric ethics as a maternal-fetal conflict, as opposed to a woman-doctor conflict could lead one to the conclusion that a physician’s ethical obligation to “first do no harm” applies to fetuses, but not to women — an untenable position for a profession devoted to caring for women, and a dangerous position for public health. The panel’s failure to condemn practices such as court-ordered cesareans and child protective services intervention to coerce women’s compliance with doctor’s orders poses major questions about whether and how personal convictions may have been at play in this discussion.

I read this, and I think ack! The maternal-fetal conflict is real, but biological and strange and nobody really wants to talk about what that really means because by the time the conflict presents itself, it has to be come to terms with.  If my partner chooses to have a child, he deals with feelings of maturity, fears, finances.  If I choose to have a child, I have to decide whose body comes first in my judgment, the kid’s or mine. My freedom is probably tanked, but hopefully on my own terms.  If I choose to continue my pregnancy, I am both hijacked and hijacker’s big boss. But that problem is not one of obstetric ethics, it’s of how maternity is a strange feat.  And Spence here focuses on how doctors should support women in this moment: as individuals with full rights.

And, while the horrors of court-ordered cesareans exist, it sounds like the panel’s opinion is not the majority’s perspective.  Spence says:

The position taken by the consensus panel directly contradicts the thoughtful and comprehensive presentation given 24 hours earlier by Dr. Anne Lyerly of Duke University, the invited expert speaker on the ethics of vaginal birth after cesarean. Dr. Lyerly reminded the panel of “a lesson that we need to keep learning but should know by now.”

“In obstetrical decision making,” she said, “women retain their rights of bodily integrity, just as people do in all other situations. So when a woman declines a cesarean, even when it is absolutely indicated, she cannot be forced to undergo it, [n]or be punished for her decision not to. American jurisprudence supports that, as well as ACOG [the American Congress of Obstetricians and Gynecologists].”

I’m happy to see this opinion offered so eloquently, but what worries me is that the establishment still fumbles with the question.  And I shudder to think what a Law and Order episode would look like dealing with this topic.  We’re taught early on that if a woman is pregnant, the stakes are raised (think of any movie with a holdup at a restaurant or bank…usually there is a pregnant woman among the hostages).  A useful narrative device, yes:  two lives in one (get her off the boat first!).  But, while it usually expands her freedom in these fictional situations, she loses voice and power so often in real life.  The idea of woman as baby container/host/russian nesting doll is so scary—-Not because of the act of reproduction, but because of the transformation from person to object.   Here’s hoping, like Spence offers, that this is becoming a less standard standard in the medical field.

Thanks Tuba City!

Dear Millicent,

In this article in today’s NYT, Denise Grady does a great job of covering the major issues surrounding the maternal healthcare debate in the US by looking at the successes of a small hospital run by the Navajo Nation in Tuba City, Arizona.  There is a lower rate of cesareans, most births are attended by midwives, and most women deliver at their own pace with friends and family supporting them. In a quick two pages, the article justly illustrates:

  • the issues surrounding VBACs (Vaginal Birth After Cesarean)
  • the benefits of the midwifery care model
  • how insurance costs often affect care
  • the benefit of emotional support during delivery
  • the benefit of a community that is familiar with the birth process (in Tuba City, several families members attend a birth, meaning that most people have seen the process several times).

Grady asks “Can the rest of the country learn from Tuba City?” and finds that doctors are “intrigued by the model” but don’t know “how transferable it is.”

The model is not a complicated, as Tuba City proves.  There are midwives, doulas and OBs working within this model every day.  They trust women, celebrate and normalize birth in our culture, and worry less about profit.  But, they, like Tuba City, are the exception, hopefully transforming the rule.  Still, it’s great to see articles like this that so clearly show what is out there, and what is at risk.

And for those who think shit isn’t superserious in America’s maternity wards, I offer  this video from 2007 of one woman’s account of how she was arrested mid-labor and forced to have a Cesarean because of hospital restrictions on VBACs.



What Utah’s Miscarriage=Homicide Laws Could Mean: Some Scenarios

Dear CF,

Your post about the pregnant Olympians was so damn good, and so timely: I opened the Internet the next day and found this news on legislation in Utah, which would allow any woman whose pregnancy ended in miscarriage due to an “intentional, knowing, or reckless act leading to the pregnancy’s illegal termination.” If the Winter Olympics had been held in Salt Lake City this year instead of in 2002, every one of those pregnant Olympians would have risked being charged with homicide if they happened to have a miscarriage.

This is clearly one of those bills that stemmed from a sensational news story—the kind we love, the kind that 20/20 and its ilk have fed us for decades. Remember when everyone wanted to come up with some way to legislate away Megan Meier’s suicide, caused by Internet bullying? This bill—which does not allow women to be prosecuted for arranging a legal abortion—was passed because “a Vernal woman allegedly paid a man $150 to beat her and cause miscarriage but could not be charged.”

Easy to see how that story caught Utah’s imagination. Let’s sit a minute with the wording of that bill, though: any “intentional, knowing, or reckless act” followed by miscarriage can result in a woman being charged with homicide. As Jezebel and others have pointed out, that last little word, “reckless,” means that legally, anything that has ever been labeled as a suboptimal practice for pregnant women could be retroactively used to charge a woman whose pregnancy has ended. Correction: it can be used to charge a woman whose pregnancy has been “illegally terminated,” meaning not that she obtained a legal abortion but that she miscarried through some other means, the legality of which is to be determined by the circumstances leading up to the miscarriage.

To see how dangerous this is, let’s pretend we’re looking to prosecute a woman who miscarried. For this exercise, we’ll look to the newspapers to get a sense of what might reasonably count as “common knowledge” that a pregnant woman disregarded, neglected or disobeyed, and how any of the following cases could arguably have resulted from “reckless” behavior.

Case 1: She got pregnant. She didn’t get the swine flu vaccine. She got swine flu. She lost the baby:

On Sept. 29, 2009, the New York Times printed this story: “Pregnancy Is No Time to Refuse a Flu Shot,” in which authors Lyerly, Little and Faden note that pregnant women “are deluged with advice about things to avoid: caffeine, paint, soft cheese, sushi. Even when evidence of possible harm is weak or purely theoretical, the overriding caveat is, ”Don’t take it, don’t use it, don’t do it.'”

They point out that many pregnant women avoided the flu shot and got terribly sick or died:

This is a sadly familiar pattern. After the thalidomide disaster of 1960s, and the very real concerns it raised about the impact of drugs on fetal development, many ended up viewing the use of any medicine by pregnant women as anathema. As a result, doctors and women alike often eschew or discontinue medications for serious illnesses, even when the harms of untreated disease, for women and the children they bear, are worse than any risks of medication.

The Montreal Gazette puts it more strongly in their Dec. 2, 2009 headline: “Pregnant women urged to get shot; Only way to protect fetus, expert says.”

(Note the language here: The ONLY WAY to protect your fetus is to get the shot. It’s a cut-and-dried case. By avoiding the flu shot, our case study was reckless. The language of the bill specifies that her behavior could be  “intentional, knowing OR reckless.” There’s no need to prove all three.)

Case 2. She got pregnant. She DID get the swine flu vaccine. She lost the baby.

“Stillbirths deter women from swine flu shots,” printed January 24, 2010, in the South China Morning Post, in which “a nine months’ pregnant woman gave birth to a stillborn baby three weeks after receiving a swine flu vaccination, the second stillbirth case involving a vaccinated pregnant woman in a week.”

Case 3: She got pregnant. She exercised. She lost the baby.

The June 21, 2005 headline of The Globe and Mail: “Pregnant women especially prone to summer injuries, study finds.”

Case 4. She didn’t exercise enough. She lost the baby.

“No Excuse for a Pregnant Pause,” Washington Post, November 29, 2005, talks about how women who don’t exercise enough are endangering their babies.

Case 5: She got pregnant. She works on a farm. She lost the baby.

The January 12, 2002 Belfast News letter “WARNING FOR PREGNANT WOMEN AT LAMBING TIME” states that pregnant women “should avoid close contact with sheep during lambing periods, the Department of Health, Social Services and Public Safety (DHSSPS), the Department of Agriculture and Rural Development and the Health and Safety Executive for Northern Ireland have advised.”

Case 6. She got pregnant. She was depressed. She took antidepressants. She lost the baby.

“Pregnant women warned by FDA to Avoid Paxil,” Washington Post, December 5, 2005.

“Taking Zoloft During Pregnancy Leads to Birth Defects.” Lawyers and Settlements, June 7, 2007. “A recently published case-control study has shown that infants born to mothers who took selective serotonin reuptake inhibitors (SSRIs) after the 20th week of pregnancy were 6 times more likely to have persistent pulmonary hypertension (PPHN) than infants born to mothers who did not take antidepressants during pregnancy.”

Case 7. She got pregnant. She was depressed. She didn’t take antidepressants. She lost the baby.

“Dealing with Depression and the Perils of Pregnancy.” The New York Times, January 13, 2004. “Depressed women also have a higher rate of obstetrical complications and preterm deliveries, and a review of 11 studies has shown that they have 45 percent more miscarriages, said Dr. Gideon Koren, a pediatrician and the director of the Motherisk program at the University of Toronto, a risk-counseling service for pregnant women.”

Case 8. She got pregnant. She goes to the doctor as soon as she realizes it. There’s a birth defect. She lost the baby.

“That Prenatal Visit May Be Months Too Late.” November 28, 2006, New York Times. “The problem, doctors say, is that by the first prenatal visit, a woman is usually 10 to 12 weeks pregnant. ‘If a birth defect is going to happen, it’s already happened,’ said Dr. Peter S. Bernstein, a maternal fetal medicine specialist at Montefiore Medical Center in New York who helped write new government guidelines on preconception care.” So they’ve restructured their recommendation: “Public health officials are now encouraging women to make sure they are in optimal health well in advance of a pregnancy to reduce the risk of preventable birth defects and complications. They have recast the message to emphasize not only prenatal care, as they did in the past, but also what they are calling ‘preconception care.'”

Case 9. She got pregnant. She lost the baby.

“Study Finds 31% Rate of Miscarriage,” The New York Times, July 27, 1988. “Thirty-one percent of all conceptions end in miscarriage, usually in the early months of pregnancy and often before women even know they are pregnant, according to a new study.”

“Trying Again After Recurrent Miscarriages,” The New York Times, March 25, 2008. “More than half of pregnancies are spontaneously lost even before the woman has missed a menstrual period and knows that she is pregnant, and about 15 to 20 percent of recognized pregnancies are miscarried in the next few months. For couples who want a baby, these are daunting numbers.”

The point—which I hope I’ve made sufficiently clear—is that miscarriages happen all the time. The cause of a miscarriage is much harder to pinpoint than, say, the cause of death in a crime victim. To pretend that “homicide” is an appropriate category here is beyond irresponsible: it’s insane. It’s hopelessly unrooted from the physical realities of pregnancy, a high-risk biological process during which a million things can and do go wrong every day. Let me be clear: to impose a causal relationship where in the vast majority of cases there is none is to devolve to a legal system where witch hunts were sensible judicial proceedings.

The other point is that the above studies are meant to be helpful and not prescriptive. Here, scientific and legal process are at odds. These findings are published in order to add to a huge data set that will, over time, allow us to form some reasonable theories on how to proceed. They are not definitive. They are not proscriptive. Anyone who has been alive for more than ten years is familiar with the health fads the medical community cycles through, in which fat, sugar, salt, cholesterol and carbohydrates star in turn as the main medical threat to our immortality. In pregnancy, as in health, there is not a clearcut right answer. The medical profession understands this, and bases its recommendations on what amount to “best guesses”.

The legal system does not. This piece of legislation is opening the door to exactly the kinds of arguments I’ve made above. You might think some of the examples I’ve chosen are eccentric or ridiculous. They fly in the face of common sense. This is exactly my concern: common sense plays no part in legal argumentation, which is why legal phraseology is counterintuitive and why it is imperative that we get that phraseology right and eliminate “recklessness” from that bill. ‘Course, my hypotheticals are nothing compared to the legal arguments that get made in real life. As an example, I give you the following article, which offers this dubious hope: should any pregnant women end up jailed by this system (charged perhaps with attempted murder—maybe she was caught driving without a seatbelt) they can argue that the fetus hasn’t been tried and sentenced and is incarcerated in violation of its rights.

Missouri Fetus Unlawfully Jailed, Suit Says

New York Times, August 11, 1989

A Missouri law restricting abortions has been used by a pregnant inmate to file two lawsuits against the state for what she contends is the illegal imprisonment of her fetus.

The suits, brought last week in Federal District Court on behalf of Lovetta Farrar, 30 years old, and the fetus she carries, contend that if life begins at conception, as the Missouri law states, the United States Constitution should protect the fetus from illegal imprisonment. The suits assert that the fetus has not been charged with a crime, granted a trial, received counsel or been sentenced.

The Supreme Court upheld the Missouri law, which bars abortions in publicly financed medical units. But the court did not rule on the law’s preamble, which states that life begins at conception.

The Kansas City lawyer representing Ms. Farrar, Michael S. Box, argues in one suit that if the Missouri law grants a fetus personhood, the 13th Amendment protects the fetus from being forced to serve a prison sentence for another person. The other suit asks for improved prenatal care for Ms. Farrar.

Fetus Called Endangered

”The fetuses should be treated as persons and should not be put in prison without a trial,” Mr. Box said. ”The fetus should not serve a sentence for the mother.”

One suit contends that the fetus is endangered because Ms. Farrar is not receiving adequate food, exercise or prenatal care. The baby is expected to be born in late November or early December, and Ms. Farrar, who was convicted of forgery, is not scheduled to be released until 1991.

The suit asks the court to vacate Ms. Farrar’s sentence or require the state to provide a special site where pregnant prisoners could receive better care. Mr. Box plans to ask the court to hear the case on behalf of the estimated 25 pregnant women in Missouri prisons.

The case has been assigned to Judge Scott O. Wright, who ruled two years ago that the Missouri law restricting abortion was unconstitutional. That was the ruling overturned by the Supreme Court.

Both opponents of abortion and proponents of the right to abortion would like to see better prenatal care for prisoners. Yet some abortion rights advocates worry about the impact of the case.

”The court might agree with some of the contentions that the fetus is entitled to personhood, which could set a bad precedent,” said Dara Klassel, senior staff attorney with the Planned Parenthood Federation of America in New York. ”I hope that if the court awards anything, it is based on the woman’s rights rather than the fetal rights theory.”

Samuel Lee, the state legislative chairman for Missouri Citizens for Life, an anti-abortion group that helped draft the legislation restricting abortions, said: ”I think it’s a legitimate application of the law. I can’t speak to the validity of the claim that the prisoner is not receiving adequate prenatal care, but I think it’s something the court should look at.”