Birth: Fears and Dreams

     I have to admit something, I am either entirely unlike most other midwifery students or everyone else is lying to me about their fears. I am afraid (and inspired) at every birth. Every time I am afraid the baby could die, the mother could die, everything could go wrong. I am afraid I could end up in jail. I am afraid that women I want to serve could not afford my services. I am afraid that I will not make enough money to stay a midwife. I am afraid that one day, one of the babies I received will hate me for their assigned gender at birth. What it, what if, what if. 

      I am sad when I welcome a girl into the world knowing that I am welcoming into the world someone who will be treated as a second class citizen. I am afraid she could be raped, beaten or that she could kill herself under the weight of patriarchy. I am afraid that the new mother will go home to a husband who abuses her or home alone as a single mother to face the judgements of an unrelenting world. I am afraid she will need to return to a job she despises to pay the bills. Every time a baby is born I am scared. I am scared that the world will be a scary place and this new, gentle soul is now part of the mess with the rest of us. 

     But, and it's the real heart of the matter, with every birth I grow a little bit softer. A little more open to the mystery. For no thing that I am never afraid is of the process. Every birth convinces me that women have this power inside them, even when we doubt ourselves or each other. Every birth I grow a little more faithful that we could start the world anew. In birth, we face life and death to come out the other side. Nothing will ever be the same again for anyone in the room. I think this is my real fear; that I will never be the same again. I am afraid that birth will touch my so deeply that it will change me all the way to the core. Afraid that the person I thought I knew will not face me in the mirror tomorrow. Because every single birth has changed me. Sometimes irrevocably.  

    

    I can feel my heart softening and opening. The walls which I have so carefully constructed throughout my life, to shield me from my pains, my trauma and past start to come down. Because being a midwife means you have to open yourself to two new souls; one who has never seen light and the other whose life has changed forever. 

   I feel so profoundly touched to have found a calling after having been lost for so long. I hope that I never lose these fears. I am so in love with all of the women whom I have touched along the way. I hope every single birth changes me and I try to open myself completely. I hope that these fears never paralyze me but connect me. That these fears of changing completely never stop me from working, from pushing through them. Because, in all honesty, fear is not the enemy of living. Allowing your fears to stop you is. 

Postpartum Care in the USA

   

      So anyone who has been around me lately knows that I have been thinking a lot about the state of postartum care in the USA. And frankly I am appalled. The overwhleming majority of women in the USA will stay in the hospital for 24 hours and then have one postpartum visit six weeks later. This is the standard for postpartum care in the US. Compare this to the frequent prenatal screenings women recieve throughout their pregnancy. This is despite the reality that the overwhelming majority of pregnancies are low risk and remain uncomplicated.
        The postpartum period is both clinically and socially a crucial time in a woman's life. Socially, the transformation is obvious. A first time mother moves from a pregnant woman to a mother. A woman with multiple children will have their family life changed with the addition of a new baby. She will have to adjust to the new role of mother and her relationship(s) with sexual partner(s) may be changed dramatically. She will have to learn how to feed, clothe, change and soothe a new baby
with needs of it's own. It is pretty hard to overstate how significant the postpartum period is for bonding and the beginning of a new life. Unfortunately, most women recieve little to no maternity leave in the US leaving them having to both work and bond with their new baby. This is probably on of the main reasons that despite the overwhelming majority of women choosing to try breastfeeding, drop off rates are high. It is simply too difficult to balance work and motherhood in the US. In addition to caring for a new infant, women's bodies and emotions change significantly in the postpartum period. Women deserve access to health care providers in this period who can help women navigate the social changes in the postpartum period and to answer any questions they might have about both themselves and their infant.
       Clinically, the postpartum period is also very important. Childbirth is a major event that comes with some potential increase clinical risks. It is important to emphasize that most pregnancies and labors will go well, but their are some potential risks in the postpartum period. These include; mastitis, infection of sutures or Cesarean scars, late postpartum hemorrhage, inappropriate uterine involution and postpartum depression/psychosis and more mild problems such as fatigue. Most of these postpartum issues are preventable with postpartum assesment but can lead to dangers if unrecognized. For example, mastitis is easily prevented with a proper breastfeeding latch, but if unrecognized can lead to a generalized infection which can require hospitalization to fix. Mastitis generally will not develop within the traditional 24 hour hospital stay and generally before the six week postpartum visit. We are doing women a huge disserve in our current health care paradigm for postpartum care
        Recommendations: It is hard to even begin to imagine a health care system in the US that truly provides for women's postpartum needs because it is so far from our grasp. To begin with, all family members deserve paid leave for the postpartum period. This would greately increase breastfeeding rates, decrease stress and improve family bonding. Second, women deserve access to health care providers throughout the postpartum period. Postpartum standards and screening tools need to be developed that focus both on the social, medical and family aspects of the postpartum period. I will provide and overview of some possibilities in a future blog post.

The Death of Clinical Thinking

Luckily, feminists have been writing about, thinking about and advocating for universal health care system for a very long time. Without a universal health care system; health outcomes are significantly worse for the poor, women and people of color. For too long, people have languished in sickness, unable to receive care due to the inability to pay for a doctors visit. I feel so lucky to live in a state that has been on the front line for fighting for health care with dignity and feel excited to continue the crucial struggle for access to health care for all. https://www.workerscenter.org/healthcare

But there is more to the tragedy that is health care for profit that few have talked about: the reduction of medicine to factory production. Anyone who works in health care knows that insurance companies have come to dictate clinical practice. Clinical thinking has been reduced to routinized, non-personalized care and clinicians have been reduced to technicians. Due to high overhead costs, intense insurance bureaucracy and lack of autonomy, "Doctors are leaving private practice in droves." http://www.healthcarefinancenews.com/news/doctors-leave-private-practice-droves
Despite evidence that physicians have the best clinical outcomes, the overwhelmingly majority of hospitals in the country are run by CEOs with an MBA. http://well.blogs.nytimes.com/2011/07/07/should-hospitals-be-run-by-doctors/?_r=0
Meaning we literally have people who have never interacted with a patient dictating hospitals policies and protocols!

So how does this impact clinical thinking? Let me give you an example from a patient I have head recently:

I have a 22 year old patient who has started trying to conceive a baby with AB- blood type. Nearly two years ago, she had an ectopic pregnancy, which was undiagnosed for six hours in the emergency room leading to an laproscopic tubal ligation when one of her fallopian tubes burst. She received no RhoGam post-op (the standard of care for an Rh- woman with the potential maternal-fetal blood mixing during the surgery). Now that she is trying to conceive, she is trying to find a provider who is willing to test her for antibody screen to insure that there has been no blood mixing.

The standard of care is: to run an antibody screen during the second trimester, administer RhoGam at 28 weeks and if the patient goes past her due date to administer a second injection of RhoGam at 40 weeks. If a second injection is no administered during the pregnancy, then a second injection should be administered within 72 hours postpartum. These protocols insure the protection of Rh-women with Rh+ babies in subsequent pregnancies from bad outcomes. If there are antibodies to the babies blood during a pregnancy, the baby is at risk for very serious conditions including fetal hydrops.

So here's the dilemma, protocols dictate that all Rh- women MUST receive an antibody screen during the second trimester. What these protocols do not say that a woman COULD NOT receive a blood screen earlier. So now back to our case, My patient has a simple request: to know whether or not she will have a low risk pregnancy. If she has antibodies present to reduce her risks as much as possible to protect her future baby. So her desires are life and death matters. And the only risk to the screen is a blood draw that she desire.So why is she having such a hard time getting an antibody screen from her doctor? Because clinicians no longer consider personal circumstances when determining her plan for care. Because we, as clinicians, are now spending longer talking to insurance companies than to our patients. Because we, as clinicians have learnt to read protocols rather than take patient histories when we have questions about how to proceed. Because we have allowed insurance companies and the profit motive to take over our practice. So lets fight for a universal health care system not only so all people have access to health care but so that we can be clinicians again.