Laurita Dianita

Reflections and art on the topics of public health, social justice, and love

On Love and Obligation

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I took this iPhone pic of Ida as she air sucked (continuing to nurse even after she fell asleep and I pulled her off the breast), asleep in my arms on the beach

Written April 5th in Princeville, Hawaii. Ida Luna is 10 weeks old.

On Love and Obligation

I have experienced two new realizations about love lately.

One is that I have never felt love anything like this before. This full, this large, this deep. It is not intense in the way that falling into romantic love is intense – like a bonfire, like an explosion. It is, rather, a slow flame that can’t ever be extinguished. It feels as though it comes burbling up from a fuel source deep inside my body and beyond my body (I think people call that the soul) and it fills me up, fills my head and face and chest and gut. I love this baby with my heart splayed open. I love this baby with my hands held open, always ready to pull her to my chest, to respond. Which brings me to the second realization…

I think that love and responsibility come from the same source. They’re intertwined in a way that makes them feel like the same emotion, the same physiological and psychological and spiritual process. My obligation to Ida, to meet her needs and let her know always that she is loved and safe, to stimulate her brain and make sure that she is healthy and strong and smart, my obligation to follow her through all of her growth and protect her and teach her the skills to protect herself, this feeling arises in me just as the feeling of love does.

Although this is my first time feeling this so strongly and certainly my first time being the primary person responsible for any child, I have encountered this nature of responsibility-love before. As a third-grade teacher, I felt a deep debt of responsibility to my students, and I loved them.  I suppose I shouldn’t have played favorites in any way, but I couldn’t help but love most those who needed it most, those for whom I felt the most responsibility to offer help with socio-emotional and academic needs. Especially S, who would run to my classroom crying because the children in her classroom bullied her and she would fight with them, S who eventually just joined my class even though she didn’t speak Spanish because I made sure that my students treated her with respect and that she could learn in peace, S whose grandmother beat her and then punished her after I reported it to Child Protective Services. I loved her the most because her soul was radiant and full of kindness and hope despite everything, and I loved her most because I felt the most responsibility to her. (Little 23-year-old me, I wanted to adopt her, but it wasn’t an option.)

This love–responsibility feeling is something born out of our evolution as a species. Empathy, compassion, and protection of the young is a requisite for our survival. As I heard a biologist once say, it is “survival of the kindest.” It is produced by pregnancy, by the prolactin and oxytocin that flow through us as we labor and give birth and breastfeed and hold our babies to our chests, by the hormones present in our partners and family members who surround our children’s birth and early life, by the hormones and impulses that can be produced in anybody—blood kin or not—who cares for a child.

But obviously, that isn’t all. If that were all, everybody would be a responsible parent (well, except that high intervention birth and formula feeding do, on a population level, place some barriers between many parents and these natural processes—nothing impossible to overcome, but a formidable issue). We have to be well enough cared for ourselves and with the resources to offer such care to children. Our brains, if they are too damaged by our own childhood torment or by drug addictions or severe depression, struggle to produce those same impulses.  And we have to be equipped to translate those brain/hormone messages into action; that is, we have to be supported in our roles as caregivers, with knowledge of successful and culturally-affirming parenting passed on, with practical and emotional support available, and without an endless torrent of competing demands placed on us by a callous economic system. There are, unfortunately, many things historical, political, economic, familial and intergenerational, that interfere with this love-responsibility feeling for children and being able to put it into action. And of course, even when we do try to put this into action, we will mess up in all sorts of ways. Lord knows I can attest to that –especially as a teacher. Or we will do our best but the messages we receive about how best to raise children places contradictory demands on us (this is what I am going to write about next). We are up against a lot in caring for children, especially in countries with a high degree of inequality.

This means, I think, that part of this love-responsibility feeling for my baby Ida Luna must extend beyond her and add to my motivation to undo the many barriers that stand in the way of good parenting and healthy childhoods.

But for now, for these last two weeks of maternity leave that we are spending here in Kaua’i, my focus will simply be on feeding and connecting to our baby girl as much as possible, filling her body and brain with a sense of connection and security, holding her to my chest as she is right now, asleep, and observing this well of love that keeps burbling up. (Okay, admittedly, I am also reading a book about trauma and addiction, and also working on getting back in shape, but Ida attachment is my main focus).

Oscar (www.avephoto.com) took this photo of us at Anini Beach. (But don't worry--we were only in the sun for about 45 seconds. She's too young for sunscreen yet.) Ida squirms most of the time that she's awake and sometimes while asleep, and is doing so here while eating.

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April 6th, 2014 at 10:13 am

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On Breastfeeding

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Oscar (avephoto.com) took this picture our first time eating out at a restaurant

The first few days of breast-feeding, I kept asking myself, “Why is it that the female of the human species has not evolved to have more arms?” The conclusion I came up with is that we haven’t needed them because humans are a cooperative and inventive species. Sarah Stevens, the lactation consultant at Geneva Woods Birth Center, said she thinks it’s because we have traditionally lived in tribes and had aunties and grandmas and sisters to help.

I think often of this help, of what it looks like today and what it may have looked like over our time on this planet. We have survived as a species because women have breastfed. For most of our existence, there was no alternative. And yes, there were wetnurses, but this was not available or affordable to most women. We have survived because women have breastfed successfully.

This fact might not seem remarkable at all, but the more I muddle through and learn in this process and the more I talk with other mamas and with those who work in the field of supporting mamas, the more evident it is that to survive, women have had to teach and support one another a considerable amount. Breastfeeding is not as easy as I thought, and struggling with breast-feeding related challenges is far more emotionally charged than I thought.

Breast is Best

I should preface anything else I write about the difficulties by saying that I don’t mean to scare anyone away from breastfeeding. It is absolutely the best choice for babies and mamas and families. It is free, it is convenient, it helps prevent postpartum depression, and it helps mom and baby bond deeply and form secure attachments, which will affect baby’s lifelong mental and physical health. It gives the child mom’s immunity to diseases and provides specific and responsive immunity to germs that baby encounters in the world. It protects against allergies, helps prevent obesity in the future, and populates the child’s gut with healthy microbiota. It also helps the child’s brains develop and contributes to higher IQs. Also, it’s just awesome—we can create the most nutritious food in the world from our bodies in whatever quantity our babies need! What a superpower!

But It’s Not Always Easy…

Knowledge & Support

We are meant to do this, but that does not mean that it all just falls into place naturally. There are baby issues, such as tongue-ties and high pallets. There are nipple issues. There are milk supply issues. There are all sorts of difficulties with latching.  Some women experience considerable pain because of some of these issues, and some babies are slow to gain weight until these issues are resolved. The very good thing is that with only some rare exceptions, they can be resolved and successful breast-feeding can be initiated and sustained.  However, this requires skilled lactation support.

When my mom was breast-feeding me and my sister, Claire, in the late 70s and early 80s, she had no real support. There were no nurses or lactation consultants to advise her on proper latch. She and my dad thought that bleeding nipples were just part of the deal. The “medical knowledge” about breast-feeding at the time, which my parents had access to as medical professionals, was often erroneous, such as the guidance to nurse only for eight minutes on each side. Fortunately, her milk supply was fine, and we plumped right up.

How is it that by the mid century in the United States of America, so much of our ancient breast-feeding knowledge was lost? Given that women have breastfed over the history of our species, I assume that there were always women in every community or tribe or family who were particularly skilled and were able to teach the younger women about latch issues, how to get their supply up, etc. In the US, I imagine there were people, probably outside of more urban areas, who retained their traditional knowledge of how to breastfeed even as it was lost in medicine. But boy oh boy the formula industry and medicine’s adoption of it really did some significant damage to our capacities as a whole.

We’ve come along way in medical and mainstream US American culture since I was a baby and my mom was a baby. We now have far more research on the science of breast-feeding. We have International Board Certified Lactation Consultants (IBCLCs), who go through extensive schooling, practice requirements, and examinations. We have personal breast pumps—which are finally covered by most insurance plans, thanks to the Affordable Care Act. Also thanks to Obamacare, employers have to offer breast pumping space and reasonable milk expression breaks to employees. Far more people have begun to understand the benefits of breast milk and question the sneaky tactics of the formula industry. WIC now encourages breastfeeding and gives out pumps. And there are more spaces now (especially online) for dialogue about changing the culture to accept public breast-feeding. As a result, far more women breast-feed now and do so for longer. (And yes, we have a long long ways to go yet.)

Fear, Inadequacy, and Shame

I have been involved in discussions of the cultural, medical, and economic issues around breastfeeding for a long time. I entered motherhood prepared to ask Sarah, the IBCLC at Geneva Woods, for help and prepared for the haters who were going to give me a hard time for nursing Ida in public. But I was not prepared for the feelings of fear, inadequacy, and shame I would experience when issues arose—feelings which, I have since learned from friends, are quite common among women who struggle with breastfeeding or whose babies have any kind of weight gain or other issues.

I hesitate to write about our experience because I am afraid of judgment, afraid of that societal chorus that hangs women out to dry for every outcome associated with their children, even afraid of a whole lot of well-intentioned (and often contradictory) advice about what I should have done differently. But I am writing about it anyway because so many of us go through these things and feel isolated and alone in the process.

I did everything I could to get Ida as much colostrum as possible and encourage my milk to come in. I wasn’t too too worried when her weight had dropped a good bit at her first Pediatrician visit, especially when I discovered at the end of the visit that my milk was coming in. She started to gain back her weight as my breasts became heavy and hard with milk. But then, about a week later, she stopped pooping regularly and she started nursing all the time, almost without break. She was acting hungry. (Though, as my mom and a few others said, she didn’t look like a worried, hungry baby and she was still strong and relatively content and alert and peeing a lot, so no one except me was exceedingly worried).

We didn’t have an opportunity to weigh her until she was 13 days old. When I saw the scale and saw that she was still 3 oz. below birth weight (you want babies to be back to birth weight by 2 weeks), I started to cry. I cried off and on through my 2 week visit and the lactation consultation. We had quite a few visits over the next few days and figured out that I needed to get my milk supply up and that Oscar and I needed to keep her awake and eating more actively. (She has this very slow approach to eating and can tend to fall asleep at the breast and just quiver her mouth instead of suck.) We also wanted to reduce anything that might be causing her to burn more calories than needed, so we turned up the heater in the house and took a hiatus from walks and even tummy time for a while until she was able to retain enough calories to poop.

By feeding her every two hours around the clock, trying different sleeping arrangements—including co-sleeping on the floor, which I said I wouldn’t do but baby girl was fussier and I had to feed her all the time so we did this for a few nights—, pumping after almost every daytime feeding, taking herbal tincture, upping my intake of fat, tickling and changing her to get her to stay awake and eat more actively, my milk supply increased significantly. By week 3, she weighed 6 oz. above her birthweight, she started pooping again, and I had (and still have) huge, heavy breasts.

But until we got that reassurance that she was alright, I was so scared. So worried, so embarrassed, so…ashamed. And I know better than to give in to shame! I know that shame is a toxic product of our culture and belief systems. I know that it’s useless. I know the importance of critical thinking, shame resilience, and connection with others. I tried to absorb the empathy offered to me to combat it. But I also didn’t want to be around people other than my mom and Oscar most of the time because I was embarrassed and scared. I didn’t want to talk about it publicly until it was over and resolved… until I could prove that I was a good mom, I think.

I think I experienced something shared by many mamas—we want nothing more than for our babies to gain weight and be healthy and happy. So when they aren’t doing this adequately, and it has something to do with us, we feel like we are failing our children, like our bodies are failing them, like our bodies can’t just do their jobs. I felt this same way about my body when it took us a while to get pregnant and everyone else I knew was getting pregnant all around me, many of them on accident. I am a critical-thinking feminist woman, and yet I had lodged somewhere in my psyche this old biblical, patriarchal (not to mention super gender essentialist) judgment system that came out to taunt me, to tell me I wasn’t a real woman.

Overcoming Shame and Secrecy

What the hell? How does this patriarchal stuff survive, even in the minds of feminists? One thing I know is that it survives much better in silence than it does when we share these feelings and experiences with one another. The women who shared their miscarriage stories after we miscarried (and the men who shared the miscarriage stories of their moms and sisters and such), the couples who talked about their efforts to get pregnant, and now, the mamas who have confessed to me similar feelings of inadequacy as they struggled with latch issues or the like—all this weakens the power of these woman-blaming discourses. Y’know, this old axiom:

El pueblo

Unido

Jamás será vencido!

(The people/united/will never be defeated)

I love how Anne Lamott describes both the fear and the triumph of this process when her son, Sam, is just a little older than Ida is now:

Sam is so much bigger every day, so much more alert. It’s mind-boggling that my body knows how to churn out this milk that he is growing on. The thought of what my body would produce if my mind had anything to do with it gives me the chill. It’s just too horrible to think about. It might be something frogs could spawn in, but it wouldn’t be good for anything else. I’ve had the secret fear of all mothers that my milk is not good enough, that it is nothing more than sock water, water that socks have been soaking in, but Sam seems to be thriving even though he’s a pretty skinny little guy.

I’m going to have an awards banquet for my body when all of this is over.

I have been a little hard on my body, and I think I owe it an awards banquet too.

For now, I will celebrate with a little image gallery of iPhone photos I’ve made representing how we spend much of our time—breastfeeding and falling asleep at the breast:


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February 22nd, 2014 at 12:49 pm

13 days postpartum

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I think pregnancy is as long and as challenging as it is to prepare us for birthing our babies. And birthing is as difficult as it is to prepare us for parenting. It’s a good design.

Still, this first week and a half of being mother to little baby Ida has been full of surprises, realizations, and feelings that I had no name for or experience with previously. I am writing these things by dictating my voice to the iPad while nursing or pumping or while Oscar is driving. I am doing so in part because I am so grateful to Anne Lammot for writing her uncensored feelings and experiences of this strange new period of life in her book Operating Instructions: A Journal of my Son’s First Year, and I want to be able to contribute similarly useful. Plus, I think I have to write to keep my sanity.

Some of the surprises of parenthood so far:

The Corporeal

It is strange and exciting to have my body back; that is, to be able to hug Oscar with my arms and chest and stomach against him, to move through spaces without worrying about hitting my belly on things, to have a lower back that amazingly does not hurt, to have soft and non-itchy skin, and to be able to eat runny egg yolks and sushi and a bunch of other delicious things. Of course, there are also the discomforts of having birthed a baby and some residual iron loss that I am now making up for, and an inability to regulate my temperature for the first week or so. But mainly my body feels familiar.

And then there are the new sensations – learning to get a good latch so that breast-feeding doesn’t hurt so much (again, I am so grateful for Geneva Woods for having a lactation consultant to problem solve with and for her offering a class during pregnancy so that we were prepared). How hungry and thirsty I am from breast-feeding. What it feels like to sleep an inadequate amount for some many days in a row. (I never even did this in college, so this is brand-new to me.) What it feels like to have my baby’s skin against my skin as she feeds and how soft her hair is under my fingers and how smooth her little cheeks are when I kiss them and how much this fills me with love.

The most startling thing about my body, however, is the way that I have felt fear for Ida grip my chest and stomach many times, and how on two occasions in the first week, I experienced fear, stress, worry, and anger in my body like an earthquake, like an explosion. It is both a physiological and an emotional reaction that is some combination of mama bear and sleep deprivation and post birth hormones, I suppose. It frightened me.

The Cognitive and Emotional

Shame versus useful self reflection and critical learning

It is hard to write about the things I have been experiencing cognitively and especially emotionally. For some reason, during pregnancy I felt so comfortable being vulnerable and exposing whatever truths for happening in me. But doing this in motherhood feels different, feels like I am opening myself and Oscar up to endless torrents of judgment. This realm of parenthood and especially motherhood feels like a coliseum in which shame and judgment are released onto parents—especially moms—with their teeth and claws bared, while others spectate.  And I am among those judging parenting decisions; as a social worker and epidemiologist who works in child maltreatment, domestic violence, and maternal child health, I do learn and think and try to do a lot about what is best for children in their raising, and that means critiquing and improving. And of course, I hold our decisions up for the same judgment. But how fraught with shame this can be! My goal is to stay out of the realm of shame, to learn about parenting for us and Oscar so we can do the best job we can, to share that journey here in a nonjudgmental way, and to engage in open conversations with other people who raise or care about children. And it is to walk that line between acceptance and self reflection and critique in a healthy way.

But I can’t say that it has all been done in a healthy way so far. I mostly feel better now than I did the first week, especially after getting a few  nights of slightly longer sleep and after experiencing some of the things that scared me and them going just fine. But I am sure that the fear and guilt will resurface in many ways throughout Ida’s life, and it resurfaces every time that I realize we have made some mistake. I feel like such a terrible person for any mistake made at her expense. (I know, this isn’t sustainable. We will do our best and we will make mistakes. I’m working on having more acceptance and levity about this.)

Ida Luna during tummy time on her 11th day of life. Baby girl's neck muscles are so strong already.

Paralyzing fear versus useful caution

Throughout pregnancy, I remained cautious at every moment, watching where I put my feet on the ice, making sure that I had my spikes on my shoes, being careful not to slip on rugs or things under my feet, making sure my animal-based food was fully cooked, avoiding second-hand smoke and environmental toxins, trying my best to breathe deeply through stressful situations, etc. It took attention but I didn’t experience an inordinate amount of fear.

But oh, safe sleep and the floppiness of newborn necks and suffocation risk and the dangers of falling and the risks of being too hot and the risks of being too cold! This all feels so much scarier than when she was safely contained in the environment of my uterus. I am scared for her but also know that Oscar and I and our friends and family who have visited are careful and caring. And this fact, that we are doing things (mostly) right but still I worry because it takes vigilance, makes me so scared for all the babies out there in worse situations. I have this pain in my chest for the babies who are being born right now to women in abusive relationships, to parents who drink and smoke and use drugs, to parents who because of their own trauma histories lack emotional self-regulation skills, as well as those born to women who are malnourished or otherwise can’t or don’t make adequate milk. I also find myself worrying for women who have very little leave time from work and/or chores, women who do not have supportive partners or family members, and for those many many many families who cannot afford or find quality daycare. As it did during pregnancy, the ill-informed policies and funding priority of the United States and the conditions of poverty and sexism around the world upset me on a political and deeply personal level.

I  also find myself wondering that more babies don’t die. I find myself thinking about Alaska’s infant mortality data: Sudden Unexplained Infant Death (SUID) in unsafe sleep environments is the #1 cause for our higher-than-the-U.S.-average rate of post-neonatal death. Neglect, especially by an impaired caregiver and inadequate follow-up by child protection both play major roles in these deaths. Abusive head trauma is one of the leading causes for post-neonatal deaths as well. We have so much work to do to prevent these deaths.  I also find myself thinking about the neurobiological effects of babies left to cry for long periods without their needs met, of inadequate nutrition, of depressed or angry caregivers, etc. Of course, I work in this field so I think about this stuff all the time anyway, but now it is with the awareness of how I feel about protecting and nurturing Ida’s little growing brain.

I know that all of this stuff is important to think about and work to change. I also know that I need to be happy and not sick with fear for my daughter or other people’s sons and daughters. And given that this has already gotten way easier in the past week, I suspect that this balance is something that I will go developing with time and that many other parents, probably especially breast-feeding moms filled with mama bear hormones, struggle to achieve. Because the simple fact is, when you have a child that is in your care, you do walk around “with your heart outside of your body,” as they say. This means that you can look upon the child and love them and find immense joy and happiness and fulfillment in them. It also means that there is always this sort of terror—whether well-subdued or hyper present–that they could be hurt. This just is. Probably especially so during infancy, childhood, and adolescence, which strike me as the most dangerous times.

They are also—and primarily—all joyous times. Oscar and I experience so much joy playing with Ida, reading to her, singing to her, doing tummy time with her and watching her strong little neck develop its muscles, wearing her on our chests, dancing with her, watching her silly sleep faces. We love her so immensely and she is so fun and beautiful. If I am going to experience worry, I can’t imagine a better reason for it than this.

Oscar took this on Ida's 3rd day of life. He used foam alphabet letters and a complicated set-up of glass to reflect the letters.

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February 6th, 2014 at 2:15 pm

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Birth

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Our daughter, Ida Luna Avellaneda-Cruz, about 3 hours old. All birth photos by Ash Adams

Baby has joined us on the outside.

She is the most beautiful, amazing little blessing I could’ve ever imagined. Oscar and I love her so much and are having fun figuring out this parenting thing—despite a lot less sleep than normal.

Here’s the story of how little Ida Luna came to be born. I’ll spare you much of the graphic detail, but if you are squeamish about how our species reproduces, you might want to stop reading here.

Her due date was Monday, January’s 27th. My last scheduled day of work was Friday the 24th. However, I had a feeling she might come early, and that Tuesday morning, the 21st, I had requested a cervical check, which showed that I was 1 cm dilated and 70% effaced, but with a firm cervix, meaning that I could go into labor in the next few days or maybe in over a week. I went to prenatal yoga on Thursday night, the 23rd, where I received a beautiful sendoff from our instructor and all of the other women there. I was ready for whatever was going to happen.

The beginning

That night before bed, my mom texted me to tell me that she had two women in labor. So when I woke up at one in the morning with what I thought was broken water, I figured I could call her cell phone because she would be awake. Luckily by then, one of the women had already given birth at the hospital and another midwife was with the second one at the birth center, so my mom headed over to my house with test strips. It appeared that it was amniotic fluid, but the findings weren’t super definite because apparently mucus plugs can change test strips too and the color wasn’t super dark. She advised me that we both needed sleep if I was going to be in labor soon, so I managed to sleep a few hours and we agreed to meet at the office in the morning. The second, more accurate (slide under a microscope) test at around 9 a.m. did not show clear signs of fluid, but by then I was having contractions every 10 minutes. So I spent the morning at home getting through the contractions in the shower with Oscar spraying me and then in bed, trying to sleep.

Early labor

During this period of early labor, the technique I used to cope with the pain and to breathe was a Kundalini breath meditation I had learned during prenatal yoga. It is a structured series of four breaths and I was able to get through about two cycles of it per contraction. It really helped me be at peace mentally and physically during this stage. It continued like that, with the contractions coming about five minutes apart, and then four, until I started puking. By that time, which was around 12:30 p.m., my mom had arrived to check me and I was 4 cm dilated and 95% effaced. With this happy news, we headed to the birth center.

Active labor

After checking vitals and fetal heart tones, texting our friend Ash to come, and having a few contractions in bed and one more good puke, Oscar and I headed to the shower. There I labored sitting on the birthing ball, on hands and knees with my arms on the birthing ball, and laying down with pillows for the next two hours. Oscar had on his knee pads so that he was able to help me in whichever position, spraying my hips, back, and pelvis with the shower nozzle. I was very specific about which parts of my body needed to be sprayed because my hips and back and pelvis hurt a lot with each contraction. Ash took photos and he and Ash took turns giving me water or juice or ginger ale, and ice water rags for my head. My mom and the other midwife, Trina Strang (CNM), came in to check baby’s heart tones with the fetal Doppler and suggest position changes.

Oscar used the shower nozzle to relieve pain and keep me warm as I sat on the birth ball or tried various positions.

During this stage of labor, I practiced two basic coping techniques. The Kundalini breath had stopped being useful as the contractions had intensified, so my breath had become vocalized with low sounds accompanying each exhalation. I kept my eyes closed most of the time through contractions in order to visualize. Now, I am not very good at deep, in-depth visualizations like many techniques teach. However, I had discovered during pregnancy that if I had to cope with some sort of pain (usually related to my carpal tunnel syndrome), that a very simple visual of heading up a grassy hill bathed in golden light with an apple tree on top seemed to help. I turned to this hill while laboring in the shower. I discovered I needed to include baby in this visualization because what we were doing was a partnership—me birthing baby and baby cooperating nicely and being born. (And baby was definitely doing her part—heart tones stayed normal and, being who she is, she kept wiggling and kicking). I also wanted to stay focused on the purpose of all this, which was meeting our child, who we loved so dearly. For these reasons, I imagined myself carrying baby up the hill during each contraction. Not yet knowing baby’s name, I thought of baby as baby Riolda, as my cousin Lilia had jokingly called her—a combination of our boy name Rio and our girl named Ida.

Each contraction stood by itself. Each one was a journey uphill and, as far as I was concerned during the contraction, it was the only journey up the hill before I could head downhill. I had to take each one at a time. I did think a few times, “Wow, this could last a lot longer. How will I get through it?” But my answer to myself generally was that this is how the species has reproduced for as long as we have existed, so it will work out fine and I better just concentrate on the contraction at hand and trust that everything will progress as needed.

Oscar was smart and brought kneepads. My sister said they are now inspired to buy some to keep at the birth center for labor partners and they can nickname them "dad pads."

As the pain intensified, this imagined hill became the tundra-covered last uphill of the Lost Lake race. And as it intensified further, I realized I needed to use a different coping technique, so I turned to what Pam England, the author of Birthing From Within, calls non-focused awareness. It is just non-judgmental attention to the sounds around you, to the things that are touching you, to your breath, and to whatever you see with your eyes in one spot.  So I listened to the meditation music on the iPhone, the sounds of murmuring voices, the sound of the water hitting me and draining, and I opened my eyes to stare at the silver and black of the light contraption that Ash had set up in the bathroom. I also then melded the two techniques, telling baby Riolda that for this hill, we are going to play the listening game and we would go uphill playing the listening game together. After Trina or my mom–I can’t remember who–had explained to me that changing positions helps the baby move down and get into the right position, I told baby, “Now we are playing the moving game” or “now we are playing the you-turn-into-my-pelvis game as we go up the hill.”

Eventually, Trina told me that I should get out of the shower and move around to help baby move down into my birth canal and to cool off. I trusted the whole time that my cervix had been opening, but I hadn’t thought about needing to bring baby down with gravity and movement. I realized that this was a perfect opportunity to shift the tone and my coping strategies and to enjoy the labor and delivery dance mix that I had made back in the fall (after realizing that dancing through pain helps during kriyas in prenatal yoga, so it would be of use in labor). When the music started – music that I had carefully chosen because not only can I move to it gently, but because it is filled with beauty and optimism and joy – I felt enlivened. I moved my feet and hips dancing in between contractions.  I also ate mango popsicles and even chatted a little in between contractions. During contractions, I held Oscar’s forearms while he held mine and we swayed together, me with my head down, usually moving from my toes on one foot to my toes on the other, stretching my hips out, moaning and breathing deeply. For my mental coping during contractions, I listened to the lyrics (whether I understood them or not—there were quite a few songs in Portuguese, Japanese, and various Malian and Nigerian languages). I listened to the music. I let it infuse me with its joy. While moving through contractions, I also listened to Trina telling me that with each movement I was bringing baby into position, and to Oscar telling me he liked my smile (I had asked him beforehand to kindly remind me to smile) and liked how I was swaying, and all of this felt really affirming. Man I am blessed with who I had there.

Oscar helping me dance through contractions.

Interestingly, in this period of labor and all the others except for early labor, I could not stand for Oscar to touch me in any of the ways I had thought I would want, such as acupressure points on my sacrum or hip squeezes to help my back. My back and hips hurt, but I could only stand to be touched on my hands and arms and sometimes neck. The contractions that hurts the most were the ones where I felt panicked about something being wrong, such as when I asked Oscar to squeeze my hips but then realized my mistake, or when I thought that squatting would help my back as it did throughout pregnancy, but it just hurt more.  Those brief feelings of needing to control something quickly so that it would get better put me back in a state that was not surrender, that was not peaceful acceptance, and so the pain was sharper. Luckily, I can count these moments on one hand.

Transition

After dancing for a while and then pain getting much more intense with each contraction, the midwives asked me if I felt like pushing. I said I didn’t quite, but it did feel very different than before. They told me to reach up and feel my baby’s head. It wasn’t all that far up there and I could feel a sizeable piece of it, which told them that my cervix must be pretty wide-open. My mom checked me and I was complete. I said I was starting to feel like pushing, and I wanted to push wherever it would hurt less, which meant in the tub. As they prepared the water, I had a few contractions on the bed on hands and knees with Oscar’s face only inches away, telling me nice supportive things.

Pushing

In the tub, to help my back, I tried to remain on hands and knees for as long as possible, but had to shift to my side eventually so that the midwives could watch baby and be able to reach down if there was cord around the neck or anything like that. Pushing at first felt strange and unproductive. But after not too long, I learned to smile and breathe and relax as deeply and pleasurably as possible between contractions, and then start each contraction with deep inhales and strong pushes. A few times, I opened my eyes and smiled at the people gathered around—my mom and Trina, the birth assistant, Victoria, who I was so happy to see had arrived (and who checked baby’s heart tones frequently), Ash with her camera, Oscar in the tub holding my leg and looking at me with such confidence and belief.

The coolest, most amazing thing about the birth experience was when my mom told me to put my hand on baby’s head as I pushed. I did this through a few contractions and got to feel the progress that I was making. After that, pushing became fun and exciting and something that I looked forward to in my rest period between contractions. Feeling all of the hair on her head made her very real too, very much Oscar’s child, which we all sort of laughed about as we saw her thick black hair. I didn’t feel like talking at the time, but I was thinking, “I need to tell them how awesome this is.” I eventually got to feel her crown, and fortunately she stayed there long enough that she could stretch out my perineum so I didn’t have to purposely not push to avoid tears. It worked out beautifully, and my perineum stayed intact.

For the early part of pushing, we lit the tub with candle-like lights, but turned the lights on for the later part. It was more or less the same to me; I was in my internal space.

Birthing

Of course it hurt when she came through what people call the “ring of fire.” I said, “Ow!” very loudly. But it wasn’t so bad because I knew that she was about to be in my arms. My mom told me, “Probably with this next contraction she will be born,” and I can’t imagine a better inspiration to keep pushing hard. (I pushed very hard, by the way, and my mom says very efficiently. This came at the expense of my throat, which still hurts a little, and I burst capillaries in my face and chest–and yes, I know that pelvic muscles do not require my face muscles, but oh well, I can perfect my technique for next time.  But I got her out efficiently and, the midwives observed, with probably a great deal of abdominal muscle help.) Her head was fully born with one push and the rest of her body with the next, and then she was coming up towards me. Oscar helped bring her up to me along with my mom. This was 6:09 p.m., and this might have been the first time since the morning that I knew what time it was.

My two midwives: my mom, Barbara Norton, CNM, and Trina Strang, CNM embrace after the birth

Meeting our daughter

It was so amazing to meet her on the outside at last. At that time we did still did not know whether she was a boy or a girl. We made sure she could cry and her skin tone was good, and once we know she was well we took a look and saw that she was a girl, and called her by her name, Ida Luna. I remember feeling both incredible excitement and love that we had our daughter right there on my chest, and also immense relief that labor was over. They drained the tub, my mom helped Oscar to cut the cord, and they got their cord blood samples to send off. My mom handed Ida off to Oscar so I could focus on birthing the placenta. It came out easily and was kind of beautiful and gory at the same time. I looked at Oscar holding Ida with tears in his eyes and in that moment, just like at our wedding when I had looked up at Oscar’s wet eyes, I felt it too, the gravity and completeness of what had just happened and what we had now in our lives.  Oscar can always ground me in the significance of the experience.

Mi amor always manages to ground me in the emotional significance of an event, as he did when I saw him looking at Ida with tears in his eyes.

Afterwards

My sister, Claire, meeting her niece while I chow on a coconut popsicle and Ida chows down on her first meal of colostrum.

As I was preparing to get out of the tub, I started losing blood, so they gave me first one shot of Pitocin and then another—as the bleeding continued— in my leg, and they did bimanual compression to make my uterus clamp down. I went to the bed where we hung out as a new family for the next few hours, eating popsicles and animal crackers, drinking juice, being fed pho broth through a straw by Ash after my sister arrived with dinner, trying with very skilled and patient help from Victoria to get Ida to suck on my nipples (it took her a while but eventually she did, which helped my uterus clamp down better). They kept doing bi-manual compression on my uterus and finding it firm, but since I kept passing blood clots in between, they put me on IV Pitocin and fluid. I had gotten pretty dizzy and vaso-vagal and had to lay down for a good while.

While we all cuddled on the bed and tried to get Ida to feed, my dad (who is a pediatric radiologist) and the Geneva Woods staff did Ida’s newborn exam, weighed her, etc. My mom was delighted and surprised to find that Ida weighed the exact same as I did as a baby–7 lbs., 10.5 oz. My sister came and visited, as did Jen Allison with a post-partum gift and a hand-dyed rainbow onesie. It was so great to be in this warm, peaceful place with people I loved and trusted for the four hours after the birth, and then to go home that night with my dad camped out on the couch to help take baby’s and my vitals every few hours.

My dad meeting his granddaughter for the first time.

Lessons learned

Labor was not easy. It was painful. But it was beautiful and powerful and peaceful and so worth doing it naturally. What made it that way? Here’s what I believe helped:

  • Loving and competent and confident support from Oscar (thanks to who he is and also thanks to wonderful preparation we received through childbirth classes and prenatal visits)
  • Conversations over the last few months with Oscar about how we might best communicate during labor
  • A friend there to offer quiet help and take awesome photos
  • Being able to trust completely in the competence of the midwives. A few times I thought, “Hm, they’re talking to each other—should I be nervous?” or when baby was moving too much in utero to get consistent heart tones, I considered worrying for about a millisecond and then thought, “Nah, being afraid is not my job. Worrying and thinking is not my job. My job is to breathe and release positive birthing hormones so baby can be born.” I knew that me being nervous or even asking a bunch of questions about my progress would serve no one. So I just did my mama job and let them do their midwife job (and later, let Victoria do her birth assistant job). And they all did a damn good job because they are intuitive and evidence-based and safe and compassionate. I want care providers like them for every birthing woman.
  • No one trying to make me afraid
  • The right music
  • Being in a birth center where I could make as much noise as I needed to without being self-conscious and without any nurses giving me the stink eye
  • Being in a birth center where they use dopplers for fetal heart tones instead of making me lay in bed on a fetal monitor belt, and where I didn’t have to listen to machines and where, as Oscar said, I didn’t have to look like I was sick or be treated like a potential surgery patient
  • Being in shape. I used my core muscles to get baby out! It also helped for maneuverability that I had only gained 22 pounds during pregnancy and didn’t feel burdened by my body’s size in any way.
  • An arsenal of available coping techniques that made sense for who I am
  • No rigid ideas about the “right” way to birth (e.g. silent and stoic, must do “hee haw” breathing, hypnobirthing breathe-your-baby-down-you-don’t-need-to-push, etc.)
  • The understanding going into it that pain serves a purpose for the hormones of birth and that pain is okay, and one need not suffer due to pain (the latter being a particularly useful insight I learned from Vipassana meditation)

For these things, I have to thank the Geneva Woods “Childbirth Basics” class taught by Janie, “Birthing From Within” class taught by Jen Allison, the book Birthing From Within, awesome prenatal care, the birth stories of my friends who have had natural and empowering births, the stories that other dad friends have shared with Oscar, prenatal yoga at Open Space studio, the confidence that my community and all of my people have instilled in me, and of course, my midwife mama for helping me filter out all of the fear and misconceptions about birth and birth intervention that are rife in our society and in U.S. medical practice.

My mama midwife, holding her granddaughter for the first time.

Most of all, I’m grateful to my partner in life and parenthood, to my body and mind, and to our wonderful, healthy little baby.

My favorite photo. This is our family now.

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January 28th, 2014 at 5:42 pm

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Week 39

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1.) Prenatal yoga has been such a blessing, so Oscar suggested we honor that by photographing at the Open Space studio; 2.) In honor of what might be the last drawing, I returned to drawing with my right hand this week

This may be my last blog entry for this pregnancy—at least it feels like it will be, but apparently the work of baby and pelvis and cervix getting ready can go on for a good while, so who knows.  At any rate, I feel some pressure to really make it count. But maybe, to take the pressure off myself to write some profound summative reflection, I could treat this (potential) end the way bloggers treat the end of the year by making lists. Multiple lists.

List 1:  Things I did not know about pregnancy going into it (do people not talk about these things or was I just not paying attention?)

1.)  How much more our gums and noses bleed

2.)  That carpal tunnel/tendinitis pain was a pregnancy thing

3.)  How much my breasts would grow

4.)  How incredibly long it feels and how important it is that it is so long a process – how this long period of changes and adjustments and preparation is exactly what we need to get ready for birthing and parenthood

5.)  That my body would find it necessary to protect baby with new blonde hairs all over my belly

6.) How dry my skin would become and therefore how much shea butter I’d go through in order to not itch all the time

7.)  How vulnerable I would feel, especially near the end. And I don’t mean vulnerable in a bad way–more in the Brené Brown way.

8.)  How sensitive I would feel, both emotionally and physically. I knew that my olfactory senses would be heightened, but I didn’t know I would become so sensitive to sound as I have in the last week or two! My mom says it’s to prepare me to hear my baby’s needs.

9.)  What pregnancy brain would be like. It’s not at all what I expected. Most of the time, I feel just as lucid and smart and productive, am still able to give effective presentations and analyze policies and organize my appointments, etc. But sometimes memories simply do not store on the hard drive of my brain. Or I do things like show up a week early (but an hour and a half late) to a party. It totally catches me off guard.

10.)  How annoying it would be for people (especially men and strangers) to use terms like “pop” and “squirt” to describe women’s imminent labor and delivery (though I had been warned about intrusive conversations and touches)

11.)  How insular and quiet I would feel and how much in need of the company and support of other mamas–and my own mama

12.)  The degree to which our country’s and my employer’s failure to adequately support mothers and breast-feeding and healthy parenting through policy would feel overwhelming and enraging and hurtful on a personal level

13.) Just how much I would love pregnancy

14.)  How much time this project would take

[I am curious to know what came as a pregnancy surprise to other people. Pray tell.]


List 2: Things that I have missed during pregnancy

1.)  Beer. Definitely #1 on the list. Especially spiced pumpkin and Christmasy beers. We have some waiting in the fridge downstairs for when I am ready to have them.

2.)  Runny egg yolks. I am going to make myself hella poached and sunny side up eggs post-pregnancy.

3.)  Ice skating

4.)  Skate skiing (I know some people do this while pregnant and that is totally legit, but I don’t trust my balance well enough to do this in my third trimester)

5.)  My colorful pants and skinny jeans

6.)  Free use of my right hand

7.)  Being able to lift my own heavy stuff

Honestly, there’s not much. Pregnancy has been fun.

List 3: Things that I will miss about pregnancy

1.)  Feeling baby move inside of me, kicking at my left side, rolling my belly with his/her knees. Sharing these movements with Oscar and seeing his face light up.

2.)  Knowing that baby’s needs are being met at every moment

3.)  Full(ish) nights of sleep

4.)  Prenatal yoga class at Open Space

5.)  The constant changes in my body that feel exciting and wondrous and not at all embarrassing (not that postpartum body changes will be embarrassing, but that typically, after infancy, our bodies never change quite this quickly unless we are rapidly and unhealthily gaining weight or starving or deteriorating from a disease. It’s a rare opportunity to experience rapid change.)

6.)  Oscar says he will miss my roundness

7.)  Something to talk about with strangers and people I don’t know very well. I like how people come together around pregnancies, especially in the office. (There have been many in our office recently.) These conversations are generally pleasant, with a few exceptions (this could be another list for another day—things not to do in conversation with pregnant women).

8.)  This project: the discipline of weekly art-making in multiple media, working creatively with Oscar and seeing him engineer lighting and scene creation, reflectively writing, the conversations with you all that have arisen from blog posts or photos.

By writing about what I miss or will miss, I don’t dwell on these things to complain. Nostalgia can just be something beautiful to observe and then let go of. Just as I was with pregnancy, I am so excited—even if a little scared—for what is to come afterwards. (Mainly, I am scared about the sleeplessness. I don’t do well with sleeplessness. But I will survive.) Very soon, our lives will dramatically change from one in which we know baby only through the movements inside me and the midwives’ measurements and exams and from in-utero photos of other babies and from people’s eager guesses about baby’s sex, etc.  to one in which baby makes his/her needs known quite loudly, one in which we will be able to smell baby and hold baby and see in the light the same movements that we have been feeling for months.

We are looking forward tremendously to this shift in our lives.

Drawn using a Lennart Nillsen photograph

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January 19th, 2014 at 10:16 pm

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38 weeks

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baby's room

In the small amount of baby’s room that we could fit into these photos, visible are many things gifted and borrowed. The toys, books, decorations, clothing, and equipment that we have amassed for baby come from many people. We are so grateful to bring children into community and to be community for others who are raising children.

_ _ _ _ _ _ _ _ _ _ _ _

p.s. This is the same outfit I wore in the week 12 photos. The blouse fits a little differently now.

p.p.s. The drawing came out difficult to see with light on it. Oh well. Someday when Oscar and I have an exhibit of all of the photos and drawings, it will be easy to see.

p.p.p.s. Looking at these photos tonight was the first time that I really thought,  ”Wow I look super big and pregnant!” It’s fun to see.

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January 12th, 2014 at 9:26 pm

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Week 37. Term.

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Childbirth instructor, doula, nurse, and artist/artisan Jen Allison of moonbellies.webs.com preparing my belly with henna the day before the Blessings Way ceremony she led for me

“Connection is why we’re here.”

I have good people in my life.

And I need them more than ever.

It is true that in these last few weeks before giving birth, I find myself wanting to den the way a cat does when she retreats under the dresser of a dark room to birth her kittens. I find myself needing that privacy, that avoidance of big social gatherings, some time alone to reboot. But it is also true that I need my people, that I am aware of my vulnerability and the importance of my connections.

A few nights ago, induced by overheating, I imagine, I had the apogee of nightmares. I dreamt that the Nazis were rounding us up to take us to camps. The first night, they separated me from Oscar and my family, making me share a bed in a dank blue room with two men from México who were equally afraid to find themselves separated from their loved ones.  The next day, they brought all of the prisoners together in one building, where I was temporarily reunited with my parents and sister and with Oscar. But I knew what was coming next; I had learned all about the Holocaust growing up (this was taking place in 2014 and I had my iPhone with me, but that’s another story). Before me I knew there would be Dachau, Auschwitz, the separation from my loved ones, the labor, the starvation, the death. I kept searching for my family, afraid they would get away from me. And I clung to Oscar so hard. I knew that the worst part would be losing him. I knew that separation was how they would try to break our spirits, just as slave plantation owners did to slaves in the Americas. Luckily, I awoke before meeting this fate.

Another left-handed creation, this time imbued with the features that often force their way into my art: blocks, scraggly lines, yellow shapes, dirty textures. It is a different--and deeply satisfying--way of thinking altogether when you let your eyes, your body's movements, and your artistic impulses do all of the work.

I woke up profoundly aware of how much I need my husband/labor support partner/father of our baby and how much I need those closest to me. I am not sure how much I will use them or reference them during birth — my perception is that birth is essentially an internal process that each woman’s body knows how to do, a process in which she listens to her body and its guidance and is deep in her own mental space. But I know that I will need them to be there, either in person or in spirit. I know that the great safety and security I will feel comes from their presence, their readiness, and their eagerness to be a part of this process. That sense of security comes now from the confidence, love, and blessings they offer me during this time of preparation, and will come later as they—and our larger community—supports us through the difficult transition into new parenthood and sleeplessness.

Last weekend, a small group of trusted women gathered at my sister’s house for a Blessings Way ceremony for me, and a few who couldn’t attend offered their blessings from afar. Their words, the beads and candles they contributed, and their warm intention (plus the example many of them set as they breastfeed and parent) made me feel all the more ready for this journey into birth and motherhood. Below are a few photos from the afternoon, taken by Ash Adams.

I’m grateful to be on the kind of journey that brings people together to offer blessings. I am grateful for the state of profound vulnerability that surrounds childbirth and new parenthood. I am grateful because it makes me all the more aware of what Brené Brown means when she says, summarizing decades of research:

“Connection is why we’re here. It gives purpose and meaning to our lives.”

Indeed, connection is what allows humans and the soft little brains with which we are born to survive, and what allows us to bring life into the world safely.

I am grateful to have the connections I do.

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January 8th, 2014 at 8:52 pm

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Protected: Week 36

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December 30th, 2013 at 9:14 pm

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Week 35 & God Yul!

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I am grateful to Oscar for indulging me in my desire to do photos in front of the Christmas tree. This week's art of baby is a left-handed drawing with watercolor pencils, water, glue, and glitter to reflect the season and the Solstice.

God Yul!

As I understand it, this is how they say “Merry Christmas” in Norwegian. I like this way of talking about Christmas because it uses the word Yule, which is the word for the pre-Christian, pagan celebration of winter Solstice. And yes, although Christmas celebrates the birth of Jesus of Nazareth, the timing of the celebration and the fact that we decorate trees with lights to celebrate it, has everything to do with the ages-old Northern European honoring of the darkest day of the year and the return of light.

I love Christmas and I love Solstice and I love the idea of them being rolled up together in one expression and together in this beautiful snowy period of a few days between them. I enjoy Christmas primarily for the aesthetics and the family tradition and togetherness. Oscar has not been that into Christmas and decorating the tree, so I explained to him that for me, it’s about the peaceful way the tree looks and the songs of Christmas and going skiing with my family and the smells of certain foods and the light on the snow. After we decorated the tree together this year, and we sat in its peaceful light, he understood what I meant about the aesthetics. There is something about creating light in the darkness that makes you feel at peace with the dark.

I think one of the reasons that I love Solstice and love to mark it is because it reminds me to be at peace with the dark, with whatever season is upon us. When I was learning Vipassana meditation, the teacher told us a story about one brother who wanted to control everything and then another brother who excepted that things, including the seasons, will come and go. The brother who excepted that things will come and go was much happier and some sad fate befell the other brother; I don’t remember what. I think of these brothers when I feel the urge to complain about something that I cannot control. I think also of the lessons I have learned from Inuit and Cup’ik friends and coworkers about the importance of viewing the weather objectively. As my Cup’ik colleague, Uyuriukaraq, explained, the weather is simply part of the Creator, chellam yua, so you would not want to complain about the weather because you would be insulting chellam yua. Or, as my friend Karina from Greenland explained, in her culture they just notice the changes in the weather and describe them, without assigning values like good or bad. Since I have learned this, I cannot bring myself to label a rainy day as bad or a sunny day as good, etc. It just is rainy or is sunny–who am I to judge that? Judgment is only useful when it guides efforts to change something that can and should be changed. (Now, I do make an exception for weather that is clearly the product of global climate change, which is human-made and which we have a responsibility to reverse course on.)

Celebrating Solstice/Yule and, well, Christmas, rather than bemoaning the darkness (and it is quite dark here in Alaska), feels like practicing the art of acceptance. It feels like living the lessons of the serenity prayer. These are precisely the kinds of reminders and lessons that I need to be at peace, and precisely the kinds of lessons I need to get past my controlling nature in order to accept whatever labor brings to me, and to accept whatever little baby Avellaneda-Cruz brings to us.

So, Merry Christmas and happy Solstice and, for those of us in the Northern hemisphere, happy winter, happy darkness.

This photo, which I took in 2012, speaks to so many things I love about this season.

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December 22nd, 2013 at 9:35 pm

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Week 34

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Oscar took these photos with the tripod in between us getting the house ready for our baby shower/Oscar's 30th birthday party. We are so grateful for our friends and family who helped put the party on (esp. Ash Adams who made almost all the food and decorations and ran the Photo Booth all night) and who support us in so many ways.

Being an informed birthing woman and finding the right care provider, Part 2:

I cannot claim to be an expert on this subject, but because of the access I have grown up with and acquired through my work in public health, I am eager to share a few tips and tools for finding the right prenatal and birth care provider.

For brevity, let’s skip the part about finding insurance and assume that you have some way to pay for care, whether through work or the Affordable Care Act’s individual plans or Medicaid or the tribal health system, or because you live in a country other than the USA that believes health care is a right. So, payment aside, yhe first question would be:

A.) What kind of prenatal care and birth experience do you want?

One good tool for helping you examine what type of experience you want and what kind of care provider—Obstetrician/Gynecologist (OBGYN) vs. a Certified Nurse Midwife (CNM) or direct entry midwife (CDM or CPM) –can be found at this website:

http://www.babyzone.com/pregnancy/prenatal-care/ob-gyn-midwife-choosing_71051

Also, Our Bodies, Ourselves: Pregnancy and Birth book has clear and thorough information for understanding the differences in approach.

This website has an incredible wealth of information about types of providers and birth settings and ways of understanding your options as a mama and patient:

http://www.childbirthconnection.org

B.) What kind of prenatal care and birth experience do I want for myself and for others?

  • I want patients in general, and in this case pregnant women and families, to get attentive, informed, compassionate, competent, culturally-humble care.
  • I believe that prenatal appointments should be long enough to not only listen to fetal heart tones, etc. but also to talk about nutrition, exercise, stress, preparation for birth and other issues—and that the provider should be well-informed enough to do this effectively.
  • I believe that the provider should be attentive to the psychosocial needs of their patient and invite patients to think about issues that might come up for them in the birthing or breast-feeding or pregnancy process, such as sexual trauma, body image, relationships, social support, etc. Providers should also ask about and support patients with logistics (e.g. Do they have a car seat? Leave time? Do they need referrals for social services or assistance programs?)
  • The provider should be competent, able to use evidence-based approaches, and do what helps women and babies. That is, they should neither push women into the cascade of interventions that is so common in the medical approach to birth, nor sit passively by letting them labor for far too long without active help or under dangerous conditions (e.g. breech babies or moms with preeclampsia at home). That cascade of interventions I mentioned often begins with inductions  (The decision to induce labor –> Pitocin –> tremendous pain –> epidural –> fetal distress and/or failure to progress –> c-section) .  In fact, first time moms who receive elective inductions  have a 45% chance of a c-section.
  • And of course, on the most basic level, the provider should believe in each woman’s ability to give birth and should see birthing a child as a natural process to safely help along rather than as a problem that has to be solved or, worse, extricated.

If this sounds good to you, as it does to me, then how do we go about determining whether a provider or a practice is like this? In the websites above, I could not find a handy little interview guide, so that’s what I will try to share here. It fully contains my biases and areas of interest, and might leave out some of yours. Totally add to it or subtract from it as you see fit.

C.) Laura’s interview guide for determining whether the provider/practice is, on the one hand, intervention happy, or on the other hand, reckless and out there:

[First, a tip on asking questions: Don't ask in such a way that they know what answer you want. Word your questions in an open-ended way where the answer you want is not stated in the question, and pay attention to what your voice and face are communicating.]

I. General Qs:


1.) What is your C-section rate?
(The World Health Organization recommends 10% or lower. Unfortunately, the C-section rate in the United States as a whole is ~34%, so you have to be selective if you don’t want a high-risk for C-section. Now, if, as in the case of the Alaska Native Medical Center (ANMC) in Anchorage, AK, all of the high-risk women from around the state have to go to that place rather than stay in their regional clinic, then you would expect the rate to be higher because there is a higher-risk population, but generally you should be looking for a pretty low rate. And it is meaningful that even so, the ~12 – 15% C-section rate at ANMC is far lower than the ~34% at Providence Hospital in Anchorage.)

2.) Which patients do you induce?
Sometimes it needs to happen, but it shouldn’t be happening very often. It should only be done under circumstances such as preeclampsia or hypertensive patients or those who are well overdue and low on fluid—not, for example, because the provider says your baby is big.

3.) What is your episiotomy rate?
Shouldn’t be higher than 5%. For the most part, they do not need to be cutting open women’s perineums.

4.) How long are the prenatal appointments?
Seriously, that 15 minute business is not enough.

5.) When in labor will you be with me?
Funny story: Oscar and I recently took a tour of Providence Hospital, in case we have to get transferred there from the birth center or in case we have a preterm labor. The woman giving the tour said something about how the provider won’t be with you in labor until near the end, that you will primarily be with the nurses. I asked her, “But what about with midwives?” She replied, “Yeah, they tend to come near the end too, like the doctors.” I furled my brow confusedly and asked, “Do you mean the midwives who are based here in the hospital? Because I am with Geneva Woods…” She quickly replied, “Oh, yeah, they will be with you the whole time.” Lesson learned: not all midwifery practices follow the same model. And docs tend to stroll in  quite late. Don’t be afraid to ask questions.

6.) If for medical reasoning I have to be induced, what methods will you try?
Say your water has broken and you haven’t gone into labor yet, or you have been diagnosed with preeclampsia.  Then you do want some help getting labor going. But you don’t want someone starting with Pitocin and breaking your water, as is standard in many hospitals, because it causes absolutely torturous pain and increases risks.

Providers should work on cervical ripening prior to even considering Pitocin. This includes:

  • Cervadil
  • Misoprostol
  • Balloon catheter insertion
  • Stripping of membranes

There are also some things a practice might suggest you try at home to get labor going if you want to move it along but an induction is not needed yet. These include black and blue cohosh, enemas, breast pumping, nipple stimulation, and sex—that is, as long as your water hasn’t broken)

Also, FYI: in Alaska, direct-entry midwives’ licensing regulations do not permit them to do inductions.

7.) What percentage of your patients’ babies have Apgar scores lower than 7 at five minutes?
You want good outcomes, so you want this percentage to be very low, somewhere less than 2%.

8.) What will happen with baby right after she/he is born?
Given the overwhelming evidence in support of immediate skin-to-skin bonding, you want a provider (and a facility) who understand and support it, who will determine baby’s Apgar score while baby is on your chest (barring any major complications that require NICU or other kinds of attention), who will promote breastfeeding, who will wait to cut the cord if that’s what you want, who won’t let the nurses whisk the baby off to be weighed right away, etc.

You may not even get answers to all of these things because the practice might not track or have that data available. That says something. Or you might get a provider who is defensive and upset that you are asking these questions. That also says something.

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II. Qs specific to midwives who practice out of hospital (homebirth or birth center)


[First, some background: Both Certified Nurse Midwives (CNMs) and direct entry midwives, who are called either Certified Direct-entry Midwives (CDMs) or Certified Professional Midwives (CPMs), can practice out-of-hospital birth. However, they have different skills and different licensing regulations. This is because CNMs are advanced practice nurses who also function as women's health care nurse practitioners, meaning they provide well-women's care (e.g. yearlies, family planning, menopause, STI treatment).  CDMs and CPMs, on the other hand, entered midwifery directly without a nursing degree, generally can't do well-women's care, and only care for low-risk women. Also, licensing of midwives and of birth centers is different for each state.

Research has shown that midwives are, on a whole, safe and effective care providers for birth and that out of hospital birth is a good option for women who are not high risk. However, there are some whack job or incompetent or ego-driven midwives out there who do not follow their own regulations, whose risk-taking drives up licensing fees for other direct-entry midwives, who have bad outcomes for babies and moms, and who give the profession a bad reputation. I believe that all families deserve to avoid such midwives and their birth centers and that it is important to advocate for better training and higher standards.]

1.) If a complication arises in my pregnancy, what will you do?
You want to provider who is safe and humble enough to transfer you if your pregnancy becomes higher risk than is allowed by her regulations. CNMs can work with women with complications, but they may consult a doctor and/or work with the patient  in the hospital. They may also collaborate with a physician if it is a high-risk issue, or transfer to a doctor if it’s a very high-risk issue. Direct entry midwives are required to transfer a patient if she has certain complications (e.g. high blood pressure, gestational diabetes). You want her to have a collaborative, friendly working relationship with CNMs to whom she can transfer patients, rather than just dumping you. If she has a contentious relationship with the other practices in town, that might not be a good sign. And if she disregards her regulations by offering to deliver breach or pre-term or VBACs or women over 42 weeks out of hospital, then she is one of those risky midwives who, for real, have bad outcomes, including higher infant mortality and even maternal mortality rates.

2.)  [if a birth center:] Is your birth center licensed by the state and accredited by the Commission for the Accredidation of Birth Centers?
Google is our friend here, because all of this information is publicly available on the Internet. But it might be worth asking too, to see what they say. Accreditation is voluntary, but means that the birth center is held to a higher standard and that its staff receive support and training through the national organization.

3.) [if a birth center:] What is your transfer rate?
According to the two major birth center studies, the average transfer rate is around 15%. Too too low (or birth centers who say they never transfer patients) would mean they are not transferring people who need it and too high might mean that they may not be managing labor very well, resulting in obstructed labor, fetal distress, etc. which can often be avoided.

4.) If I have to transfer to the hospital, who will be my care provider? And will you be there with me?
It is a great relief to me and Oscar to know that if we do have to get transferred,  the CNMs in the practice have hospital privileges and will take care of us there. But if we were going to a practice with only direct entry midwives and this were not possible, I would hope that the provider or practice would have good working relationships with doctors or midwives who do have hospital privileges rather than dumping me on whichever doctor happens to be on call—because some of the docs are not so nice or competent… and that is putting it mildly. I would also hope she would stay with me as a support person if I had to be in the hands of an unknown doctor.

5.) What do you do if I hemorrhage?
I am not an expert on hemorrhaging, but basically, listen for a confident, competent, medical evidence-based answer. There are medicines they should have handy and they should provide bi-manual compression.  Plus, there should be an emergency transfer option if needed.

6.) [Insert your own questions and concerns about medical issues, such as shoulder distocia or cords around the neck or whatever to make sure that they practice according to the evidence and experiential wisdom.]

And it may go without saying, but make sure that the midwife’s license exists and is up-to-date. Apparently, there are a few women in Alaska who call themselves “lay midwives” who have no training or licensure at all but who catch babies. These women are breaking the law, deceiving families, and putting women and babies at risk. In Alaska, the only “lay midwives” allowed to practice are Alaska Native ones who were trained in the traditional way, such as tribal doctor, midwife, and Yup’ik elder Rita Blumenstein.

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Again, this comes from me, a social worker in the public health world, with a lot of help from my mama, a CNM and birth center owner and former Board member of the American Association of Birth Centers. So here are our biases and interests. But it also comes from the research, the evidence—including evidence that the American College of OBGYNs puts out. And it comes from what I hear from women and families about their experiences with prenatal, birth, and postpartum care. It also comes from the boards or offices charged with investigating the licenses of those in Alaska who don’t practice as they should. So I hope that this bit of insight is helpful for you or your friends, and that you can use it to create your own interview guide to bring to first appointments when looking for a provider.

On a totally different note, here is the art project invitation & CD cover that Oscar and I created for the baby shower/30th birthday party:

And here is the close-up of this week’s rainbow-colored ink painting/drawing:

Printable interview guide:

perinatal_provider_interview_guide

Written by admin

December 18th, 2013 at 8:14 am

Posted in health

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