Laurita Dianita

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

Archive for the ‘art’ tag

Two additions

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1.) Today is my due date, and I am still pregnant! This is a first for me. In a way, it’s satisfying to get to that nice even number of 40 weeks, and to be able to make the last page in the pregnancy section of Rio’s baby book. So, as an update to this post on the “pre-baby book”, here are the two most recent pages:





2.) Also, Geneva Woods Birth Center, where I am fortunate to receive care and at which I will soon give birth, has a blog on their webpage, and they let me guest blog for them! It’s an abbreviated version of my blog entry “Birth is Painful for a Reason. I am grateful for it.” You can see and read my guest blog entry here, and look at their other great entries written by CNMs Dana Deane and Barbara Norton:

Screen Shot 2016-07-22 at 10.03.28 PM

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July 22nd, 2016 at 9:05 pm

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Pregnancy #2: Pre-Baby Book

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Of the many thoughts and essays tumbling around in my head for the last 2 years, most have remained unwritten; some have been spoken to friends or family, a few articulated in facebook posts (because I could do that on my phone), a few incorporated into my job. Since going back to full-time work after Ida was 3 months old (insert angry rant about the United States’ lack of parental leave) I have not found the kind of work-life balance to keep up my blog, nor to make very much art. I know each of us does our best to find a balance and so we prioritize certain things over others; blog and art-making are two of the many things I’ve had to let go in order to work, be a present and loving parent, feed us (relatively) well, maintain social connections that keep us sane, and sometimes have a clean house.

But in this balance, I have managed to keep a baby book for Ida this whole time, Ida book4896Ida book4897because it felt impossible to let all of the observations about her growth and development slip by without record.  I also know how much it meant to me to have my own baby book to read when I was a teenager and young adult, especially now that I am a parent and can compare. Mostly the book has included monthly entries, all written to her like letters. It is a record of her growth but also a reminder that she is valuable and loved — a reminder that I hope will sustain her through the harder parts of life.

When I became pregnant with our second child, I was at a bit of a loss for how to track and honor this pregnancy, because I knew I wouldn’t be able to do anything quite as ambitious as the art and writing project that Oscar and I undertook for our first pregnancy. It occurred to me that I could make this baby a book, a book to precede the baby book, one that chronicles the pregnancy and also the love and belonging into which he or she would be born. I set the slightly less ambitious goal of making entries every 4 weeks rather than every week, and of using whatever format and medium I felt called to use. Also, because this pregnancy was fraught with worry early on because of a Zika scare, I made the time to co-write an article about this experience with Alaska Dispatch News journalist Jill Burke, and of course to staple the article into the pre-baby book. I am now at week 27 of this pregnancy; here’s what I’ve got so far of the pre-baby book for the little person growing inside me who we now know is baby boy Rio Esteban Avellaneda-Cruz:

Rio book-5

Rio book-8

Rio book-12

Rio book-16

Rio book-20

Rio book-24


Updated 5/31/16, here are the next two pages:



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April 24th, 2016 at 10:53 am

“You Grow Inside Me, I Grow Around You” Exhibition

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On Friday, March 6th, the International Gallery of Contemporary Art teemed with people. There were four shows up that month, one of which was our show in the South gallery of the series of drawings/paintings/collages + photographs + writing we made during Ida Luna’s gestation.

weeks 33, 34, 35, & 39

From left to right, people walked through the exhibition in chronological order, Ida growing from the size of a poppy seed to the 19 1/2″ long baby she was when she emerged, this mama’s body becoming stretched and rotund while my senses and my soul became more sensitive, more aware, turning inward in preparation for baby.

Oscar and I felt so honored that friends and family and colleagues came, some sharing with us what moved them and even made them cry. I know that I also felt so honored by the presence of strangers and acquaintances who took the time to travel through the images and words of this pregnancy. I loved having the opportunity to hear from people as they experienced the exhibition, hear their own stories of a difficult pregnancy or a healing homebirth or parenting a newborn in a dry cabin during the Fairbanks winter or their future hopes to become parents. I love being the recipient of these stories — or the little glimpses of them that I got that night trying to chase around a toddler at an art show. I loved the feeling of convening and being immersed in a community of parenting and birthing and caregiving. This is a community, as I wrote in my Week 15 blog and quoted in the show, that should not be a clan exclusive to those who are biological parents. It includes all who care for children and maternal-child-reproductive health.

Photo by Clark James Mishler

I left that night feeling so touched by all the people I had interacted with. We made this series and this exhibit because it offers one honest conversation about pregnancy, birth, bodies, and parenting, with the hope to create space or inspiration for other honest conversations. I hope that it can continue to do this.

Ida and I returned the next weekend so I could photograph the show in peace and quiet.

The owners of Busy Beans Café in Anchorage asked us to show the exhibit there in May, so if you did not get a chance to see it in March, you can come to the First Friday on May 1st or anytime during that month. Busy Beans is a coffee and sandwich shop with children’s play areas and a children’s menu located on Government Hill. It is a friendly and logical venue for an exhibit about pregnancy.

Also, per the suggestion Oscar received from the director of an arts non-profit for people with disabilities, we may make some sort of audiovisual version of the exhibit, or of the whole series, to share more broadly.

first trimester

weeks 20 & 21

Ida Luna with weeks 20 - 26

I am so glad I can share this with all of you and so very glad I can share this with Ida as she gets older, and later if/when she begins her journey towards parenthood.

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April 8th, 2015 at 8:18 am

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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 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 person* and finding the right care provider, Part 2:

[* As a 2016 update to this guide, I will use the words person and woman interchangeably, with the recognition that women and people with female reproductive organs who have other gender identities (trans, gender fluid, androgynous, etc.) can become pregnant and give birth.]

I cannot claim to be an expert on this subject, but because of the continuous learning about birth that I have grown up with and the maternal child health (MCH) knowledge I have acquired through my work in public health over the past few years, 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, the 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:

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

These websites have an incredible wealth of information about types of providers and birth settings and ways of understanding your options as a mama/parent and patient:

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 patients and families, to get attentive, informed, compassionate, competent, culturally-humble and culturally-competent 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 pregnant and laboring patients and babies. That is, they should neither push patients 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. This varies significantly by practice and hospital. For example, 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, so you would expect the rate to be slightly higher than other hospitals because there is a higher-risk population — though you would still want it to be fairly low. Interestingly, 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, or because of call schedules or vacation.

3.) What is your episiotomy rate?
Shouldn’t be higher than 5%. It is sometimes needed when baby’s heart tones are down for a while and progress is not being made well, but 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. Especially for first time parents.
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%. (Note that this may be a little higher if this is a hospital-based practice or EMTALA doctor who takes walk-in patients who have not received prenatal care and/or who have been using substances during their pregnancies.)

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 until it’s done pulsing in the vast majority of cases, who won’t let the nurses whisk the baby off to be weighed and bathed 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.

_ _ _ _ _ _ _ _ _ _

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 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.

The American Association of Birth Centers website is a wealth of information on this subject.]

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 pregnant patients 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 the CDM 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 a CDM disregards her regulations by offering to deliver breech or pre-term or women over 42 weeks, women whose water has already been broken for 24 hours without labor starting, or VBACs out of hospital, then she is one of those risky midwives, and these midwives tend to have worse outcomes, including babies who go long enough without oxygen after birth that they can suffer brain damage, and even higher infant 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) may 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 — it’s luck of the draw… I would also hope the CDM 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 such as Pitocin and Methergine they should have handy and they should provide bi-manual compression.  Plus, there should be an emergency transfer option if needed.


6.) Are all of your midwives and birth assistants certified in the Neonatal Resuscitation Program? How often do they have to renew their certification?

You want the people there to know how to assess the need for and administer neonatal resuscitation correctly. The Commission for the Accreditation of Birth Centers requires updating of certification every two years for accredited birth centers, so that is one standard you could look for. You also want to make sure that they have Positive Pressure Ventilation equipment with them at the birth and have it at the ready, just in case. I don’t say this to make you afraid; if I know that my birth attendants have all that taken care of, it can free me from fear so I can just relax and let my birthing hormones do their thing.

7.) [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 up-to-date 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 — with some very bad outcomes. These so called “lay midwives” 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.

Bonus question idea:

If you can, ask nurses or providers at the nearby hospitals, especially Labor and Delivery (L&D) and Neonatal Intensive Care Unit (NICU) nurses, as well as paramedics and ambulance drivers, about the kinds of transfers they get from different birth centers and home birth midwives. They see the safe transfers and the transfers that clearly resulted from poor care — breech babies that got stuck, babies that didn’t get resuscitated in a timely manner, and so on.

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

Again, this comes from me, a social worker in the public health world, with help from my mama, a CNM and birth center owner and Board member of the American Association of Birth Centers who is very familiar with the research on risk and outcomes and best practices. So here are our biases and interests, but also 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. 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:

[Note: This guide was written in Dec 2013, and some updates were made to this guide 3/19/16, including adding the bonus Q, adding the Q about neonatal resuscitation, and adding some gender-neutral language.]

Printable interview guide:


Written by admin

December 18th, 2013 at 8:14 am

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Week 33

with one comment

A Christmas-decorating night at my parents' house and another left-handed drawing. I am getting a little better with my left hand.

Being an informed birthing woman and finding the right care provider, part I

The photo series Oscar made of me for this week with my parents relates to a post I have been planning out and wanting to write for a long time now, but will have to truncate tonight in order to finish setting up baby’s crib and get to sleep. I want to write about and offer some useful websites and other tools for helping to find the right prenatal and birth care provider. I want to share some thoughts and interview questions for distinguishing whether a provider is, on the one hand, overly intervention-happy and doesn’t fully support mothers’ ability to birth naturally and make choices for herself, or, on the other hand, if the provider is out there and not evidence-based and puts moms and babies at risk by doing too little. At least here in Alaska, there are plenty of folks on either end of that spectrum. How to determine who those folks are and what the risks are may not be so apparent. I think through open dialogue, we can help make this process more transparent.

What does this have to do with my parents? Well, being raised by Bradley Cruz, a pediatric radiologist who is much more critical of the many arrogances of his profession than most in the field, and by Barbara Norton, an RN-turned women’s health Advanced Nurse Practitioner (ANP)-turned Certified Nurse Midwife (CNM) who teaches and advocates on reproductive health issues, I feel that I’ve been blessed with a lot of tools and insight in this arena. By critically taking apart health care systems and health issues at the dinner table, by helping me do my 8th grade biology report on herpes or my persuasive argument in high school speech class on continuous fetal monitoring, by my dad asking for my help with language interpretation or my mom bringing me in to help her create lectures on the c-section rate, aby learning from me about the areas of health research and practice that I am involved in, and most recently, by being available to listen to baby’s heart rate or answer questions about this pregnancy, my parents have gifted me a certain comfort with, access to, and ability to engage critically with health care systems and health research.

My mom in particular has prepared me, over many years, to be excited and realistic about birth, to better understand the options out there, and to be a smarter consumer of information about perinatal and women’s healthcare.

So that is what I intend to share with all y’all (with the hope that you will add to it).

Next week.

Good night for now.

Written by admin

December 10th, 2013 at 8:55 pm

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