You Shouldn’t be Doing That in Your Condition

“You shouldn’t be doing that in your condition!” How many times have you heard these words? If an American woman is pregnant, it seems like everyone’s ready to share their opinions. Whether she’s pushing a grocery cart to hand-digging a well, our society seems obsessed with the idea that bed rest is the best and only solution to a swollen abdomen. Maybe they’re afraid that the baby will just drop if a pregnant woman wiggles too much. Whatever the reason, it’s something I’ve never understood.

It makes no sense to tell someone who’s gearing up for the most intense workout of her life not to move or lift. We certainly don’t give the same information to runners gearing up for their first marathon. In fact, there’s set standards for increasing physical endurance, steadily graduating from high-protein to high-carbohydrate diets, and creating game plans for exact very exact segments of time and geography within the event. After all, you’re using a huge amount of your muscles and energy for the greater part of a day.

Imagine using a huge amount of your muscular energy for more than a day. Imagine working out hard for a day and a half or two days, only in this instance, you are unable to get off the treadmill once you’re completely exhausted. Imagine the treadmill is set to gradually increase in slope and speed until long after you thought you’d never make it a step further. In birth, there’s no getting off when you’re tired.

Fitness during pregnancy has evolved tremendously since the days of dads passing out cigars in the waiting room. Where women were once told to physically exert themselves as little as possible, it is now widely understood that fitness will do more good than harm. That does not go to say that everyone agrees on what “fitness” is. Today, the trend is more toward cardiovascular activity than strength training. This is largely due to the fact that there was enough medical evidence to support a hypothesis that strength training may be detrimental to the developing fetus. And one thing we know about supposed medical contraindications is that testing for research purposes, especially on gestating women, is a very slippery slope for an unethical investigation.

That has changed dramatically this week. On March 26^th of this year, Science Daily released an article, “Supervised Weight Training Safe for Pregnant Women, Study Suggests,” highlighting a University of Georgia study focused specifically on strength training. A sample population of 32 pregnant women participated in a supervised strength training program for 12 weeks, while their blood pressure and general comfort were measured against standard norms. One of the potential hazards of strength training has been thought to be increased blood pressure, delivering greater risks of issues such as preeclampsia. However, after 618 training sessions which increased in intensity by an average of 36%, the study found no change in blood pressure.

The study, funded by a grant from the National Institutes for Health, did report some minor complications among the pregnant subjects. Out of all 618 sessions, there were issues with 13; including headache, pelvic pain, and dizziness. Pelvic and/or back pain is often expected, due in part to a dynamic body which is undergoing constant changes during pregnancy. “The one thing you have to be a little careful about is dizziness,” says Patrick O’Connor, a researcher in the UGA study. Dizziness is associated with overheating, that big reason your grandmother told you to stay in bed while pregnant. Dizziness is a sign of dehydration and hyperthermia, both of which have a higher risk of fetal damage during the first trimester. In the event of dehydration, maternal blood volume decreases, which increases oxytocin concentrations in the blood. Oxytocin is something we typically like to see a lot of-in labor. Higher blood concentrations before term can actually promote early labor, which again is the opposite of the desired effect. Further complications of hyperthermia (“overheating”) come up when it’s taken into account that fetal body temperature is always 1 degree Celsius higher than maternal body temp, and babies don’t have the ability to sweat. This is an issue particularly during the first trimester, where greater heat concentrations may inhibit healthy fetal development.

The Science Daily article had more encouraging information to deliver about dizziness than the mere fire and brimstone of subjecting a defenseless fetus to a fiery death of hyperthermia. The study found that maternal dizziness rates actually decrease as the strength training program increases in intensity. O’Connor mentioned that the trend was due to the fact that “…the women learned to lift weights while maintaining proper breathing techniques for exercise.” I find this particularly significant because it highlights the point that a gestating body is not static; women do have the ability to become more physically fit during pregnancy.

It’s an idea supported by the Mayo Clinic as well. Mayo has a lot to offer women in terms of what their physical exercise options are during pregnancy, and in a lot of ways it mirrors the results O’Connor found in his strength training study. In one of that organizations’ articles, “Pregnancy and Exercise: Baby Let’s Move,” women are encouraged to exercise at least 30 minutes a day, 5-7 days a week. The article mentions that athletes, or women who already subscribe to an exercise regimen, need not adjust their regular patterns due to pregnancy. In fact the Mayo Clinic also recommends gradually increasing endurance over the entire course of gestation. Pretty sound advice considering the uterus is the strongest muscle, pound-for-pound, in the human body. For an organ weighing roughly 40 oz, the uterus is able to exert about 100-400 newtons of downward force with each contraction. That’s going to use a lot of energy, and if the laboring mom is in the condition of great physical fitness, her ability to push out a baby after 12-30 hours of exertion is going to be exactly where she wants it to be.

I think Mayo says it best: “Regular exercise can help you cope with the physical changes of pregnancy and build stamina for the challenges ahead. If you haven’t been exercising regularly, use pregnancy as your motivation to begin.”

Why Wax Paper Doesn’t Work (OR) Liars, Damn Liars, and Statisticians

In July 2010, a very controversial study by Joseph Wax was published in the American Journal of Obstetrics and Gynecology. The paper asserted through a meta-analysis of 12 home v hospital birth studies that children born outside the hospital setting are 2-3 times more likely to die within 28 days than those born in a hospital. The backlash in the birth community has been huge.

The controversy surrounding this journal article is not so much in the statement it purports, but in the statistical methods utilized in the research. A recently published Scientific American article, “Home-birth Study Investigated,” highlights some of the article’s issues as presented by various academics and statisticians. “Divergent methods” appears to be the academic world’s biggest complaint. Wax’s paper was a meta-analysis of 12 studies, which means that rather than designing and implementing his own research study, the Wax was analyzing 12 prior studies and reporting with inferential statistics that home birth is bad.

Scientific American mentions that Wax selected from his 12-study data pool a subset of only 4 studies from which to draw his inferential data. Maybe he was a slacker and only wanted to do just a little number crunching, but it’s more than likely that he was selecting from his data pool the sample population best suited to make his anti-homebirth agenda a more convincing one. That’s a statistician’s job. But this one really blew it by eliminating from his data pool a certain 2009 Dutch study of 300,000 home births. This study found no increased risk of death after home birth. That’s a very large population of excellent home birth outcomes to exclude from an ethical investigation. Given such dramatic number errors, I personally feel it’s safe to say the Dutch study would have annihilated Wax’s thesis statement completely.

Dutch birth is a different league of birth than we see here in the United States. American Midwifery is based on the Dutch model of birth, in which well-trained, licensed midwives are the de facto care providers of gestating women. When birth outside the hospital setting becomes the norm, the providers are so familiar with and well-trained in natural home birth that their aggregate results are inevitably far greater than a country that is still hot to incarcerate midwives in a large percentage of its states. Statisticians investigating the Wax paper are calling this study omission the biggest fundamental flaw in the research findings. Diana Petitti, Arizona State University Center for Health Information and Research epidemiologist mentions, “The problem of excluding the Netherlands study dwarfs any problem related to software or the statistical methods.”

Oh that’s right: there was a software issue. The journal that published Wax’s article, the American Journal of Obstetrics & Gynecology, launched an investigation on the study, though they are not ready to retract the article. Carl Michal, a physicist at the University of British Columbia recognized a flaw in the study’s calculations that lead the investigation to identify an error in the online meta-analysis calculator used by Wax’s research team. No one can deny the numbers are off. That calculator’s developers have warned other potential users of the problem, but it remains online as-is. And Karin Michels, a Harvard Medical School epidemiologist, points out that research methods “did not provide measurements of the variations between the studies.” It’s a problem because studies with data concentrated toward one result should not be combined with studies concentrated with opposing data, because “readers can’t know how much the studies included may differ and whether it was appropriate to combine them.”

American Journal of Obstetrics & Gynecology reportedly mandated Wax to publish online full summary graphs for each of the study’s outcomes. They’ve been posted. But the results posted online are now different from the original results published in the journal article. Risk of newborn death and postmaturity among home birth babies is now higher than originally asserted; and the risk of prematurity is now lower. How come, Joseph Wax? The results are different now, but he’s never reported whether it was due to recalculations, statistical errors, or any other reason.

The critics are not happy. Home birth is an endangered piece of our American culture, and the big boys playing hardball to eliminate it completely doesn’t help. Especially when they use their power under the big titles like ACOG to produce inaccurate assessments of what is safe and what is not safe. The Wax paper’s researchers did not see or touch a single woman in their research to blacklist home birth. Bad methodology bridged with tertiary information from the meta-analysis recreated an image of statistical lying made famous by the Bush administration. And now on top of that, Wax is refusing to comment until further investigation of the study is underway.

No comment? Who are you; Lindsay Lohan?

The Slow Birth Movement

I’ve just read Gloria Lemay’s article The “Slow Birth” Movement from her Birth Blog homebase in Vancouver, BC. Lemay is a midwife who carries a lot of weight in the Pacific Northwest birth community. And this post she blogs about touches very close to home.

It touches close to home because I’m a vegan. This is related. This winter in Seattle, my partner and I, two warm-water California girls, learned how to survive in a freezing city with minimal funds for recreation: Netflix. The two of us are perennial students, and we tend to prefer multi-episode documentaries to movies or television. The favorite from this frigid season was without a doubt PBS’ 6-part documentary Auschwitz: Inside the Nazi State. Try to imagine all the horror you could possibly witness in a 6-hour sitting; how many thousands of people you could watch being herded into a gas chamber; how many tens of thousands of bodies bulldozed across a verdant campus, how many thousands of small children you could see tortured in the name of “medicine.” The Nazis did not only murder Jews, but Catholics, Gypsies, homosexuals, and anyone who might be considered “unfavorable.” Now I’m an educated woman; so I was familiar with Auschwitz and the Nazi Holocaust long before this documentary. What I did not know beforehand was how much industrial engineering went into the mass-extermination of human beings. What I did not know beforehand was humankind’s ability to see a human being and legitimately not see them as a person.

The energy of Auschwitz sits with me tremendously when I think of other similar circumstances. Factory farming, for example, is a modern-day diorama of Auschwitz. I could go into details and get all crazy animal-rights on you, but I’m very sure you’re at least a little familiar with how our food gets to our tables, and I really want to focus on birth here. In the process of becoming a vegan at the beginning of this year, as anyone might understand, I experienced some cravings for a big ol bite out of a lamb’s leg or a nice juicy cheeseburger. Even under the recommendations of my doctor, I considered returning to my standard diet for “health” reasons, though my heart seemed unsure. Then I read this quote:

“Auschwitz begins whenever someone looks at a slaughterhouse and thinks: they’re only animals.”
-Theodor Adorno

Way to rock if for me, Adorno! I used to have this puppy, Penny. She was a very badly-behaved Beagle, and I loved her with all my heart. She would be so thrilled to see me come and so sad to see me go. Every day. This dog knew what was up; and it would have been the end of me if anyone ever tried to hurt her. And this is such a small example of humanity. I loved that dog; but to anyone else, she was just a dog. In some other country, she’d be lunch. And that sickens me. In this country, it’s okay to eat animals because, “they’re just chickens,” or whatever. In this country, it’s okay to subject animals to ridiculous industrial factory farming because a lot of animals have to go through the system to reach our homes. In this country, it’s okay to do all of that because that’s the way we were brought up, and that’s the way our parents told us the world worked.

Unfortunately, the American industrialization of unlikely subjects has now insidiously extended into the realm of almost every home. Hospitalized maternity care is the new Auschwitz. That’s a very bold statement, and I mean what I say sincerely. Forget for this moment that you were born in a hospital and it seemed to work. Forget for this moment that “the hospital is the safest place to be,” or that even in nurse-midwifery care, a surgeon’s just a door-knock away. All of these “perks” are the gloriously shiny distractions AMA and ACOG have spent billions of dollars defending. The best part is: most of the individuals in these organizations and most of the individuals working in any hospital across the US have never seen natural birth.

This becomes an issue when women are getting what they consider to be valuable, ethical, and correct information from a source as reputable as a board-certified physician. We all want to trust these people, especially considering our lives are in their hands. But lives are not their area of expertise. Readings are. What a midwife can learn with an ear and small-scale megaphone, a physician needs to infer from machines, monitors, and medicines. And if the readings are not all pointing directly toward rapid-growth (see the industrial link here?) a woman is told she is failing to progress, and will either be sliced open (think chickens), injected with synthetic hormones (again, chickens), or prodded into unnatural positions with unnatural instruments to release the product of desire….like an egg, but really.

Stepping into that hospital voluntarily is like stepping into Auschwitz, involuntarily. Any semblance of a normal life, in which you are in control over your body and your experience, is checked at the door. If your cervix needs an hour more to dilate than your roommate’s, too bad: it’s time for the OR. That’s America. We’ve got several other pregnant women in triage waiting for your labor room, and we can’t just sit and watch you waddle around until you’re ready. We’re ready. Now.

My greatest wish is that one day industrial birth will be a thing of the past. But based upon what I’ve seen thus far, I’m afraid it will get worse before it will get better. In an article titled Maternal Mortality in the United States: A Human Rights Failure, the Association of Reproductive Health Professionals point out that the system is, in fact, very flawed. In the developed world, the US has among the highest maternal mortalities. Would you believe you are, in fact, 20% more likely to die when you give birth in a hospital? Statistics aren’t facts packaged into percentages, but they do sort of knock some common misconceptions out of the water.

So to you my friends, I just want to emphasize that your wife, your sister, your mother-is more important than the system. Trust her instincts, listen to her body. She knows what she is doing and she knows what she wants. She is no chicken to be debeaked and caged.

Slow Birth, like Clean Eating may change our culture dramatically.

Guided Transfers

Today, while I was logged onto my WordPress page, realizing I still don’t really have a clue how all this online networking technically works, there was a link to a program called Guided Transfers. When I clicked on it, the page showed how to transfer your blog into a dot-org site. Cool. But I couldn’t help thinking how nice it would be to get some advice and guidance on how to transfer my now-career into my visionary career.

There are so many add-ons we can use to make money as doulas. Upgrade your packages from birth doula services to birth doula AND postpartum doula services. Discounts if you purchase a reiki/prenatal massage session, extra percents off for private yoga. A hell of a lot of thought goes into everyone’s decisions for the add-ons she chooses to pursue enough to integrate into a trade. A lot of money. A lot of personal dedication and commitment.

What I find unfortunate is that some of the “add-ons” I’d consider to be the most important are never going to be reimbursable. Coming into contact with the Full Spectrum Doula Network this week reminded me what it really means to think outside the box in terms of support and how varied each little shade of life’s “full spectrum” can be. Doulas supporting women having abortions. Doulas supporting women incarcerated while pregnant. Doulas supporting surrogate mothers, adoptive parents, queer families; and misscarriage doulas. These are the services that I, even as a doula, had never thought of nor heard of any practitioners in my community.

Now I’m dying to get on board with the network, and I’ve even submitted a letter of interest in becoming a core organizer. I’m discovering that there is a very rich source of “underground” support here too. I never would have guessed that there are so many self-identifying “Radical Doulas” in my community; and just because I’ve never met them doesn’t mean they’re not out there.